Reframing the Right to Healthcare in Terms of Insurance Cover Is a Bad Idea [opinion]

The primary aim of any health system must be to improve people's health. Universal access to healthcare is recognised globally as a public good. It embodies universal social values such as solidarity, fairness, social justice, and shared responsibility. It is entrenched as a fundamental human right in the International Covenant of Economic, Social and Cultural Rights (ICESCR), and the UN Convention on the Rights of the Child (UNCRC). Furthermore, Section 27 in our Bill of Rights guarantees access to healthcare as a human right.

There has recently been a subtle and little-noticed shift in the discourse around universal health care towards framing it as Universal Health Coverage, including in the language of documents from the United Nations (UN) and the World Health Organization (WHO).

For example, Goal 3 of the UN Sustainable Development Goals (ensure healthy lives and promote well-being for all at all ages) includes a commitment to universal health coverage. Its target 8 is to:

"Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and safe, effective, quality and affordable essential medicines and vaccines for all."

According to the WHO, Universal Health Coverage (UHC) means that all people and communities have access to the promotive, preventive, curative, rehabilitative, and palliative health services they need where and when they need them (equitable access); that the services are of sufficient quality (effective); and that using them does not expose them to financial hardship (affordable). Equity is fundamental to UHC.

The shift from "care" to "coverage" blurs the meaning of universal health care. "Care" implies a caring relationship between provider and recipient based on shared human values. "Coverage," on the other hand, is a market-orientated statistical concept more concerned with the number of beneficiaries covered by medical schemes than with equity and quality of care.

Unlike access based on medical scheme cover, human rights are universal (they inhere equally in all of us everywhere), inalienable (no one can take them away from us), and indivisible (they are all interconnected and interdependent). As primary duty bearer, the state must respect, promote, protect, and fulfil the rights of all people under its jurisdiction--the rights holders. The latter, in turn, have duties and responsibilities, including respecting the rights of others and holding the state accountable.

NHI will stand or fall on Parliament's approach to corruption, say civil society bodies https://t.co/lPWXywLwIO via @dailymaverick

-- PMG (@PMG_SA) April 4, 2022

The focus on "coverage" reveals a radical shift in thinking away from health as a human right toward healthcare as a potentially marketable commodity. This rules out the principle of universality. "No market will ever shift corporate investment from where it is most profitable to where it is most needed." Conflicts of interest and opportunities for exploitation by organised groups with vested interests in private healthcare (typically through voluntary membership-based insurance schemes) are inevitable and equity flies out the window.

Equity necessitates a major redistribution of resources. Gro Harlem Brundtland, former prime minister of Norway, director-general of the WHO from 1998 to 2003, and member of The Elders believes that UHC is desirable and achievable. Political commitment is the key to overcoming opposition. In the British Medical Journal in 2017, she wrote:

"... across the world, we know that in every country, extending health coverage is an inherently political process, especially when it comes to creating an equitable health financing system. UHC can only be achieved by the state compelling healthy and wealthy members of society to subsidise services for the sick and the poor. In effect, UHC can only be reached through public financing where the state has a big role in raising revenues fairly, according to people's ability to pay and allocating pooled resources according to health needs.

This transition to a publicly financed health system is often challenged by interest groups that benefit from a fragmented privately financed system--for example, private insurance companies, private hospitals, and those ideologically opposed to a welfare state. This opposition can be extremely well-organised and powerful as we see in the United States and South Africa."

A study of 11 countries attempting to move towards UHC supports Brundtland's arguments. It showed that universal coverage for the entire population needs cross-subsidisation from the rich to the poor, and from low-risk groups (e.g., the young) to high-risk groups (e.g., the elderly). The study also found that economic growth was not a necessary precondition for starting to move towards UHC and that strong political will was essential to confront interest groups. Furthermore, social movements play a catalytic role in putting UHC on the political agenda and encouraging governments to face opposition and implement meaningful change.

South Africa's National Health Insurance (NHI) project aims to achieve UHC through a large NHI Fund (NHIF) that the Bill seeks to establish as the single-payer for healthcare. Unsurprisingly, various interest groups made submissions on the NHI Bill to Parliament's Portfolio Committee on Health. While almost 90% of respondents commenting on the NHI Bill expressed their support for UHC, only 28% supported the NHI.

Free-market devotees and powerful, well-organised corporate groupings in the profitable private sector reject the idea contained in the Bill of the NHIF as a single-payer system. Instead, they argue for substantial private sector involvement in rolling out UHC through a multiple payer system involving medical schemes. For example, the Free Market Foundation's Michael Settas argues against the NHI and the single-payer idea in the Daily Maverick.

Settas blames South Africa's poor health outcomes mainly on the "corruption, graft, jobs-for-pals and other forms of malfeasance" that strip the health and education departments of their capacity to deliver. He is partly correct. The scale of corruption in the public and private sectors ruins any possibility of good, accountable health service delivery.

However, the underlying causes of our national health crisis lie upstream from the delivery of health services. Our massive quadruple national burden of disease is mainly the result of inequitable access to the socio-economic determinants of health. The social determinants include safe housing, transport, neighbourhoods and environmental conditions; good nutrition, freedom from poverty and inequality; adequate water and sanitation; good education and literacy; decent work and income; personal security; fair access to the economy; and an end to discrimination, racism and violence. Moreover, this national health crisis has been growing since long before the COVID-19 pandemic.

The simple truth is that too many South Africans live in conditions incompatible with good health. Then, when they become ill, they encounter a fragmented, inefficient, and inequitable health system. The public sector is dysfunctional and demoralised after decades of austerity that included the worst years of the HIV/AIDS pandemic. The private sector is well-resourced but predatory. It is hospital-centred and owned mainly by highly profitable multinational corporate hospital groups (see here and here). Financing is channelled through a byzantine set of insurance schemes and plans. This system operates under the inverse care law--those who need healthcare most have the least access. This is the very opposite of UHC based on human values.

In common with others who oppose the NHI, Settas' main beef with the Bill is that it sets up a publicly funded single-payer system. He claims, without evidence, that as "the most extreme form of a monopoly one can imagine", single-payer systems "never improve efficiencies or reduce costs--they always do the opposite". He is wrong. Abundant evidence in the public domain shows that single-payer systems can reduce costs and achieve progress toward UHC.

A systematic review of economic analyses of the impact of introducing a single-payer health care financing system in the United States found that cost savings would be significant due to lower drug prices. A separate review of primary care prescription drugs purchased in 10 High-Income countries found that drug expenditures were lower among single-payer financing systems because they led to lower prices and lower-cost treatment options.

Single-payer systems also have beneficial externalities beyond better and more equitable healthcare delivery and cheaper drugs. In February 2022, the Congressional Budget Office (CBO), a non-partisan agency in the legislative branch of the United States government, reported on a study of the economic effects of five single-payer health systems. They found that GDP could fall by between approximately 1.0 and 10 per cent by 2030, but this would be offset by growth in economy-wide productivity. The labour force would grow, resulting in less unemployment. Workers would enjoy higher wages and pay lower insurance premiums and out-of-pocket expenses. Disposable household income would increase, leading to more savings and non-health spending. Workers would choose to work fewer hours, and families would have more time for activities outside their paid work.

On the other hand, multiple-payer systems make UHC more difficult to achieve. Joseph Kutzin, Coordinator for Health Financing Policy at the World Health Organization, says that voluntary insurance schemes designed for the benefit of members tend to benefit some people at the expense of the rest of the population and the system as a whole. Their interests conflict with UHC objectives to benefit the system as a whole. If we want to make progress towards the goals of equity and universality, we must focus on the whole population and the whole health system from the start.

This information is readily available in the public domain. Michael Settas ignores it. This can only be because he has a vested interest in the delivery of scheme-based healthcare himself. He runs his own health insurance business. He puts this forward in his byline -- not as representing a conflict of interest but as adding to his credibility and authority.

As far as we know, no individual or organisation who made submissions on the NHI Bill to the Portfolio Committee on Health was expected to make a declaration of conflicts of interest. This has to change. Civil society has a critical role in remaining watchful and forcing the state and the private sector to eliminate corruption and ensure that the country's healthcare resources work collaboratively to deliver quality, equitable health care to the whole population.

South Africa can't afford not to work towards UHC. It's the right thing to do. The Constitution commits us to "Heal the divisions of the past and establish a society based on democratic values, social justice, and fundamental human rights". We face enormous obstacles quite apart from our dysfunctional health system. The most obvious is the rampant corruption that has brought us to the brink of being a failed state. Nothing can work while this continues.

Beyond this is a pervasive mindset that favours private wealth above public health. We can and must be bigger than that. We can't allow vested interests to obstruct progress towards a rights-based UHC. We must harness all the country's health resources to move towards UHC that meets patients' needs, free at the point of use, funded by progressive taxation. We need a publicly funded single-payer financing system, strong political will, and energetic action from civil society.

*Reynolds is a retired paediatric respiratory and ICU specialist, and Associate Professor in the Department of Paediatrics & Child Health at UCT. He has no conflict of interest.