GRO HARLEM BRUNDTLAND: Delivering health for all a key test of SA’s global leadership

SA’s G20 presidency is a historic moment for the country on the world stage. It will provide a tremendous opportunity to demonstrate global leadership in building a just world and a sustainable planet.

With the world facing multiple crises and existential threats, it is vitally important that all nations collaborate effectively.

Solidarity, equality and sustainability are the themes SA has chosen for its G20 presidency. They are also core values for The Elders, the group of former world leaders brought together by Nelson Mandela, of which I am a founding member.

The Elders welcome the focus of SA’s G20 presidency as an antidote to the short-termism and self-interest that is now so prevalent across the world.

As G20 president, the decisions SA takes at home will be reflected worldwide. The time is therefore right to finalise the implementation of the National Health Insurance (NHI) Act to deliver high-quality, affordable health care to all South Africans.

SA spends 8.3% of GDP on health care, but about half of these resources are spent through inefficient private insurance schemes. These cater for only 16% of the people, who tend to be better off. About 72% of SA’s white population belong to one of these schemes compared to only 10% of the black population. 

Mandela launched universal free health care for young children and pregnant women, but since then the country has yet to make the transition to publicly financed universal health car (UHC) like many of its G20 peers. 

This is neither just nor sustainable. Why should the majority of South Africans be denied the free quality healthcare that citizens of other G20 states take for granted? Universal health coverage is the norm in 16 out of the G20 member states. It is a perfectly feasible goal for a country at SA’s income level, but can only be achieved through a publicly financed health system and sustained political will. 

Five years ago, I visited SA to lend The Elders’ support to the NHI Bill then going through parliament. Together with Ricardo Lagos, the former President of Chile, I met President Cyril Ramaphosa, MPs, doctors and nurses to learn about the challenges they faced and offer advice based on our experience of public health policy at a national and international level. 

SA has already demonstrated considerable international leadership in its efforts to improve equity and solidarity in preparing for and tackling pandemics after Covid-19, for example in securing the first ever UN General Assembly high-level meeting on the topic in September 2023. 

Now is the time to complement this international leadership with national drive and ambition, and fully implement the NHI Act that was signed into law by Ramaphosa in May 2024. 

To those who say that the current economic situation in SA makes this unaffordable or unrealistic, I would answer that many countries around the world — including my own, Norway, after the devastation of World War 2 — introduced UHC reforms as a means of national renewal. 

It is striking how many G20 nations launched their publicly financed UHC systems in the aftermath of crises, demonstrating that UHC reforms are possible, even in difficult economic times. Examples include China, the UK, France, Japan and Turkey. Outgoing G20 presidency Brazil launched its successful UHC reforms in 1988 as the country made the transition from being a dictatorship to a thriving democracy.

The only high-income country in the G20 not to achieve UHC is the US, which spends an astonishing 18% of its GDP on its health system but where — ironically — 10% of its population lack effective health insurance coverage. Despite this huge expense, the US often demonstrates very poor health outcomes, including the highest maternal mortality ratio in the OECD. 

In the G20, the US and SA are outliers in having such a high proportion (roughly 50%) of funding for their health systems coming from private health insurance. 

As a former prime minister and director-general of the World Health Organisation, I have no illusions about the difficulty of launching and sustaining UHC reforms. Based on my many visits to SA over the decades, I am well aware of the technical and political challenges faced by leaders in creating an equitable health system. And I am not in the slightest bit surprised that many of the same vested interest groups that want to perpetuate a privately financed health system in the US are also opposing the NHI Act in SA.

Private health insurance groups and their allies in the pharmaceuticals industry and some sectors of the medical profession have consistently opposed UHC reforms in every major country since 1945. Yet their prophecies of doom have largely come to naught, and public health systems have proven extremely popular with electorates and are now anchored in the social fabric of most G20 nations. 

To truly implement UHC, SA will of course need to improve the efficiency of healthcare spending, strengthen procurement systems and tackle corruption throughout the health sector.

But I am convinced that all this is possible. With sufficient political will, the NHI reforms can play a key role in cementing SA’s national unity and international leadership in the year of its G20 presidency. 

^•Brundtland, a founding member of The Elders, is a former World Health Organisation director-general.