LETTER: SA is far from delivering universal health coverage

As SA and the world prepare to mark Universal Health Coverage Day on December 12, it is concerning that despite claiming support for universal health coverage, many within the health sector still believe our current system, particularly the private sector, delivers universal health coverage.

The World Health Organisation (WHO) defines universal health coverage as ensuring that “people have access to the health services they need, when and where they need them, without financial hardship”. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care.

Breaking this down into distinct elements, universal health coverage thus comprises:

• Coverage of the entire population, regardless of financial status and ability to pay;
• Financial risk protection through pooling of funds, cross-subsidisation and prepayment mechanisms to reduce co-payments and out-of-pocket payments; and
• A benefits package that consists of a full range of personal health services.

Taking the above into account, the SA private sector cannot be used as a justification upon which to claim universal health coverage is present.

Firstly, access to health services in the private sector is strongly dependent on an individual’s ability to pay for private health insurance or out-of-pocket. This precludes a significant percentage of the population (about 85%) from accessing private care, a proportion that has been stagnant over the last decade and is unlikely to change in the current economic climate.

The private insurance market consists of multiple fragmented risk pools, leading to poor cross-subsidisation, and even where this does occur the subsidisation only occurs from healthy to sick individuals and not from richer to poorer individuals. Furthermore, at an individual level the phenomenon of providers charging more than 100% of medical aid rates either leads to out-of-pocket co-payments or proves to be a deterrent to care seeking.

Finally, even with medical scheme coverage, access to specific personal health services is dependent on scheme and benefit package selection, provider networks — again both of which are dictated by affordability — and whether a patient is charged the prescribed scheme rates.

This not only limits the range of services that are available to a person but also hampers choice of provider, which is an important factor in establishing provider-patient relationships, enhancing patients’ health knowledge and agency, and ultimately health outcomes.

While there is no doubt that the public health sector in SA needs to be optimised with respect to equitable access to health services, quality measures such as waiting times and improved outcomes, it is dangerous to equate costly care with high-quality care, and even more so to equate costly private-health-sector care of variable and largely unknown quality and outcomes with population health strategies aimed at achieving health for all, regardless of socioeconomic status.

Atiya Mosam
Public Health Medicine Specialist

JOIN THE DISCUSSION: Send us an email with your comments to letters@businesslive.co.za. Letters of more than 300 words will be edited for length. Anonymous correspondence will not be published. Writers should include a daytime telephone number.​