In South Africa, the National Health Insurance (NHI) Fund is the vehicle through which UHC will be implemented. President Cyril Ramaphosa signed the NHI into law in May.

And almost immediately there were threats of court challenges with the constitutionality of the Act being questioned in various quarters of society – including political parties that are part of the Government of National Unity (GNU). 

It’s been said that the implementation of the NHI would be phased in over several years. But it’s not clear what the next steps towards this ideal will be, despite the recent announcement of the Cabinet. 

Health-e News speaks with Kaymarlin Govender, Research Director, HEARD, at the University KwaZulu-Natal, who explains the pivotal role of social determinants in influencing health. 

What are the social determinants of health?

Health, in any country, is located within its political economy. It relates to historical injustices, racial and gender discrimination, economic disparities, inadequate infrastructure, and income inequality. These issues shape the determinants of disease, access to healthcare, quality of services, and our overall well-being. In South Africa, our health and well-being are affected by multiple and intersecting factors linked to our history and current circumstances. This is very apparent in our fragmented healthcare services, where an ailing public health system caters for about 84% of the population, and a private healthcare system that covers about 16% of the population. 

Health care in South Africa, progress, amidst persistent challenges 

Despite the longstanding and historical disparities in our health system, we have come some way in trying to address the challenges in accessing health care in the face of some major and persistent obstacles. 

Post 1994, South Africa prioritised the expansion of primary health care (PHC) through using a decentralised governance approach via the district health system and the implementation of community-based health services, prevention, and health promotion. This has been a significant mark in the trajectory of health care in South Africa. But PHC has faced significant challenges since then. This includes, among other things, a high disease burden in geographical localities, inadequate access and coverage of PHC services, as well as limited governance and management capacity, and weakened health infrastructure. The COVID-19 pandemic has posed a significant challenge to South Africa’s health system, which was not adequately prepared to handle the scale and complexity of the crisis. The health system response included the availability of telephone consultations, re-purposing of available services, establishment of isolation centres, and provisions of COVID-19 guidelines in some settings. But the negative impact on the country’s healthcare infrastructure and service delivery has been substantial. 

Another big moment was the rollout of the antiretroviral (ARV) programme. Despite growing demand for ARV treatment in the 1990s, the South African government only began the roll-out of ARVs in the early 2000s. The delay in the provision of ARVs can be attributed to the lack of political leadership, the politicisation of HIV/AIDS and the spread of disinformation regarding the efficacy of ARVs. The Treatment Action Campaign (TAC) and its partners – through lobbying and advocacy, taking legal action, challenging the government’s stance on AIDS denialism, and stepping up treatment literacy – played a crucial role in pressuring the South African government to provide access to ARV treatment in the public health system in the early 2000s. The roll-out of HIV treatment, through these efforts, gained significant momentum in the mid to later 2000s. 

Today South Africa has the largest antiretroviral treatment (ART) programme in the world with domestic funding to counter the epidemic being above 70% of the country’s HIV response, an unparalleled commitment in sub-Saharan Africa. Alongside the massive scale-up of ARV access, South Africa has also seen a plateauing of the HIV epidemic in recent years. However, social and structural factors are major challenges in reducing HIV incidence. For example, issues like harmful gender norms, sexual violence, and age-disparate relationships, which drive HIV transmission, are rooted in broader socioeconomic inequities and power imbalances.

What needs to happen for policies to translate into better health outcomes?

The NHI represents a critical milestone in South Africa’s journey towards achieving UHC. The NHI aims to provide all South Africans with access to quality, affordable healthcare, regardless of their socioeconomic status. However, there are diverse views on whether the NHI will achieve its intended goals. Forging the path to achieving UHC will require careful navigation by the new government of national unity of the benefits and risks associated with implementing the NHI. In addressing the social determinants of health, there are some areas for consideration to bear in mind.

1. Reduce financial hardships: Poverty, lack of economic opportunities, and poor living conditions are major determinants of ill-health in South Africa. While there are social assistance programmes like child support grants, old age pensions, and disability grants that provide direct cash transfers to vulnerable populations, many people (especially unemployed youth) fall through the social protection nets. A universal basic income grant is one poverty alleviation option (with positive outcomes in countries like Brazil, Namibia, and Kenya). While the current social relief of distress grant (now seen as a proxy for a basic income grant) will extend to 2025, better fiscal planning is needed to sustain this for the medium to longer term.  

2. Tackle discrimination and marginalisation: Tackling these historical and structural injustices is essential for promoting health equity. People living with HIV, sex workers, people addicted to drugs and members of the LGBTQIA+ community often face challenges when interacting with health services. They face poor treatment, and even discrimination and hostility, which have discouraged them from getting and seeking anti-retroviral treatment and other health services. 

More investments are needed in the public sector to improve the quality of HIV and TB services provided through our community-led clinic monitoring system (see for example, Ritshidze project which is being rolled out in hundreds of primary healthcare facilities across the country to improve quality of HIV and TB services.) 

3. Strengthen primary healthcare: The weaknesses in South Africa’s PHC system, including inadequate access, coverage and quality of services, have hindered progress. The NHI intends to expand primary healthcare to all. Key areas to focus on are: improving access (catering for a higher volume of people, for people who are mobile, convenient times for those working and the sick), offering a better quality of care through expanding family-orientated physicians that can bring additional clinical skills, commitment to person-centred care, clinical leadership and improvement to the quality of care, improving patient-provider relations, and proactive/outreach community-oriented care to prevent disease, promote health and identify people at risk. 

More generally, effective implementation of UHC with a social determinants emphasis requires coordinated action across different government sectors (e.g. health, education, housing, social welfare) and engagement with civil society. Fostering effective intersectoral partnerships and governance is key. Community participation, ownership and leadership in health initiatives is vital for ensuring interventions are responsive to local needs and contexts. Empowering marginalised communities to advocate for their health rights is crucial. Further robust data collection, monitoring, and evaluation systems are needed to track progress in addressing social determinants and hold stakeholders accountable.

Tackling the social determinants of health in South Africa requires a comprehensive, equity-focused approach that addresses structural inequities, strengthens primary healthcare, promotes multisectoral collaboration, empowers communities, and ensures rigorous monitoring and accountability. This is essential for achieving sustainable improvements in population health. – Health-e News