Can Universal Health Coverage Exist In South Africa?

The first point of discussion regarding universal healthcare in South Africa, is whether the country is able to achieve universal healthcare at present or not. Although everyone could just be given healthcare for free, this does not truly answer the question. Universal healthcare is not just a matter of everyone receiving healthcare, but more so a matter of everyone receiving and being able to access adequate healthcare from a high-quality health system. In other words, the true question is if South Africa currently has the means to provide a high-quality health system for all its citizens.

South Africa has both a public and private health system. While the private side of the dual health system checks many of the boxes in the criteria for a good health system, it fails in equitability and accessibility, which means that most South Africans, in a country with immense inequality and poverty cannot access it.

The issue with accessibility lies in the fact that majority of South Africans have to use public transport (45.2%) or walk (37%) to seek health services (Harris et al., 2011). This is an important thing to consider when discussing the accessibility of private healthcare, as private healthcare institutions are far more concentrated in more developed, or wealthier areas (Lifehealthcare.co.za, 2024), which are the areas where the minority of the population, who are also likely to be using private means of transport are located. Approximately 54% of people used public health institutions because it was closer in distance (Harris et al., 2011). On a financial equitability level, more than half of people who used public hospitals were recorded to have done so due to the financial aspect of not needing to pay for their healthcare (Harris et al., 2011).

On the other hand, public healthcare seems to have all the opposite problems. While being logistically accessible and financially equitable, these institutions lack in service delivery aspects. South African public health institutions are well-known to be of poor quality due to ineffectiveness, inefficiency, and lack of patient safety. One study in the Free State stated that public health facilities in the region experienced many challenges, including poor services, staff shortage, and financial problems (Malakoane et al., 2020). Recently a video went viral on social media and made the headlines, showing the experiences of a patient at the Helen Joseph Public Hospital, a teaching hospital based in Auckland Park. The patient filmed and complained about the horrors of the patient experience at a public hospital. The patient claimed that staff showed negligence for patient wellbeing and safety, that the facilities were poorly maintained and unhygienic, and that the overall service was completely ineffective and damaging to patient wellbeing (Luvhengo, 2024). While this is just one example of a public hospital, it highlighted the average experience of a patient seeking public heath care in South Africa.

An important caveat here is the competition for experienced human resources between public and private health systems (Savas, 1981). Private health institutions are able offer far more enticing employment opportunities for highly skilled health workers due to better salaries and job security. This consideration brings light to the fact that either the public and private sector need to collaborate in some way, or there needs to be a single sector that brings the best of both sectors. The private sector needs to become more financially equitable and accessible to all citizens, which requires resources to be sustainable, as the private sector is able to achieve its high standard of care through income from patients. The public sector needs to be improved in most aspects of quality, to deliver better health outcomes to patients, which also requires resources to have and keep good quality workers and to develop and maintain infrastructure that is able to support quality care.

The question then becomes: does South Africa has the resources to sustainably create a system that can fuse the best parts of both sectors? According to SARS (The South African Revenue Service), South Africa collected R2.155 trillion in taxes in the 2023/2024 fiscal year (SAnews, 2024). R272 billion of this went to the health budget the following year (Standard Bank, n.d.). Comparatively, the UK spends about R4 trillion on the NHS per year (The King's Fund, 2023). After comparing South Africa’s yearly spend on healthcare with a healthcare system that services a smaller population, it is clear that South Africa is relatively far behind the mark in resource allocation to healthcare. South Africa’s total tax collection does not even equal the NHS’s usual budget. This shows that currently, South Africa does not have the resources to sustainably fund a top-quality healthcare system. Another caveat is the vast inequality in South Africa. A single percentile of South Africans own 90-95% of the country’s wealth, and a single percent of South Africans own over half of its wealth (Orthofer, 2016). Most of this wealth is hoarded and never even made of use. If this top percentile was to be taxed more heavily, significantly more taxation could be collected. Although this increase still would not be enough to support a high-quality health system, it is important to note that, as earlier mentioned, the goal is not to recreate the NHS, but rather to combine public and private health. This would create equitability instead of equality, which is far more sustainable, as those who do not need support would still be sustaining such a health system. This is similar to how the proposed National Health Insurance needs extra taxation to work. In the NHI, extra health taxation would form as a national health insurance for all to be distributed to those who need it.

In summary, South Africa might not currently have the means to sustainably support a health system that fits the formerly mentioned definition of a high-quality health system without key policy changes.