What we need is health system transformation and not health system strengthening for universal health coverage to work: Perspectives from a National Health Insurance pilot site in South Africa.

Janet Michel,Marcel Tanner,Di Mcintyre,Fabrizio Tediosi,Brigit Obrist,David Evans,Till Bärnighausen

doi:10.4102/safp.v62i1.5079

Abstract

BackgroundGlobally, universal health coverage (UHC) has gained traction as a major health priority. In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment. National Health Insurance (NHI) and primary healthcare (PHC) re-engineering were two vehicles chosen to reach UHC over a 14-year period (2012–2026). The first phase of health system strengthening (HSS) initiatives to improve the quality of health services in the public sector began in 2012. These HSS initiatives are still being carried out by the Department of Health in conjunction with other partners.MethodsA qualitative case study design utilising a theory of change (TOC) approach was employed. Data were collected from key informants (n = 71) during three phases: 2011–2012 (contextual mapping), 2013–2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide, adapted for each phase. All interviews were audio-recorded and transcribed verbatim. An iterative, inductive and deductive data analysis approach was utilised. Transcripts were coded with the aid of MAXQDA 2018.ResultsSix broad themes emerged: make PHC work, transform policy development, transform policy implementation, establish public–private partnerships, transform systems and processes and adopt a systems lens.ConclusionA third great transition seems to be sweeping the globe, changing how health systems are organised. Actors in our study have identified this need also. Health system transformation rather than strengthening, they say, is needed to make UHC a reality. Who is listening?

Highlights

Key messages Strong health systems are key to achieve universal health coverage (UHC)
We explored with each participant what had transpired since our last visit and what the participant had achieved in terms of the activities they had planned to carry out
This study revealed that policymakers at provincial level and implementing actors at district, sub-district and facility levels view the way the current health system in South Africa is designed as a hindrance to National Health Insurance (NHI) success and UHC

Summary

Introduction

Key messages Strong health systems are key to achieve universal health coverage (UHC). Universal health coverage has gained traction as a major health priority in many countries.[1] There is recognition of social determinants of health in contributing towards a long healthy life for all.[2] Good health is an essential and indispensable prerequisite for poverty reduction, sustained economic growth and socio-economic development.[2] In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment.[2] Multiple epidemics, powerful historical and social forces such as vast income inequalities, unemployment, poverty, racial and gender discrimination, the migrant labour system and extreme violence shaped the current health system,[2] making it two tiered, public and private, based on socio-economic status, with one for the poor and the other for the rich. Human resources shortages[2,5] and underperforming institutions, as a result of poor management, underfunding and deteriorating infrastructure, further compound the challenges.[2]

Methods

Discussion

Conclusion