The world is facing a global health crisis characterised by growing inequities within and among nations and millions of preventable deaths, especially among the poor. These are in large degree due to unfair economic structures which lock people into poverty and poor health. In 2000, concerned activists, academics and health workers got together for the first People’s Health Assembly and founded the People’s Health Movement (PHM), a global network bringing together grassroots health activists, civil society organisations and academic institutions from around the world, particularly from low and middle income countries. Their third assembly took place in Cape Town this year. Amandla! talks to David Sanders about the state of global health inequities and South Africa’s National Health Insurance scheme and Dr. Chris Hani from the Egyptian chapter of the PHM. David Sanders, Emeritus Professor and founding Director of the School of Public Health at the University of the Western Cape, South Africa, is a past chairperson of Peoples Health Movement (PHM) South Africa and on PHM’s global governing structure.
A!: What are some of the key issues and resolutions that came out of the People’s Health Assembly?
David Sanders: One, we reaffirmed our commitment to a health system which is equitable, acceptable, free at the point of care and, people-centred. We acknowledged that social determinants of ill-health remain even more stark given the current global economic situation. We remain opposed to neoliberal globalisation and the way that it impacts on health, both via its effects on social determinants of health and inequality, and in the way that it’s reproduced within the health sector by commercialisation and privatisation and the growth of public-private partnerships.
We recognised that the governance of global health is changing, so that the World Health Organization is no longer really the only institution shaping global health policies. Private organisations like the Gates Foundation are increasingly active and contribute more to global health financially than WHO does itself.
Secondly, we reaffirmed our support for our current major programmes: Global Health Watch, an international health publication, for our cadre training school, the International People’s Health University, and for our commitment to the Right to Health Campaign which takes different forms in different countries. In South Africa, the Right to Health Campaign is really centring on the NHI.
Food sovereignty and security was an extremely salient issue: it’s clearly becoming a bigger problem for global health. Both the problem of food scarcity, hunger and malnutrition, but also the other side of that coin, which is the increasing domination of the food market by transnationals which is leading to epidemics of obesity and diabetes, and so on, which we see here in South Africa.
The extractive industry was also heavily discussed in quite a prophetic way, with many participants from different continents raising the viciousness and health-damaging effects of the mining industry.
A!: How does the PHM address the NHI in South Africa?
DS: At the National Health Assembly we had quite a lot of discussion about the NHI. It’s clear that the understanding of the NHI is at a very low level. The PHM is committed to trying to improve this through publishing material, holding public meetings and through a coalition that we’ve established with other civil society organisations to raise, especially at community level, what an NHI could mean.
Many concerns were expressed about the dangers of an NHI being captured by the private sector. The Green Paper shows that the government is envisaging certain public-private partnerships around hospitals and that private sector facilities and providers will be accredited to the NHI. This means that public money will buy services from private practitioners and facilities, which is fine, except that those facilities don’t exist in poor areas and especially in the rural areas of this country. So if that happens we could see the inequities remaining or even getting worse.
There is general support for an NHI which would protect everyone from healthcare expenditure – but it’s not a new health system. The extent to which this kind of mechanism, pulling together more financial resources, can make healthcare delivery in the country more equitable, acceptable, appropriate, and so on, depends not only on the NHI, but on the resources made available. It depends on having sufficient health personnel in the right places with sufficient skills. It depends on good referral systems, which raises the issue of transport for poor people who live on the periphery, on farms.
The whole orientation of the private sector is very concerning because the private sector is into high tech specialist medicine, which is needed in some cases, but actually most of our health problems could be resolved by improving social determinants, and also providing basic but good care – and that’s not what the private sector mostly does.
These are the things that concern us and it is worrisome that they haven’t really been at the forefront of discussion on the NHI, especially from the trade unions who seem to think they’re getting a national health service like in the UK, or what the UK used to have.
A!: The public is receiving little or no information on progress with the NHI. What do you think needs to happen in order for things to start moving? Is the NHI realistic?
DS: We don’t know how or whether it’s moving because it’s all taking place behind closed doors. So one of the things that the National Health Assembly called for is greater transparency – what is going on?
There are lots of unanswered questions. We don’t know what the package of services that are provided under an NHI will include? Will it be comprehensive, or will it be a very slim package so that to get, for example, dental care or eye treatment, you will have to pay privately? We don’t know, we’ve just got no idea.
Secondly, we want to know more about the process of accreditation of facilities to be registered as suppliers to the NHI. What will protect the poorer regions of the country – because you could have a situation where all the already good facilities, many of which are private, get accredited, but you don’t get accreditation of poor facilities, which will just aggravate inequalities.
A!: After the COSATU Congress, some were calling for a ‘Lula moment’. Looking at the changes carried out by the former Brazilian president, can South Africa learn any lessons about achieving universal healthcare?
DS: Definitely. The two big policy ideas now are the NHI and re-engineering primary healthcare. Primary healthcare is the kind of healthcare that happens in districts, which means from small hospitals downwards. Small hospitals, health centres, clinics and community level.
There’s a big initiative going on about that in South Africa, which is very much influenced by the the family health programme, the centrepiece of the Brazilian model. This is good, we like it, but we have some concerns – Brazil invested very heavily in this programme, especially in introducing the personnel, the human resources, who could work well in that system. They greatly increased the number and the output of their training institutions: medical schools, nursing schools, schools of public health, and so on. We haven’t done that in South Africa. So where are our people going to come from with the right skills?
Secondly, in Brazil the health reforms are just one part of a much larger set of reforms, for example the conditional cash grant known as the Bolsa Familia. We have got grants like the child support grant, but they’re not as generous as Bolsa Familia is.
And then lastly — and perhaps most important — in Brazil they have greatly improved social determinants. If you look at what’s happened to education and literacy, to water provision, to sanitation, they have effective programmes. They focus on the key social determinants, not necessarily from a health perspective. They’ve pushed ahead with those reforms and we aren’t getting close to that.
So there’s a tendency to kind of extract from Brazil’s Family Health Programme and to think, okay, we can just implement that in South Africa without all of the other investments and reforms that have led to improve health in Brazil.