Hu­man cap­i­tal is a coun­try’s best in­vest­ment

Pretoria News - - OPINION - YOGAN PIL­LAY Pil­lay is the deputy di­rec­tor-gen­eral in the Na­tional Depart­ment of Health and at­tended the 2030 UHC Fo­rum in Tokyo last month. He writes in his per­sonal ca­pac­ity

THE RE­CENTLY pub­lished World Bank and World Health Or­gan­i­sa­tion (WHO) re­port on progress to­wards uni­ver­sal health cov­er­age sug­gests South Africa is on its way to­wards achiev­ing it, with its Na­tional Health In­sur­ance scheme.

The coun­try scored 67 out of a pos­si­ble 100. Scan­di­navia, the UK, and the US re­ceived scores of greater than 80.

To un­der­stand the scores, the in­puts used to gen­er­ate them need to be re­viewed.

The au­thors used nine vari­ables to com­pute the scores for each coun­try: san­i­ta­tion (at least ba­sic); hy­per­ten­sion con­trol; to­bacco con­trol; in­sec­ti­cide treated nets (which we don’t pro­vide, de­fault­ing to in­door-resid­ual spray­ing); fam­ily plan­ning; an­te­na­tal care (four­plus vis­its); im­mu­ni­sa­tion cov­er­age; HIV treat­ment; and TB treat­ment.

It is sur­pris­ing that none of these vari­ables re­flects on ei­ther fi­nanc­ing avail­able and af­ford­abil­ity or avail­abil­ity of health work­ers – which are of­ten raised as ob­sta­cles to the im­ple­men­ta­tion of uni­ver­sal health cov­er­age (UHC).

While ac­knowl­edg­ing that find­ing ways to score coun­tries and that the at­tempt by the bank and WHO is a brave first at­tempt, the vari­ables used and the qual­ity of the data could be con­tested.

As Ja­pan’s ex­pe­ri­ence il­lus­trates, in­vest­ing in hu­man cap­i­tal through the pro­vi­sion of ed­u­ca­tion and health ser­vices is a good buy – bet­ter than in­vest­ing in in­fras­truc­ture.

Two re­cent pa­pers in the Lancet by Prime Min­is­ter Shinzo Abe and Deputy Prime Min­is­ter and Min­is­ter of Fi­nance Taro Aso show its suc­cess as an in­dus­tri­alised coun­try with lit­tle un­em­ploy­ment af­ter World War II was linked to a de­ci­sion to in­vest in hu­man cap­i­tal.

Also noted is that coun­tries should em­bark on cov­er­age early in their de­vel­op­ment tra­jec­tory, and that it con­trib­uted to so­cial sta­bil­ity and eco­nomic growth.

In­ter­est­ingly, the Chi­nese Com­mu­nist Party re­solved at its 19th na­tional party congress to lift 43 mil­lion peo­ple out of poverty by 2020. One of the in­ter­ven­tions is to pro­vide pro­fes­sional train­ing to en­sure that at least one per­son in ev­ery house­hold is em­ployed as they recog­nise that af­ter train­ing, peo­ple are more likely to find em­ploy­ment.

At the Uni­ver­sal Health Cov­er­age Fo­rum in Tokyo last month, World Bank pres­i­dent Jim Yong Kim sur­prised many when he con­fessed that for years the bank got it wrong when it pro­moted heavy in­vest­ment by coun­tries in in­fras­truc­ture through loans and grants. He said coun­tries should in­vest in its peo­ple – hu­man cap­i­tal.

Ja­pan, fol­lowed by the Asian Tigers (South Korea and Tai­wan) all in­vested heav­ily in ed­u­ca­tion and health to de­velop the po­ten­tial of their cit­i­zens, he said. The bank now pro­motes UHC, be­cause it pro­motes de­vel­op­ment and con­trib­utes to eco­nomic growth.

Sene­gal Pres­i­dent Macky Sall, told the meet­ing, that UHC was also a pre­req­ui­site for peace and se­cu­rity.

Why are these lead­ers fo­cus­ing on what might be termed “so­cial ser­vices”

It is im­moral in the 21st cen­tury that 100 mil­lion peo­ple are driven into poverty be­cause of out-of-pocket health care pay­ments

and what is the jus­ti­fi­ca­tion for this?

One is moral – or based on a hu­man rights ar­gu­ment – that it is im­moral in the 21st cen­tury that 100 mil­lion peo­ple are driven into poverty be­cause of out-of­pocket health care pay­ments.

As WHO di­rec­tor-gen­eral Dr Te­dros Ad­hanom Ghe­breye­sus aptly states, this trans­lates to three peo­ple ev­ery sec­ond be­ing im­pov­er­ished.

In South Africa, es­ti­mates are that the poor­est re­ceive less than 15% of health ben­e­fits but need more than 30%, while the rich­est 20% use al­most 40% of ser­vices against a need 10%.

This level of in­equity can­not con­trib­ute to the de­vel­op­ment of South Africa.

The other rea­son for this fo­cus ap­pears to be a re­al­i­sa­tion that de­vel­op­ment that leaves peo­ple vul­ner­a­ble is not sus­tain­able and does not pro­vide the con­di­tions for peace and sta­bil­ity.

It is in­ter­est­ing that even coun­tries which have reached UHC are in sup­port of the im­per­a­tive that all coun­tries make health the only cri­te­rion for ac­cess to ser­vices, rather than an in­di­vid­ual’s abil­ity to pay. These coun­tries, how­ever, also face the prob­lem of af­ford­abil­ity.

Their chal­lenge, like coun­tries still on the path to uni­ver­sal cov­er­age, is to en­sure that they can af­ford to pro­vide these ser­vices. This has led some to re­vert back to the 1978 Alma Ata Dec­la­ra­tion.

What this means was clearly il­lus­trated by Sin­ga­pore Health Min­is­ter Gan Kim Yong at the fo­rum, with low birth rates and a rapidly age­ing pop­u­la­tion it is look­ing be­yond 2030 (the date by which coun­tries should achieve the sus­tain­able de­vel­op­ment goals). Sin­ga­pore is al­ready chang­ing its fo­cus from health care to health, from qual­ity to value, and from hospi­tal to com­mu­nity.

These changes clearly re­flect a re­turn to the ba­sics.

Next year, we will com­mem­o­rate the 40th an­niver­sary of the dec­la­ra­tion, so a re­turn to its prin­ci­ples may well be op­por­tune.

The sen­ti­ments noted at the fo­rum echo those em­bod­ied in the pre­am­ble to the Alma Alta dec­la­ra­tion. What was right in 1978 is still right to­day.

Let us not wait an­other 40 years to dis­cover what we know. Let’s im­ple­ment the na­tional health in­sur­ance sys­tem, South Africa’s ver­sion of uni­ver­sal health cov­er­age.

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