Human capital is a country’s best investment
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.