Kuku Voyi: Pandemic presents SA with an opportunity to design responsive NHI

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Nurses in the isolation unit at Tygerberg Hospital in the Western Cape on 11 March 2020.
Nurses in the isolation unit at Tygerberg Hospital in the Western Cape on 11 March 2020.
Gallo Images, Misha Jordaan

Covid-19 has shown that health insecurity affects everyone. As a country, we have an opportunity to put in place all the resources aimed at designing an NHI that will work for all South Africans, writes Kuku Voyi.


No country can be spared from the disruption to its economic, social and political systems, resulting in increased morbidity and mortality during a pandemic.

However, the degree of preparedness determines the extent of the impact.

Hence, the response to pandemics are global; pandemics expose the resilience of public health systems worldwide.

South Africa is part of the global system and, therefore, is not spared from the impact.

The South African health system is exposed to the novel coronavirus - and, globally, scientists and clinicians learn as the Covid-19 disease evolves.

The South African response to the current pandemic should be seen within the context of the World Health Organisation's (WHO) six "building blocks" of a health system - namely, leadership and governance, health workforce, health information systems, financing, access to essential medical products and technologies and service delivery.

These building blocks are inter-disciplinary, which highlight the challenges faced by public health systems.

All six building blocks need to function and interlink to get closer to an ideal health system, which is based on human rights and justice.

South Africa is at an advanced stage towards a National Health Insurance (NHI), an implementing tool for universal health coverage (UHC).

For a country to meet the requirements of UHC for its population, it means that all individuals and communities will receive the full spectrum of essential health services they need, without suffering financial hardship.

In addition to a local UHC, the goal of global public health security is to collectively partake in international public health actions that can build a safer future for humanity.

Urgent action on strengthening systems needed

South Africa was spared from the adverse impact during the Influenza A (H1N1) 2009.

After the last episode of a pandemic, Influenza A (H1N1) 2009, the WHO instituted a performance review which was to inform the progress towards strengthening member states' response to future pandemics.

A voluntary, collaborative and multi-sectoral global public health system of peer review, the joint external evaluation (JEE) was put in place. South Africa was peer reviewed in 2017 and the report published in 2018.

President Cyril Ramaphosa asked that South African

Health Minister Zweli Mkhize. (@Dirco_ZA/Twitter)

The review assessed South Africa's capacity to prevent, detect and rapidly respond to public health risks occurring naturally or due to deliberate or accidental events.

The review happened in the middle of the National Public Health Institute of South Africa (NAPHISA) Bill. As such, the report was based on the progress made towards NAPHISA.

The review report concluded: "In two instances, legislation on areas related to International Health Regulations (IHR) and health security is pending in parliament, which shows South Africa's commitment to the IHR 2005 and health security: the IHR Bill 2013, and the NAPHISA Bill."

Once these bills are passed by parliament, they will form the foundation for the enabling environment for the implementation of the IHR by South Africa.

There is, therefore, an urgent need to fast track the enactment of these bills. The Covid-19 pandemic happened less than two years after the report.

This pandemic reached South Africa at the time that the country faced a quadruple burden of disease, a consequence of social, economic, health and health system factors.

This burden impacts negatively on the economy and consumes health and social resources.

While disease levels are driven by the social determinants of health and weaknesses in health and social systems, there have been a number of significant improvements since democracy, including a number of health system strengthening interventions, albeit unequal.

This virus, by nature, is not discriminating. In South Africa, it managed to break the cycle of structural disadvantage that exacerbates health inequities.

Additionally, it challenged and exposed the gaps between rich and poor within the country and put the health system under enormous pressure.

'Death rate manageable'

Global models show that the death rate is an indicator of how overloaded healthcare is. The capacity of healthcare should be derived from the size of the country.

The death rate in South Africa is manageable.

Others may argue that we should be in a position to respond to this pandemic as we have experience with HIV, but the two viruses - SARS-Cov-2 and HIV - are different.

The South African response had all the components of a pandemic response, and the country is participating with confidence in all global aspects of the pandemic.

When called to act, the country was ready and prepared to respond collectively in the face of threats to global health security.

Internally, however, the scramble to gather the best technical support, relevant stakeholders in all sectors, and to mobilise the necessary resources was a strain, but was relatively easily achieved.

Covid-19 has shown that health insecurity affects everyone. As a country, we have an opportunity to put in place all the resources aimed at designing an NHI that will work for all South Africans and meet the objectives of access to healthcare, regardless of social status.

South Africa is currently the chair of the African Union, which is an opportunity to unite and strengthen the region's Integrated Disease Surveillance and Response (IDSR).

The WHO states that "an optimal target for surveillance is one trained field epidemiologist per 200 000 population".

Disease surveillance is a cornerstone of a strong health system.

The NAPHISA bill needs to be passed by Parliament to be activated, as reported in the 2018 JEE report.

Success in battling Covid-19 thanks to teamwork

The success in managing the pandemic in South Africa is borne out of teamwork from all sectors.

Differences were set aside as the country focused on one enemy - the SARS-Cov-2 virus that causes Covid-19.

The involvement of the community, academics, scientists and clinicians made it possible and I hope we will continue as we move from one level of lockdown to the next.

The political will and leadership from the executive, and their willingness to listen to scientists and clinicians made learning about the disease as we go palatable.

The Gauteng government deployed a team of health w


The Gauteng government deployed a team of health workers to the Stjwetla informal settlement to test people for Covid-19. (Alet Pretorius/Gallo Images)


However, the most important lesson learnt from previous outbreaks was the need to strengthen infection control programmes globally - because protecting health workers is of paramount importance.

We struggled and faltered with this, which is one of the six building blocks of a public health system. The WHO emphasises protection of workers to be of utmost importance.

In conclusion, universal health coverage and health security are two sides of the same coin: improved access to healthcare and strengthened health systems provide a strong defence against emerging threats, whether natural or man-made.

As the WHO states, pandemics, health emergencies and weak health systems not only cost lives but pose some of the greatest risks to the global economy and security faced today.

In the global public health system, every country has the responsibility to keep its population healthy and safe.

The South Africa we want is a global partner, but also locally relevant to its population's health and welfare.

- Professor Kuku Voyi is academic chairperson of the School of Health Systems and Public Health at the University of Pretoria.

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