“ ….. you can have the nicest of Constitutions on paper. If it doesn't relate to reality then there are difficulties…one can't speak of a person’s dignity when that person is living in squalor and that person can't have access to facilities, medical facilities, and it is for that reason I presume that we have in our Constitution … socio-economic rights.”

- Interview with Justice Skweyiya, Constitutional Court, October 2003

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The Right to Health: Rights and responsibilities –

developments in health policy (incl NHI)

Free State Consultative Workshop6-8 June 2011

- Elroy Paulus (Black Sash)

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Current Context and Recent Policy Developments

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Interrelationship across the Health Sector Negotiated Service Delivery Agreement, the 10 Point Plan and the

National Health Insurance

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Health Sector 10 point Plan NSDA

A LONG & HEALTHY LIFE FOR ALL

SOUTH AFRICANS

Defined TargetsDefined

Timeframes & critical milestonesNHI

Human Rights?Legitimate and valid demands or claims on society – claims are for:

• Social and material resources,• Respect, tolerance• At core - respect for human dignity• Represent some fundamental need• General or universal• “ … in some sense equally possessed by all human beings

everywhere..”• Inherent - exist by virtue of being human

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International Law and Health• 1948 Universal Declaration of Human Rights• unanimously proclaimed by the UN General Assembly

as a common standard for all humanity• The Declaration sets forth the right to a “standard of

living adequate for the health and wellbeing• of himself and his family, • including . . . medical care and . . . the right to security in

the event of . . . sickness, disability• . . . or other lack of livelihood in circumstances beyond

his control.”

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International Law and Health • The Declaration does not define the components of

a right to health; however, they both include and transcend medical care.

• The right to health was included in the International Covenant on Economic, Social and Cultural Rights (ICESCR).

• Article 12 of the ICESCR explicitly sets out a right to health and defines steps that states should take to “realize progressively” “to the maximum available resources” the “highest attainable standard of health” 8

What does it mean to have a right?

• Rights imply a claim; more than charity• For every right corresponding duty bearer• Usually duty bearer = government• With rights go responsibilities e.g. Cannot

enjoy right to health care if you target a clinic for crime

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How is govt obligated?

• If govt ratifies a treaty or has a Bill of Rights, it must• – Pass laws• – Budget for implementation• – Put in place programmes

4 obligations To respect rights:- • Refrain from actively violating your right• Through laws, policies• To protect your rights from third parties• To fulfill right through active programmes, resources, etc.• To promote rights: Knowledge, opportunities to use rights

machinery, Chapter 9 Institutions10

Rights and Civil Society Action

• Rights are not just about the law• A human rights approach can:

– Hold govt accountable– Shape policy– Get redress for violations– Build civil society mobilisation

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Health as Human Right in SA• Access to health care services• Emergency treatment; reproductive health care• Right to Life• Safe, healthy environment• Access to adequate housing• Access to sufficient food and water• Bodily integrity; freedom and security of person• Children - basic nutrition & health care services, shelter• Dignity, equality, non-discrimination• Access to information

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Health and the Constitution(check with in in your Constitution p.13)

27. Health care, food, water and social security

(1) Everyone has the right to have access to - (a) health care services, including reproductive health care; (b) sufficient food and water; and (c) social security, including, if they are unable to support themselves and their dependants, appropriate social assistance (2) The state must take reasonable legislative and other measures, within it’s available resources, to achieve the progressive realisaiion of each of these rights.

(3) No one may be refused emergency medical treatment.

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Social Determinants of Health

Social Determinants of Health

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Vulnerable communities and social determinants of Health in SA

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Progressive realisation

• Not possible to provide all forms of health care• Resources are limited• So rationing decisions are permitted, but:

– Must be transparent – Must be based on evidence – Cannot be unreasonable or arbitrary• Even if unable to afford now, must show how state will provide in future, over time

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Policy Developments• Department of Health Strategic Plan 2006/07 to 2008/09 - Some

elements of the Strategic Framework (5 years) • “ We will introduce a National Health Insurance scheme in a phased

and incremental manner. ...to initiate the NHI, the urgent rehabilitation of public hospitals will be undertaken through Public-Private Partnerships - State of the Nation Address by President J G Zuma (3 June 2009)

“ We have made it clear that our POA is being implemented within the context of the National Health Insurance (NHI). A major aspect of this policy direction is the need to create a national health insurance that is based on the principles of universal coverage, social solidarity and efficient of public administration - late Deputy Minister of Health, Dr Molefi Sefularo (2 September 2009)

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Policy Developments

• THE 10 POINT PLAN OF THE HEALTH SECTOR 2009-2014 - DEBATE ON THE HEALTH BUDGET VOTE, SPEECH BY DR AARON MOTSOALEDI MP – MINISTER OF HEALTH, NATIONAL ASSEMBLY 13 APRIL 2010

“.....second year of implementation of our 10 Point Programme for transforming the health sector into a well functioning health system capable of producing improved health outcomes. To refresh the memories of Honourable Members”....

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Policy Developments“.......the 10 Point Programme consists of the following priorities:(i) Provision of Strategic leadership and creation of a social compact for better health outcomes;(ii) Implementation of National Health Insurance (NHI);(iii) Improving Quality of Health Services;(iv) Overhauling the health care system and improving its management;(v) Improved Human Resources Planning, Development and Management;(vi) Revitalization of infrastructure;(vii) Accelerated implementation of the HIV and AIDS and STI National Strategic Plan 2007- 2011, and increased focus on TB and other communicable diseases;(viii) Mass mobilisation for better health for the population;(ix) Review of the Drug Policy; and(x) Strengthen Research and Development.

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Recent NHI developments

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Quick guide to an NHI (ANC NGC Discussion Doc): (21 Sept 2010) – a mere 9 months ago • Founded on principles of the right to health care,

universal coverage, social solidarity and public administration, in which access to health care will be based on need, not only ones ability to pay.

 • Free at point of service as it is prepaid through

mandatory tax contributions and general tax.

• A universal system covering everyone, irrespective of whether one is employed or not.

Quick guide to an NHI - continued

• Inclusive of all South African citizens will be under a single publicly funded and publicly administered national health insurance rather than two-tier system

• An integrated system in which health care services are delivered by accredited public and private sector.

• Based on quality and affordable facilities that meet criteria for quality and cost and need

• Patients will have a choice within the district on where they can register for health care

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Key Proposals of NHI

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• Founded on the principles of the right to health care, universal coverage, social solidarity and single public administration in which access to health will be based on need(and therefore ensuring universal free access to health care, at the point of service, to all South Africans) rather than ability to pay.

• A publicly and publicly administered NHI Fund – operating like SARS and situated within the Ministry of Health - will be created to receive to receive funds through a single-payer system.

• This refers to one entity acting as administrator, or “payer”, set up by the government to receive all health care funds, and pay out all health care costs for all South African citizens and legal residents through a single “insurance pool”.

Key Proposals (contd.)

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• NHI Fund will provide a comprehensive cover of health services primary, secondary, tertiary and quarternary (high-care services) which will be provided by accredited public and private providers to ensure quality health care standards.

 • At the core of NHI would be primary health care, which is the

first point of entry into the health system. The report foresees a “reengineered primary health-care system”, served by teams, each consisting of a doctor or clinical associate, a nurse and three to four community health workers.

 • Membership to the NHI would be compulsory for the whole

population, but the public can choose whether to continue with voluntary medical scheme cover.

Funding and funding sources

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• Liaison with national treasury to explore NHI funding and various sources of revenue.

•Funding methods include a surcharge on taxable income, payroll

taxes (for employees and/or employers) and an increase in value added tax which is earmarked for the NHI.

•Main sources of revenue for the NHI Fund : allocations from general taxation. All of these funds will be combined in the NHI Fund, from which all services covered by the NHI system will be funded.

•Preliminary costs Increase from R128 billion in 2012 R 267 billion in 2020 R376 billion in 2025, expressed in current financial terms (real terms).

Funding and funding sources

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•The budget for 2010/11 was R107 billion, the current budget is R115 billion and increases to R122 billion in 2012/13.*

• Over R200 billion (public and private) spent on health

services in South Africa in 2010. The NHI will provide comprehensive quality health care at less than the current spending by the public and private health sectors.  

• The costing sub-committee’s preliminary findings suggest that the health sector’s share of the overall government budget will need to increase from 12% to 14.5%.* Budget Review 2010 - Chapter 7

Proposed process for NHI

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• Will kick off with wide consultations with all interested parties review of the current legislation and the drafting of new legislation to facilitate the NHI system.

 • Implementation : phased in over 14 years roll out will

start in 2012 in the seriously underserved areas where people have difficulty accessing health care.

 At same time : various mechanisms will be put in place to revitalise the public health infrastructure, the introduction of quality improvement and assurance programmes, and the development of human resource programmes.

Legislative processes (2010-2011)• 2010/11 - draft national health insurance policy proposal

document submitted to Cabinet for consideration, after which an interministerial committee was established.

• A revised policy document has been developed and will be resubmitted to Cabinet in 2011/12.

• The department is also in the process of preparing enabling legislation for establishing the National Health Insurance Fund, to be submitted to Cabinet before December 2011.

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• Amartya Sen (1999): “... the issue of social allocation of economic resources cannot be separated from the role of participatory politics and the reach of informed public discussion. ...If it is the doctor or the schoolteacher or the nurse who feels more threatened by resource considerations than the military leaders, then the blame must lie partly on us, the public, for letting the militarist get away with these odd priorities. Ultimately, there is nothing as important as informed public discussion ... The public has to see itself not merely as a patient, but also as an agent of change. The penalty of inaction and apathy can be illness and death...”

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To conclude....

"The day will come when nations will be judged not by military or economic strength, nor by the splendour of their capital cities and public buildings, but by the well-being of their people: by, among other things, their opportunities to earn a fair reward for their labour, their ability to participate in the decisions that affect their lives; by the respect that is shown for their civil and political liberties; by the provision that is made for those who are vulnerable and disadvantaged“

- UNICEF Progress of Nations Report (1998)

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