Universal coverage at the heart of global health

Interview with Pakishe Aaron Motsoaledi, minister of health, South Africa

As South Africa holds this year’s G20 presidency, health minister Pakishe Aaron Motsoaledi makes the case for universal health coverage as the foundation of equity, security and progress

What are South Africa’s health priorities for its G20 presidency this year?

In our G20 presidency we have five priorities. The first is universal health coverage based on primary health care. Our overall presidency theme is solidarity, equity and sustainability. None of those can be met without universal health coverage, whereby people get good-quality health care free at the point of care and don’t suffer unduly. The second priority is pandemic preparedness and prevention, because we don’t want to repeat what happened during Covid. The third is human resources for health, which can be problematic especially in the Global South, whose doctors go to the Global North. The fourth is the scourge of non-communicable diseases, and number five is science innovation for economic development. 

These five priorities affect each and every country. Let’s take NCDs – no country can claim they are not a problem – even countries in Africa that face constant challenges from infectious diseases. Nor can any claim human resources are not a problem: either the number of trained health workers or the number of those who want to work in public institutions, or in particular regions. On pandemic preparedness and prevention, simply, pandemics don’t know any borders. They can start in one area and spread throughout the whole world. No country can say it is not interested in that.

Universal health coverage is about healthcare financing. Countries may have more money for health, like the United States, but their method of healthcare financing does not help them achieve better outcomes. There are poorer countries, like Cuba, with better outcomes in child and maternal mortality, even overall mortality. That relates to healthcare financing. That’s why every country should look at universal health coverage, where everybody is covered, regardless of their social or economic status.

Science innovation for economic growth also affects every country, especially in this era of artificial intelligence. How do we put that into health care, and how do we increase our research and development? How can innovations – that start from science and technology – help build the economy?

What are South Africa’s greatest successes in health care?

Our biggest achievement ever is increasing life expectancy from 54 years in 2010 to 66 years in 2024, because we put together the world’s biggest HIV counselling, testing and treatment campaign. We have also dramatically reduced maternal mortality: in 2010 there were 240 deaths per 100,000 live births; by March this year we have gone down to 109 per 100,000 live births. In 2004, 70,000 children were born HIV positive; we have reduced that to only 643. 

In 2010, when we planned this programme, there was an argument about how to finance it. Private health care, well funded through medical aid or health insurance, takes care of only 14% of South Africa’s population, who are well to do and employed. The rest pay out of pocket. Some argued we needed to differentiate so people on medical aid pay for themselves. I argued that if you are fighting a huge pandemic and money is a factor, you will not win. Eventually we agreed that whether you are a billionaire or a pauper, employed or unemployed, a public servant or a gardener – if you test for HIV/AIDS it must be free; if you test positive you should receive antiretroviral treatment provided by the state. Let people be equal in fighting that disease. That’s where our success lay. 

And that is why we believe that universal health coverage is very important, because we have seen it in action. If you treat people equally, they all come to access health care. We went to far rural areas and offered testing, and people came in large numbers, knowing that if they test positive they are given treatment.

What are the particular health challenges for South Africa’s large youth population?

The biggest problem is HIV/AIDS, especially among young adolescent women who are affected more than their male counterparts. That is why we look forward to the new preventive drug lenacapavir. The second biggest problem is teenage pregnancy. And the third one is massive unemployment among youth, because it affects people’s health status, especially mental health.

What are the key political choices for health at the G20 Johannesburg Summit?

The biggest achievement that could ever be delivered for health is for countries to reach universal health coverage. That is an equaliser between rich and poor. You can deal even with pandemics when there is universal health coverage. 

I have never met anyone who says they are against universal health coverage. In South Africa, six court cases are challenging the national health insurance programme, which is for the whole population. Each, in its affidavit, said it supports universal health coverage but not national health insurance. In other words, the concept is widely accepted but people define it differently. That is where the problem is. If we can agree that universal health coverage means everyone having access to good quality health care and should not experience financial hardship, then we understand exactly what universal health coverage is.

In South Africa, the people who oppose it believe there must be healthcare financing for those who are well to do and who have higher salaries, and other healthcare financing for the poor, unemployed, elderly and marginalised. That is not universal. I don’t know a medical or nursing textbook that says here are two people with diabetes: one is a domestic worker and should get this treatment, and the other is a billionaire and must get better treatment. Or this person is rich, so we treat their cancer like this, and that one is poor, so we treat it like that. Such textbooks do not exist. ▪