Politics and leadership in global health delivery: lessons from South Africa's HIV and health insurance initiatives

Abstract

Background South Africa's Health Minister Aaron Motsoaledi inherited an HIV epidemic and a weak public health system when he took office in 2009. His priorities were to establish a national programme to address HIV and to create a system of national health insurance (NHI) to increase access to affordable and high-quality health care. By 2015, Motsoaledi's work on HIV was considered as a success; however, work on the creation of NHI was stymied. Here, we aimed to compare the design, promotion, and implementation of the national HIV programme-a primarily vertical programme-with that of NHI, a horizontal programme.Methods In January and February, 2015, we conducted 20 semi-structured interviews in South Africa with government leaders, civil society, researchers, health-care practitioners, private insurers, and international non-governmental organisations. We analysed interviews and available quantitative data from government, academic, and industry sources and distilled key themes in two teaching cases.Findings We identified several key differences between the HIV programme and NHI efforts, including the role that leadership and politics play in health policy and care delivery; the effect of historical, economic, and cultural context on outcomes and leaders' ability to institute change; and the importance of strategy in planning and decision making. We noted both contextual barriers (such as public distrust of government) and catalysts (demand for HIV treatment) in the programmes. Furthermore, the approach used by the Minister of Health sometimes hindered programme success (for example, the exclusion of private insurers from NHI design) and sometimes enabled success (such as the engagement of civil society in the HIV response). For both programmes, the availability or absence of outcomes data affected the Minister's ability to advocate for change and to make strategic decisions about how to invest in health.Interpretation The comparison of South Africa's well known and effective HIV programme with its stalled NHI efforts-both led by the same person with very different results--sheds light on important considerations when approaching complex, large-scale change. Our analysis of the politics of health systems shows how explicit acknowledgement of the political nature of health will lead to more effective health promotion strategies and policies. Political leaders can either drive or hinder the implementation of evidence-based public health practices.

The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis

“…Fiscal space for health analyses would explicitly take into account budget cycle planning and would account for political economy considerations. The Sin Tax has been widely commented on [9,36] and puts the Philippines into the still exclusive league of countries that have introduced sustainable alternative financing sources [37]. PhilHealth and all other government spending account for only about one-third of all health expenditures; thus public health expenditure stands at only 1.5% of GDP (compared to the Organisation for Economic Co-operation and Development [OECD] average of about 5.5% and Thailand at about 3.2%).…”

“…Amidst a generally weak tax policy and administration [8], the country reformed the excise tax on tobacco and alcohol, channeling most of its revenues to health. Within the first year, the Sin Tax raised more than 1.2 billion USD, allowing the enrolment of an additional 14 million families or roughly 45 million Filipinos into PhilHealth [9]. Eighty-five percent of revenues are allocated for health, of which 80% are for achieving UHC and 20% for medical assistance and the improvement of health facilities.…”

Covid-19, The local and the global: Lessons from Kerala

“…The South Indian state of Kerala has long been one of the best performers in India when it comes to healthcare, with indices at par with those of advanced economies, largely as a result of steady investment in education and healthcare infrastructure by various governments over time (Kutty, 2000; Madore et al, 2018). The state has repeatedly been recognised as leading the nation in terms of healthcare indices by NITI Aayog, the planning and policy think tank of India (Paliwal, 2019).…”

Improving the implementation of tobacco control policies in low-and middle-income countries: a proposed framework

“…In the Philippines, for example, elections brought about new leaders who were keen on increasing tax collection efficiency and achieving universal healthcare. This created an opportunity for advocates to convince decision makers to change the existing tax structure on tobacco and alcohol products in order to generate resources for health, which ultimately enabled the successful enactment and implementation of the Republic Act 10351, otherwise known as the ‘Sin Tax’ 21. As tobacco control transcends national borders, a country’s relationship with the rest of the world, including its trade agreements and foreign policy, may also influence the level of political commitment for tobacco control.…”