Berliner Abendpost - South Africa's Universal Health Coverage Depends on Tackling Poverty and Inequality

South Africa’s ambition to achieve universal health coverage cannot be realized through medical infrastructure and treatment access alone, according to experts who argue that addressing poverty and inequality is equally critical. Finance Minister Enoch Godongwana recently announced R1.6 billion in reprioritised funding to combat stunting and malnutrition, underscoring the government’s recognition that social determinants are foundational to public health outcomes.

The United Nations Sustainable Development Goals (SDGs) provide a framework for this interconnected approach. SDG 3 seeks to ensure healthy lives and promote well-being for all, including the target of achieving universal health coverage by 2030. However, progress toward this goal is inseparable from the broader development agenda, particularly regarding poverty and hunger.

In his October medium-term budget policy statement, Godongwana announced R1.6 billion in reprioritised funding over the medium term to address stunting and malnutrition. The funding focuses on maternal nutrition, healthy pregnancies, and the first 1,000 days of life. He also reiterated the government’s commitment to the social wage, which accounts for approximately 60% of non-interest expenditure. This social wage supports poor and working-class households through health care, education, social grants, and basic services.

The World Health Organisation recognises that social determinants of health—including the conditions in which people are born, grow, live, and work—account for a substantial proportion of health outcomes. In South Africa, the consequences of these conditions are evident in the country’s malnutrition crisis.

Data from the Eastern Cape department of health recorded 871 cases of acute malnutrition requiring clinical intervention between April and early August this year. Of these, 363 children had severe acute malnutrition, a potentially life-threatening condition. Nationally, the Human Sciences Research Council’s National Food and Nutrition Security Survey found that 63.5% of households experience food insecurity, while 28.8% of children under five are stunted.

The financial gap between support and need is significant. The Child Support Grant provides R580 a month, which falls below the food poverty line of R796. The Pietermaritzburg Economic Justice and Dignity Group estimates that providing a child with a basic nutritious diet costs about R967 a month. For families struggling to afford food, electricity, and transport, maintaining good health becomes difficult, regardless of whether health-care services are available.

This reality illustrates why SDG 3 cannot be achieved independently of SDG 1 on poverty and SDG 2 on hunger. A child may have access to a clinic, but if that child returns to a household without sufficient nutritious food or clean water, the underlying risks to their health remain. Universal health coverage must therefore be understood as more than mere access to health-care services. Although access to quality care and financial protection remain fundamental to its definition, sustainable improvements in health require progress across the wider SDG agenda.

The consequences of poor social and economic conditions extend beyond immediate illness. They also create long-term financial pressures for the health-care system. A child hospitalised with severe acute malnutrition requires specialised nutritional support, treatment for complications, and ongoing monitoring. Stunting can also impair cognitive development and educational outcomes, affecting future opportunities and economic productivity.

At the same time, poor nutrition can contribute to obesity when households depend on cheaper, energy-dense foods that lack essential nutrients. Childhood obesity increases the risk of chronic conditions such as diabetes and hypertension later in life. Research from Wits University estimated that overweight and obesity cost South Africa’s public health-care system R33.2 billion in 2020, equivalent to about 15% of government health expenditure.

These costs demonstrate why prevention must be viewed as an essential component of health-care financing and not simply an additional social development priority. While the government has a central responsibility to advance the SDGs, achieving universal health coverage requires participation from the private health-care sector.

Medical schemes and health-care funders cannot measure their contribution to the health system solely through claims paid, benefits provided, or financial reserves maintained. These measures remain important, but they do not fully reflect whether the sector is contributing to better health outcomes. It also means recognising that employment, income, and inequality directly influence access to private health care. SDG 8, which promotes decent work and economic growth, is particularly relevant to the sustainability of medical schemes, given the relationship between employment, affordability, and scheme membership.

As an industry, stakeholders are asked to consider whether their interventions address the broader conditions that influence members’ health. This requires a broader understanding of the value that health-care funders bring to society. Investment in prevention and collaboration on social determinants should not be viewed simply as corporate social responsibility. Where appropriately designed and supported by the regulatory framework, these interventions can contribute to better health outcomes and more sustainable health-care financing.

President Cyril Ramaphosa’s commitment to ending child stunting by 2030 reflects the urgency of addressing one of the country’s most pressing development challenges. But reaching that target will require more than the efforts of the department of health. It demands coordinated investment across government and meaningful collaboration with the private sector.

Unless the conditions that make South Africans sick are addressed, the country will continue financing the consequences of inequality rather than building a healthier nation.

H.Bauer--BlnAP