Why equity in health and in access to health care are elusive: Insights from Canada and South Africa

ABSTRACT

Health and access to health care vary strikingly across the globe, and debates about this have been pervasive and controversial. Some comparative data in Canada and South Africa illustrate the complexity of achieving greater equity anywhere, even in a wealthy country like Canada. Potential bi-directional lessons relevant both to local and global public health are identified. Both countries should consider the implications of lost opportunity costs associated with lack of explicit resource allocation policies. While National Health Insurance is attractive politically, Canada's example cannot be fully emulated in South Africa. Short- and medium-term attempts to improve equity in middle-income countries should focus on equitable access to insurance to cover primary health care and on making more use of nurse practitioners and community health workers. In the longer-term, attention is needed to the economic and political power structures that influence health and health care and that ignore the social and societal determinants of sustainable good health locally and globally. This long-term vision of health is needed globally to achieve improvements in individual and population health in a century characterised by limits to economic growth, widening disparities, continuing conflict and migration on a large scale and multiple adverse impacts of climate change.

KEYWORDS:

• South Africa
• Canada
• health
• health services
• funding
• National Health Insurance
• social innovation
• ecology

Acknowledgements

Thanks are due to C. David Naylor for a critical reading of an earlier draft of this paper and to anonymous reviewers for their constructive comments.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. Richard Horton, Editor of the Lancet has criticized the SDGs as being ‘fairy tales, dressed in bureaucratese of intergovernmental narcissism, adorned with the robes of multilateral paralysis. The goal “attain healthy lives for all at all ages” is a mixture of business-as-usual (the MDGs rebooted), non-communicable diseases and universal health coverage … and a strange assortment of promises … ’ (The Lancet, 2014, Vol. 383, Issue 2074).

2. The exchange rate of the SAR and for the Canadian and U.S. dollars has fluctuated considerably over several years. For the purposes of this article, an exchange rate of SAR 10 = CDN $1 is used. It should be noted that this simple conversion does not reflect purchasing power values.

3. The number of people with access to medical aid (insurance) increased from about 7 million in 1993 to about 8 million in 2008 while the number of those without such access increased from about 31 million in 1993 to just over 40 million in 2008.

4. Leadership, governance and accountability; health workforce information and health workforce planning; re-engineering of the workforce to meet service needs; scaling up and revitalising education, training and research, creating the infrastructure for workforce and service development – academic health complexes and nursing colleges; strengthening and professionalising the management of HR and prioritise health workforce needs; ensuring professional quality care through oversight, regulation and continuing professional development; and improving access to health professionals and health care in rural and remote areas.