Universal health care and the right to health - no gains without community agency

Current health care debates in the US have centered on the politics of “Obamacare” with primary attention to questions of affordability and political feasibility. In South Africa, efforts to eradicate or ameliorate heightening inequalities in health, principally related to a two-tier public-private division, and the consequent barriers to care for the majority of South Africans, have led the current ANC government to push strongly for fundamental health care reform and the policy goal of a National Health Insurance (NHI). Some lessons from the South African experience may be useful in considering current US health policy reform. Firstly, the preoccupation with financing may undermine the social justice goals of policy reform and of health equity as a value-based instrument; secondly, discussions on health insurance appear to gravitate immediately to health care rather than the more holistic view of social determinants of health. Lastly, the agency of users and communities appear poorly addressed in policy debates of this nature. All three elements – equity as a principle of social justice; health as being more than just health care; and community participation as instrumental to better health – are essential to a rights-based approach to health. Efforts at health care reform, wherever they are implemented, can only advance the right to health if equity is elevated as a social justice principle, if health reform addresses upstream determinants, and if health systems are able to strengthen the voice of those who health is most threatened by structural inequalities.