The applications of Universal Health Coverage in a pandemic


For someone who has tested for coronavirus and has shown symptoms, obtaining medical assistance is essential to managing mild symptoms and preventing more severe symptoms from occurring. Therefore it is of the utmost importance that the health infrastructure in place is able to provide adequate care and ensure that positive patients are also isolated to prevent the disease from spreading further.

In South Africa, there are two branches to the health system; private healthcare facilities and public healthcare facilities. Private health facilities require payment to be made on the part of the individual or can be covered by insurance facilities such as medical aid. Public healthcare facilities are state-owned facilities that are maintained by the government and provides free access to healthcare services and resources.

Public healthcare facilities are heavily relied upon as a large percentage of the population are unable to afford medical cover and turn to these facilities for medical services and resources. This can often lead to these facilities becoming overwhelmed or accumulating a long waiting list due to the volume of patients who need extensive care.

This has also been an issue within other countries and has placed undue strain on their health infrastructure. In order to alleviate the pressure on their health system, some countries have opted for a universal healthcare approach.

South Africa has begun to look at the implication of a universal healthcare system. The National Health Insurance (NHI) has proven itself to be the answer to ensuring that all South African have free and fair access to health facilities. Research has shown the merits that could have been offered should NHI have been active during the COVID-19 pandemic.

This research will examine the applications universal health has to effectively manage a pandemic like COVID-19. It will also look at breaking down what NHI means for ordinary South Africans. Lastly, it will critically analyse how a universal healthcare system has been implemented in other countries and the success it has had for their health infrastructure.



Defining Universal Health Coverage

Within countries across the world, there is an unequal distribution of wealth. This has meant that there has also been inequality in the calibre and rate at which healthcare is being received. Some countries have therefore decided to close the gap by implementing Universal Health Coverage.

Universal Health Coverage simply means that everyone, from every background and in every part of a country can access quality healthcare without incurring heavy financial expenses as a result (World Health Organization, 2020). This system provides accommodations for individuals who are unable to afford access to basic health-related services.

Universal Health Coverage can be a government-funded initiative and can also require that individuals also subscribe to paying an amount for insurance to be covered (World Health Organization, 2010). The main determinate for Universal Health Coverage is ensuring that individuals can access healthcare and does not necessarily mean that all cases are covered.

The implementation of universal healthcare relies on three pivotal factors. Firstly it depends on the individuals within a population that is being covered. The second factor is determining the type of services that need to be covered and the final factor is the percentage of the cost that is being covered by the system (World Health Organization, 2020).

The Universal Health Coverage concept should have the following goals in mind: firstly, it should create a system of equal access and opportunity which ensures that individuals from every walk of life are all able to receive the best quality available from healthcare facilities (Abiiro & De Allegri, 2015).

Secondly, it should facilitate processes for governments to formally acknowledge access to quality healthcare as a basic human right. It also needs to be recognized as a multidimensional concept and aspects such as financial coverage need to be minimized on behalf of the ordinary citizen as far as possible (Abiiro & De Allegri, 2015).

Lastly, the services rendered need to be in line with the guiding principles set out by the World Health Organization. All interventions also need to work towards improving service delivery and prevention programs; this then acts as a building block to strengthening the health infrastructure within a country to ensure it can effectively carry out the principles needed for a universal healthcare coverage program to be successful (Abiiro & De Allegri, 2015).

Research has also shown that there are different financial models that can be used when attempting to fund universal healthcare. Some use a mixed model of both public and private contributions, and almost all require collaboration with their government in terms of mandatory contributions through their employer or their taxation system (Valbona, 2017).

The protocols and structure of a particular universal care system can vary from country to country. This variation is dependent on the involvement of the government in its’ implementation and the coverage being offered (Gray, Pitini, Kelley & Bacon, 2017).

In instances with heavy government involvement, the delivery and approval of health service delivery are largely determined by the government. In other countries with a mixed model, the contribution to coverage is often determined by factors such as income, and the contribution cost is often shared between an employer and their employee equally (Gray et al, 2017).

Once successfully implemented, Universal Health Coverage has several different benefits for both the country and population alike. Economic protection drastically reduces the risk of poverty for citizens who are already strained financially. With the constant access to services that improve their health and reduce the risk for illness, individuals are then able to be more productive members of society (World Health Organization, 2013).


National Health Insurance in South Africa

The NHI is a financing system created within the health sphere. It has been created and carefully structured to pool funds from different sources. These funds act as the main resource in providing the highest possible quality of healthcare to all South Africans, irrespective of their socio-economic status or where they’re from (The South African Government, n. d).

As with the general universal health care model, the NHI is aimed at ensuring the needs of the individual are taken care of without any undue strain on their financial circumstances. This means that every citizen will be granted their right to a comprehensive range of healthcare services for free. These healthcare services can be accessed from verified healthcare facilities such as clinics, hospitals, and private or general practitioners (The South African Government, n. d).


These services will be geo-located, meaning that individuals will be able to access healthcare facilities based on their place of residence or where they work. To ensure efficiency and to also verify the identity of the individual, a card system will be used and this card will need to be presented when at any given facility.

The initiation of implementing NHI began in 2012 and is being implemented in different stages over 14 years. It will function through the use of a single funding source. This will then provide the government with the ability to purchase healthcare resources on behalf of the South African people according to the needs and range of cover required by the average South African (The South African Government, n. d).

Initially, there will be no taxes attached to the NHI as it is being financed by an accumulation of funds within the public sector pooled together by the government. Once the NHI has been successfully implemented and is on stable grounds, there is a slight possibility of a small tax that could be introduced by the National Treasury Department (The South African Government, n. d).

While awaiting the passing of NHI in parliament several improvements are being made to the existing health infrastructure. Currently, all efforts around NHI are being concentrated on strengthening NHI policies and infrastructure. This is being done as a means to increase the success rate of NHI in ensuring the health needs of all South Africans are taken care of (The South African Government, n. d).

While this is happening, health facilities and resources are being reinforced and renovated. This will include improving on existing facilities, training and employing more staff, and improving the quality of healthcare that is being received. Systems around medication replenishment are also being examined and redesigned to ensure that a shortage does not occur at any given point and communication systems are also being re-examined to ensure all messages and educational tools will be effectively received by the public (The South African Government, n. d).

All of these improvements ensure that there will then be a standardized quality of care. The current system which differentiates public and private healthcare facilities will cease to exist as these will all be of the same standard and under the same compliance regulations. By doing this it also roots out maladministration and destroys the possibility for corruption and misuse of funds (The South African Government, n. d).


The fragility of health systems exposed

The COVID-19 pandemic has ravaged most sectors and the impact has been devastating. One thing that it has also done is exposed the weak points within healthcare systems across the globe. The struggle that countries have had in containing the spread of the disease has been evidence of this as many countries have seen their health facilities and infrastructure buckle under the pressure (Samman, 2020).

The diversion of funds to curtail the COVID-19 pandemic has also meant that other areas of health have had to bear the brunt. The pandemic has brought attention to several needs needing to be addressed for a health system to be able to effectively manage the impact of a health crisis.

The first is how funds are being spent and what spending is being prioritized. The COVID-19 pandemic has raised a number of questions on how funds should be planned to ensure that a health system is at the most optimal version. It also has raised a quandary on the balancing act that needs to come into play when spending. The balance in question is ensuring spending is shared adequately and also does not affect other key areas such as education or sanitization (Samman, 2020).

The pandemic has also exposed gaps within the healthcare system and what counts as an essential service. Prioritizing equity in terms of service delivery is also important as everyone should be treated with the same level of service and systems with a privatized form of healthcare places individuals in poorer financial situations at a disadvantage as they may not receive the necessary services in time or may face a long wait period for service delivery (Samman, 2020).

Vulnerable groups such as the elderly and homeless also need to be adequately catered for. It is accommodations for these groups that determine the successful management of a pandemic (Samman, 2020). The COVID-19 pandemic has shown the inadequacies that exist around this as countries such as Spain and Italy found that their vulnerable groups were worst affected.

Lastly, collaboration across sectors has also been found to be of the utmost importance. Understanding the need for partnership and working together within governing bodies has assisted in decreasing the spread of the virus. For example, school closures were integral to assisting in decreasing the rate of spread.



The benefits of universal healthcare during a pandemic

The COVID-19 pandemic has created a formidable challenge for healthcare systems across the globe. In most cases, these systems became overwhelmed and were forced to re-examine the current protocols that inform their day-to-day functioning. It has also meant that the very building blocks on which these health systems were built have had to be rethought and examined closely (World Health Organization, 2020).

One of the key measures to preventing the spread of disease is good quality proactive healthcare. For this to be effective, the quality of care received by all citizens needs to be of the same standard. Universal Health Coverage plays a role in this as a standardized quality of care ensures the same protocols are applied to prevent the spread of infection. As such, these measures then act as the first line of defence in preventing an increase in spread and thereby minimizes the impact of the virus on the general population (McDonnell, 2020).

If different standards of care existed as a result of the division in the healthcare infrastructure, this could then impact the quality of care that is being received by portions of the population. These portions also tend to include high-risk or vulnerable groups and as such the impact of a virus like COVID-19 tends to affect these populations greater (McDonnell, 2020).

The COVID-19 pandemic has also highlighted the need for investment into primary healthcare which has proven to be one of the key areas that have acted as the first defence to combating the spread of the virus (Samman, 2020). Countries that have invested in a universal healthcare system have seen less of a need for more extensive forms of treatment as the virus was caught in individuals and was treated appropriately (Samman, 2020).

The implementation of universal healthcare coverage also acts as a financial buffer for families who are unable to afford the extensive care and medication that is often required when attempting to combat the COVID-19 virus (Mathieson, 2020). By alleviating the financial strain on the general population, also allows for the country’s economy to recover at a faster pace as the country can function at a certain level of normality (Mathieson, 2020).

Therefore ensuring an effective response to the pandemic and curbing the spread of infection can be seen as having a direct correlation to a standardized quality of care. Standardized care in turn is directly impacted by the system in place. The most efficient system for ensuring a high quality of standardized health care is having a universal healthcare system.

A country-based case study


The endeavours by Brazil to provide free and comprehensive healthcare to its citizens began in the 1920s. Since then it has reached many milestones and overcome many challenges to reach where it is at present with over half of the population relying on the health strategy systems put in place (Momen & Rosa-Freitas, 2015).

This has been no small undertaking and a number of challenges were faced in the implementation of their universal health system strategy. Part of this was making access to healthcare a constitutional right within the country. Primary healthcare duties fall on the shoulders of the government and are provided to all Brazilian citizens and foreigners in the Brazilian territory (Momen & Rosa-Freitas, 2015).

Due to having a comprehensive universal coverage system in place, a number of initiatives have run efficiently such as vaccination coverage and containment of endemic diseases such as HIV (Fraga, Lago & Rocha, 2020). It is also one of the first in the world to successfully ensure universal coverage to a population of over 100 million people.

Despite these many achievements within their health sector, Brazil has struggled with the COVID-19 pandemic and has been one of the country’s hit hardest. As of November 21st, there are over 6 million cases with over 160 000 deaths (Worldometer, 2020).

This has largely been due to an initial misunderstanding on the severity of the pandemic and miscalculating the impact it has within a large populace (Fraga et al, 2020). However, as a result of internal functioning structures within their universal healthcare approach, there has been some improvement in their response to the pandemic and efforts have been made towards containing it (Fraga et al, 2020).

The pandemic has also been found to affect disadvantaged populations greater. This is due to a lack of access to the necessary healthcare facilities (Fraga et al, 2020). Due to the Brazillian universal healthcare model, however, they have not experienced this and as such prevented total devastation by the virus. While there are still issues around testing, Brazil has managed to ensure the capacity of their health system was not breached and their facilities did not become overwhelmed (Fraga et al, 2020).



The model used by England has been modelled on by several different countries that have begun their universal health initiatives. It has often been seen as the benchmark for implementing a universal healthcare approach as it has functioned with an often symbiotic relationship between the government and key role players within the healthcare system (Full Fact, 2019).

Three initial principles have acted as a guide on how the National Health System (NHS) has been based upon. The first is that it meets the health needs of everyone that it serves. The second is that the services being received are free to the individual using them. The last is that the services provided should be based on the needs of the individual requiring assistance and not their financial capability to afford it (Nicholls, 2018).

This, therefore, means that citizens, for the most part, do not pay anything for any services or resources that were used in their treatment plan. The NHS has also meant that comprehensive lists of services are free for use to the general public and services are also contextualized to the needs of specific groups within the population (Nicholls, 2018).

Much like Brazil, the response by the country has been criticized due to the ill preparation and confusion around a coherent strategy (The Lancet, 2020). Due to the lack of an actionable strategy to prevent the number of cases from overwhelming the healthcare services available, the numbers of COVID-19 cases are currently on the rise (The Lancet, 2020).

The government has imposed a lockdown to curb the spread as it deals with its second wave of the virus and has several different strategies that they are implementing currently. Firstly an additional personal protective equipment has been ordered to protect staff in health facilities (The Lancet, 2020).

Secondly, additional acute beds have been assigned to dealing with the COVID-19 pandemic. This was done without taking into account the supplementation of contingency plans for non-COVID-19 cases. With budgetary cuts however in the light of the COVID-19 pandemic, the success of the country in repelling the pandemic is questionable and more resources are needed to supplement pre-existing NHS infrastructure (The Lancet, 2020).



Algeria is an example of how successful a universal health program could be within an African context. The system itself was introduced in the 1970s and has since had a significant impact on health indicators since then (Oxford Business Group, 2020).

With this system, a variation of services is free at public healthcare facilities and the government also has a reimbursement policy that reimburses citizens for any medicinal purchases they have had to make (Oxford Business Group, 2020). Currently, most healthcare facilities are accessible to the general public and a substantial budget allows for these facilities to be well maintained by the Algerian Ministry of health.

Initiatives around aspects of health such as family health and the spread of communicable diseases have also been undertaken. This has been done as a means to increase the overall wellbeing and health of its’ citizens. Some plans are focused on other pertinent issues around health such as cancer prevention and treatment and focusing on promoting vaccination programs (Oxford Business Group, 2020).

Algeria has had a relatively low caseload and as such has been able to effectively manage and contain the spread of the disease. There have been several different strategies employed by the government to curb the spread such as imposing a lockdown on provinces that were hard hit and suspending international travel (Bourabiat, 2020).

Additional measures have also been put in place to assist with easing the burden on healthcare systems. Healthcare facilities within Algeria are struggling due to a shortage of equipment. The medical staff has also been under pressure as there has been an influx of patients (Hamann, 2020). This has largely been seen as a lack of preparation on the part of the government as equipment needed to treat patients are in short supply and a shortage of personal protective equipment has also put healthcare staff at risk (Hamann, 2020).



These countries have all been seen as success stories when it has come to the implementation of a Universal Health Coverage strategy. It has taken a number of years for these strategies to be successfully implemented and for the careful planning of their governments to reach fruition.

Despite this, their strategy to effectively manage the spread of the COVID-19 pandemic has fallen short and has seen their healthcare systems placed under significant strain. It has also seen their citizens suffer as the case numbers rise and death tolls soar with no end to the devastation in sight.

In contrast, South Africa has received praise from around the world for its’ management of the pandemic. Stringent measures were put in place and collaboration across departments and sectors saw these measures reinforced. These measures eased the burden on the health infrastructure significantly and saw enough capacity to cope with the COVID-19 pandemic.

Now as the rise in cases has plateaued and the possibility of a second wave seems imminent, the South African government again needs to ensure that the risk of infection is minimized as far as possible and adherence to protocols and regulations are enforced.

The NHI could have assisted in streamlining the lengthy processes often involved in the management of a crisis with predetermined guidelines and regulations that assist in situations like the COVID-19 pandemic.

As South Africa continues to improve, the possibility of Universal Health Coverage becomes more of a reality. This ensures the future of all South Africans as healthcare becomes accessible to all and this improvement will see other sectors in South Africa improve, and increase potential South Africa has to be one of the global powerhouses and role models for universal healthcare.



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