The Constitutions of both Cuba and South Africa guarantee a “right to health” for all citizens and make it the responsibility of the government to deliver the right. The Cuban Constitution specifies that health services should be free to the consumer. The South African Constitution tempers the governmental obligation with terms like “reasonable” and within means. The countries are on very different paths to deliver these bold promises: Cuba through a State owned and operated delivery system that is free to the patient; South Africa through a National Health Insurance plan with comprehensive benefits purchased from public and private providers. Cuba has had fifty years to deliver on its promise while South Africa is just getting started. It would be unfair to declare a “winner” but it may be helpful for future policy choices to hypothesize about key drivers that set South Africa and Cuba on such different paths.

Cuba and South Africa are very different countries. South Africa has 53 million people; Cuba 11 million. Both had small ruling elites that expropriated great wealth from the forced labor of the majority of the populations. In both, the oppressed rose up and came to power: Cuba led by Fidel Castro; South Africa by Nelson Mandela. The foundational theme in Cuba is Revolution from the preceding order, while in South Africa it is Reconciliation with the past. This matters.

South Africa had major natural resources the world wanted. Cuba had few beyond sugar. International markets were open to South Africa but closed to Cuba. Some, but not all of the existing elites left South Africa. Cuba suffered huge capital and human resource outflows.

When Castro took over, more than half the doctors and other professionals fled. There was very little health infrastructure in the rural areas that were the core of the revolution. The country had to start almost from scratch in the face of US hostility that denied Cuba almost all international capital investment for decades. Castro relied on human capital and prevention as the basis for public health. Today the infant mortality rate is 2.4/1000. Life expectancy is 78. There is almost no difference between rural and urban health care access or outcomes. Cuba trains and has more doctors per capita than almost any other country in the world and regularly exports physici ans to other countries, including South Africa, for humanitarian and financial reasons. Specialists and family doctors are paid the same measly salaries, though many supplement their salaries with non medical work.

When Mandela took over, apartheid left two segregated systems; a weak public system providing minimal care to the vast majority of the residents and a private system in the White dominated cities serving the minority. The infant death rate was very high; life expectancy low and HIV/AIDS was rampant, infecting up to 20% of the adult population. Private hospitals and physicians took care of the whites in the cities, who usually paid out of pocket. About half of all health expenditures went to the private sector serving a small percentage of the population.

The theme of Reconciliation made it impossible for the ANC, the ruling party, to redistribute a significant percentage of health resource from urban whites to rural and township blacks and coloured. Redistribution had to be gradual. White clinic administrators could be replaced by Blacks over time. Capital investment in rural and township clinics could be made but in competition with other urgent public sector needs. Meanwhile private hospital operators found lucrative markets in the cities. Today there are two almost completely parallel systems, an improved but still low resourced public delivery system serving 85% of the people consuming 44% of all health expenditures and a private hospital, physician and health insurance system serving 15% of the people while consuming more than 40% of total health expenditures. The infant death rate is now significantly lower but still high. HIV/AIDs is now effectively treated throughout the country on a test and treat philosophy. Maternal transmission of HIV/AIDs has almost completely been eliminated. Waiting times at public hospitals are long.

National Health Insurance was seen, at least on paper, as a way to deliver universal health care by reconciling the differences between the public and private sectors and redistributing resources from the minority to the majority population without provoking the current users of the private system. A progressive national tax system and economic growth would finance subsidies for the poor. Access and quality would be improved by the national scheme contracting with both the existing public system and the private sector to provide comprehensive services to all. A 14 year timetable was laid out to enable the changes to be effected. Major issues of governance and finance remain unresolved. The national budget proposal for the coming year includes initial creation of a National Health Insurance Fund but the amount allocated is small and is likely to be used as supplementary funding to meet critical needs not for core financing.

There is lots of discussion among academics, career civil servants and opinion leaders about slowing things down. Conflicts between the National government that is mandated to implement the program and provincial governments that now control the delivery system are emerging, especially in areas where the dominant ANC party has lost control. Pilot projects are underway but the results have been mixed. There have been virtually no significant contracts between the public and private sectors. Few private sector doctors have agreed to public sector jobs. Some critics think the plan focuses too much on curative care rather than upstream promotion. The path to universal health care in South Africa has many potential footfalls, but the reason the country is on the path can be traced, I believe, to the founding theme of Reconciliation.