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Much current global debate - as well as a great deal of political rhetoric - about global health and healthcare is characterised by a renewed emphasis on the goal of universal access throughout the world. While this goal has been achieved to varying extents in the United Kingdom, Canada and many countries in Europe, even within those countries where national health systems have long been in place, the pervasive shift in emphasis from health as a social value to health as a commodity within a capitalist market civilization is eroding the commitment to equitable access to healthcare. Against this background the challenge is much greater in low- and middle-income countries that lag behind - especially if aspirations to universal access go beyond primary care. The challenges of achieving greater equity in access to health and in health outcomes, in a middle-income country like South Africa, illustrate the magnitude of the tensions and gaps that need to be traversed, given the vast differences between healthcare provided in the private and public sectors. Understandably the concept of National Health Insurance (NHI) in South Africa has widespread support. The strategies for how a successful and effective NHI could be implemented, over what time-frame and what it covers are, however, very controversial issues. What tends to be ignored is that sustainable improvement in health in South Africa, and elsewhere, is not determined merely by medical care but more especially by social structures intimately linked to deeply entrenched local and global social, economic and political forces and inequalities. While seldom openly addressed, some of these forces are explicated in this article to supplement views elsewhere, although most have elided emphasis on the pervasive effects of the global political economy on the provisioning and practising of health and healthcare everywhere on our planet.

Universal Access to Healthcare: The Case of South Africa in the Comparative Global Context of the Late Anthropocene Era