NHI bill fundamental to SA democracy

It is not an exaggeration that the National Health Insurance (NHI) is the health equivalent of the land question. It is so fundamental to our democracy and the kind of society that we want to create that we have no luxury of post-poning it.

Those who are opposed to land re-distribution argue that the programme will threaten food security, that it will put thousands of farm workers out of employment, that it will undermine investor confidence, that it will stifle economic growth and basically kill the agricultural sector. They quote all sorts of studies to support their reactionary view.

But they fail to say one thing. The current colonial land ownership pattern is not sustainable. It is unjust. Land dispossession was in the first instance, the primary reason why our people waged a struggle for liberation. There can never be real political stability and economic prosperity unless we genuinely address the land question.

Colonial dispossession of land robbed Africans of their capacity to use the land. Now that Africans have limited capacity, they are blamed and the argument is made that giving them land would undermine the economy and food security.

That argument is what we are experiencing in health care presently. When public health finds itself in trouble, history is conveniently forgotten and the argument is that the poor and their government brought it upon themselves through poor management, incompetence and corruption. Granted, there is corruption, incompetence and mismanagement in some provinces and facilities, but these are not the causes but the symptoms of the problems. These days we are often forbidden to talk about history as if it has no bearing on the present and the future. At the risk of being attacked for daring to quote history, I shall do it any way.

I shall demonstrate my facts through a story related to me by a doctor who went through this historical turmoil, as he was employed as a doctor when the public health-care system was still at its prime around Johannesburg.

Two important events occurred in 1967, which ironically contradicted each other. The first event was the first heart transplant in the world which was performed in a white public hospital by Professor Chris Barnard.

The patient did not have to pay anything out of pocket, he did not have to know how much a heart transplant cost. All he needed was quality health care that would save his life, and he got it.
In the same year, the first Medical Schemes Act was promulgated, under an Act of parliament, and among the objectives was that it would serve whites only.

After the 1976 Soweto uprisings, the public health-care system was progressively underfunded and the medical schemes were used to privatise what was good, though white, public health-care system. Later, out of pressure during the struggle, medical aid cover was opened for blacks, though tribally segregated.

Bonitas Medical Scheme was for Africans and Pro Sano was for coloureds and Indians. In other words, blacks who could afford were allowed to join in.
The consequences of the continuing underfunding of the public health-care system was that hospitals started failing; there were no funds for capex and equipment and no funding for human resources.
One of the major and drama-tic events unknown to the public is that this led to a very capable cardiothoracic team at the Johannesburg Hospital, which was serving whites exclusively, leaving for the private sector, joining the Milpark Hospital. Because whites who could not afford private health care were now left destitute, overnight, the cardiothoracic team at Baragwanath Hospital which was serving exclusively blacks was migrated to Johannesburg Hospital to fill in for the departed team. This means that blacks were left with nothing.

Senior doctors were then allowed to do private work and the consequences were very negative to the public health-care system.

Very unfortunately, this trend continued unabated as more and more private hospitals came into the fore with whites running away from public health facilities, just as they did from education facilities after democracy.

Any health system where the better paid, employed people and the affluent have a separate health-care system based on medical aids and other citizens are left in a separate system, is a recipe for disaster.

It is actually a violation of section 27 of our constitution. And for people to believe we must leave this type of system as it is, even though it is working for only 16% of the population, albeit, black and white, are outright immoral and unethical.

I am stating these facts because there is a belief that what happens in private health care has no bearing whatsoever on the public health-care system. This argument is devoid of historical truth and facts and is borne out of anger and frustration.

Considering how the public health-care system has been stripped bare over the years, a situation worsened by corrupt, incompetent and greedy people among us, this is understandable. But facts will remain facts.

Our democracy will be meaningless unless we are able to provide quality health care to all, without regard to their economic or social status. That is the essence of the NHI. We want to ensure that the health resources of the country are made available to all the people, whether they are rich or poor. In fact, we want to design a system in which the rich will subsidise the poor, the healthy subsidise the sick, the young subsidise the old.

Currently, the rich who are on medical aid have access to both the public health-care system and the private health-care system. But the poor, who do not have medical aid, only have access to the public health-care system.

We want to end this, and ensure that all citizens have equal access to all health facilities be they public or private. We are consistently told that we should first address the challenges in the public health-care system before we impose the NHI on everybody.

We are told that we should leave the private health-care system because it is working well and it is funded by private money. Those who make this argument fail to properly diagnose the problem.
Firstly, the problem of health in South Africa has little to do with a shortage of funds in the health-care system.

The real issue is that too much money is spent on too few people. According to World Health Organisation (WHO), a country should have good health outcomes if it spends around 5% of its GDP on health. South Africa already spends 8,7% of its GDP on health. We are in the same category as most European countries who spend about 9% of their GDPs on health, but our health outcomes cannot be compared with those of European countries.

The real problem is how these resources are shared. Of the 8,7% of the GDP that we spend on health, 4,5% is spent on 16% of the population, the well-to-do who have medical aid. The rest of the 84% of the population have to make do with the remaining 4,2% of the GDP. Health resources are too concentrated in the private health-care system. Just as a matter of illustration, one Johannesburg private hospital has more gynaecologists than all the gynaecologists found in Limpopo, Mpumalanga and North West hospitals combined. Limpopo has 43 hospitals, Mpumalanga has 34 and North West has 22, but all these 99 public hospitals have fewer gynaecologists than one private hospital in Johannesburg.

Unless you confront the real issue of how resources are distributed, you will never be able to address the crux of problem.
The other myth that we must explode is that the private health-care system uses private money. This is simply not true. Medical aids are heavily subsidised by the taxpayer. Last year, GEMS, which is a medical aid for civil servants, got a subsidy of R17.8 billion and this figure will rise to R20,5bn this year. Other public servants not on GEMS got R1,8bn last year and this year they will get R2,2bn in subsidy.

Those in the parastatals got R7,2bn last year and this year their subsidy will be increased to R8,3bn.

In total, the state will subsidise medical aids to the tune of R31bn this year. Furthermore, everybody who is on medical aid, whether they work for the state or in the private sector, get tax credits and rebates. The total amount for this was R20bn which will grow to R26bn. In total, R57bn of state funds will be channelled to those who have medical aids.

The National Development Plan (NDP), the country’s vision for growth, has actually flagged two issues unambiguously. It said in implementing NHI, South Africa has two problems to solve, namely the exorbitant cost of private healthcare and the poor quality of care in the public health system
Clearly, the NDP regards these two as the terrible twins of the health-care system.

Hence they need to be tackled simultaneously. It is wrong to pick and choose the one that favours your individual needs. As a state serving everybody, we need to tackle the exorbitant cost of private health care, while we also tackle the poor quality in public health-care system.

Some people have said that the NHI sounds like a good plan but have raised concerns about cost and how it would be funded. On this one, we should make something quite clear. NHI is not just the policy of the ruling party in its implementation of universal health coverage. It is actually an effective plan to deliver on a constitutional mandate. Our constitution enjoins us to provide health care to all. The constitution does not say only those who can afford should be given health service, it calls on the state to provide health care to all.

Questioning the cost of NHI is deja vu for some of us. When we wanted to increase the number of people on ARVs, we were asked a similar question – where will the money come from? Some even argued that we must first improve the quality of care in public hospitals before we can upscale the number of people on ARVs.

The answer I always gave them was, can we afford not to give them the ARVs? And today, can we afford not to give quality health care to all citizens? Imagine if we had listened to that argument, how many lives would have been lost, and how much the economy would be affected.

It would be wrong to try to put a cost to life. There are things that we should do regardless of their cost. But there are people who insist that we should give estimates on how much the NHI will cost the country.

No country in the world has ever tried to do that, nor was it even tried in this country when the first Medical Scheme’s Act was enacted in 1967. Today this matter is arising because we are now talking about poor people, mostly blacks.

There are too many variables to give a right answer.

For instance, some private hospitals charge as much as R7 500 for circumcision. But we perform that operation for as little as R950. What we will not do, is to pay R7 500 instead of R950.
Those who are saying that NHI will be unaffordable believe that we are going to peg it on this R7 500, because they regard the tariffs in the private health care as the gold standard rather than a serious aberration

Dr Aaron Motsoaledi,  Minister of Health of South Africa

Posted in Phambili
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