By Glenn Ashton · 12 Sep 2009
South Africa’s dual healthcare system depicts a crudely unjust and shameful state of affairs.
To state the obvious, our grossly unequal system is typified by a world-class privately funded health care system serving a narrow group of materially comfortable South Africans; sharply contrasted against a hopelessly inadequate state-funded public health care system, which the majority of South Africans, under conditions of poverty and powerlessness, use at their peril.
The grim reality of public health care in South Africa requires little elaboration. One need just flip through the pages of local newspapers for a daily dose of hospital horror stories. It is obvious to all and hardly a contentious point that our public health care system requires change.
The moral imperative for post-apartheid South Africa has always been to create a more equal society, both socially and economically.
Thus, with the principle of equity embedded in the ANC’s slogan “A better life for all,” one would have expected to see all our country’s policies being directed towards first meeting the needs of those most in need.
But this has not been the case. South Africa’s policy choices, not just in relation to health care, but more broadly, have done little to close the inequality gap leading to all kinds of disparities in addition to replicating deep-rooted patterns of racial and class-based privilege.
Nevertheless, we’ve entered an opportune period in our country’s history. The post-Polokwane ANC government has proposed an overhaul of the dual health care system giving new impetus to the goal of creating a more equal society -- at least in the provision of health care.
The idea is to create a unified health care system, which all South Africans, rich and poor will have equal access to such that the poor receive better treatment under improved conditions. It is to be funded by a national health insurance (NHI) scheme, which will see South Africa’s better off citizens paying higher taxes to fund state expenditure for a universal health care programme.
The proposed NHI scheme is a significant step towards realising policies that have a more redistributive and transformative effect. Despite details about its implementation still being sketchy, conceptually, it’s an admirable ambition.
However, the NHI has its fair share of detractors and like climate change denialists they are focused on gratifying their immediate needs now rather than thinking about a more sustainable, inclusive and healthier future for us all.
Tragically, in the current debate the middle class is being pitted against the poor. RW Johnson is quoted in an article published by The Times on 20 August 2009, saying: “Should the NHI plan go ahead, not only would most doctors emigrate but so too would many of the 7 million South Africans of all races who currently depend on private health insurance as patients.”
So what’s the alternative then? Scrap the NHI? Maintain the status quo? Do future generations of South Africans continue to play the game of ovarian roulette hoping to be born into the right family in the right social echelon?
It’s an extremely selfish position to take. Yet, for the past fifteen years we’ve continued along this parallel two-world trajectory remaining a divided nation with an extremely uneven playing field.
The naysayers have also captured the public’s attention by focusing the debate on the cost of the effort. Too expensive, they say. Can’t be done.
This is not entirely true because where there is political will; there most certainly is a way. Does the R43 billion arms deal ring a bell?
However, sarcasm aside, consider what just happened in America a few days ago. Americans have been engaged in a similar national healthcare reform debate and theirs has been as polarised as our own.
In a surprising move, that debate was decisively put to rest by President Barack Obama in a style pleasantly reminiscent of the “Yes we can!” man from his presidential campaign days. Obama threw down the gauntlet when he addressed the American Congress on 09 September 2009, urging them to pass a new healthcare bill. He said, “The time for bickering is over,” as he went on to unveil proposals for the implementation of a health reform programme with a public option. The programme will cost US$900 billion over a decade.
Can America afford the plan? It’s hard to say given that Obama walked into a US$1.3 trillion deficit problem when he entered the doors of the White House. But he hasn’t let that less than minute detail stand in his way. Obama has made a firm commitment to the 30 million poor Americans who can’t afford private health care and seems determined to find a way to make good on his promise so that the system can start working for those most in need.
This is the kind of bold decision-making we need in South Africa. We’ve taken “separate development” out of our laws, its time to take it off our landscape.
Those who fixate on the prohibitive costs of quality comprehensive healthcare for all South Africans hardly challenge themselves to think out of the box about how to bring costs down. There certainly is no analysis of why medical care is so expensive and no effort to examine ethically responsible ways to reduce costs.
Maggie Mahar is author of the book, “Money-Driven Medicine.” She argues that we should be looking at the profit margins of companies that provide inputs to the health sector and question why their profits need to be so high. In particular, she questions the motives of pharmaceutical companies that post runaway profits. Consider the profit margins of the following familiar brands: Johnson and Johnson (20.8%), Pfizer (16.3%) and GlaxoSmithKline (17.4%).
Mahar contends, “If shareholders, could be satisfied with margins of, say 8% or 9% they could, in fact, slice prices.”
The “profits before patients” mentality has also resulted in billions being squandered on unnecessary tests and procedures, including the use of cutting edge high tech expensive often-experimental solutions in many cases where patients could just as easily be treated using older, cheaper and more stable solutions, she says.
These are some of the more salient factors that keep healthcare out of people’s reach and what we should be addressing most urgently if we wish to enjoy affordable and sane medical care.
Finally, any contribution to the healthcare reform debate in South Africa that doesn’t face up to the reality of the enormous capacity constraints in our public hospitals would be naive. It is a key argument against the implementation of the NHI, but hardly a reason to justify scrapping the initiative.
What the situation should do is impress upon us the significance of fixing the public health care system so it works for all citizens. In the provision of health, education and other essential social services, the public option is always better than the private one for the simple reason that the mandate of the government is to serve the people, not shareholders.
Just because our public health sector is not working now doesn’t mean that we can’t dream about a future where it will work efficiently, effectively, affordably, hygienically, safely and compassionately.
Now all we have to do is take the bold decisions and steps that are needed to turn that dream into reality.
Not as Clearcut as You Make it Out
You pooh-pooh arguments without actually providing answers for them. While I am in agreement that we need universal health care, you don't actually make any arguments of your own, merely assertions, ad hominem attacks and declarations that corporations need to have a heart.
How are the costs to born? How are doctors to be incentivized from leaving the country? What about unintended consequences, like a lack of incentives in research and development? Why is government the most qualified to direct medicine in this country, given its appalling track record with, eg, HIV infection?
Merely wishing something into existence is NOT the correct way to tackle this debate.
To achieve the goals set out in the article we need a major change in mindset. Unless the rich learn to share their blessings this country is going nowhere.
We also need a major change in work ethic. The major problem in public healthcare is the attitude of the staff employed therein.
Finally, there are many people who are forced to take out expensive user unfriendly medical aids which fund the private healthcare system because of the poor state of public healthcare.
Government's History re Health Care
I am afraid I fail to see how NHI is going to improve healthcare for those who depend on the public sector for this service. The record of government since 1994 with regard public medical services is apalling. The quality and standards have continuously deteriorated according to all reports that I have read. This is what has to be fixed, there can be no improvement without that.
The proposal to fix things by loading the smaller private sector medical services with the vastly greater numbers of public patients, which is what NHI is attempting to do as I understand it, will just destroy the private sector. I suppose then at least everybody will have the same level of medical services even if they are bad. The inevitably consequences of that will be that those citizens who are able to immigrate will leave the country to seek another land where they can expect reasonably good medical services as they will no longer be available in their own country.
Nice article, Fazila. Ahmed is right about the change of mindset needed and the points you raise open some space for that change to happen.