Picture: ISTOCK
Picture: ISTOCK

While debates rage about the National Health Insurance (NHI) Bill and its shortcomings, Wits School of Governance professor of public governance Robbie van Niekerk says it is “a big idea” everyone should be discussing.

He says this is perhaps the most significant social policy introduced since the advent of democracy as it deals directly with the inequality of resource distribution between social classes. Health provision is a public good that affects all inhabitants of SA.

“I don’t think we have reached the point of a societal foundation because we failed to effectively communicate to the mass of society the scale of the inequality and the long-term benefits of a universal public health system as originally envisaged by the NHI,” says Van Niekerk. “That is a troubling element in how this debate is unfolding. It’s a wake-up call.”

In SA, 50% of yearly health spending — public and private combined — is incurred by the 16% of the population covered by medical aid and the other 50% on the 84% of the population wholly reliant on public health or those who make small payments for private health care.

Van Niekerk says: “Is it any wonder that our service delivery system is in a state of disarray? Notwithstanding the serious management problems, notwithstanding the issues we have control over, one of the most significant things that we currently don’t have control over is that the funding flows are going to service a deeply, deeply unequal model of health delivery.” 

He says the NHI policy is a challenge to all to think seriously about the sort of society they want for themselves and future generations. The NHI has the potential to facilitate cohesion by drawing all social strata into a common vision for achieving universal health care.

“The UK’s NHS, a system which essentially provides health care for free at the point of delivery, was also considered pie in the sky… Curiously, what was a pipe dream in 1948 is now seen today as an absolute bastion of what British society represents,” Van Niekerk says.

“The NHS is a public good that is universally defended across the society and the one thing that makes any UK government that tries to dismantle it unelectable. Skilful political leadership and mass communication to citizens across all classes offered demonstrable benefits for the whole of society and achieved this outcome.

”Our society needs to make the choice of what kind of social arrangement we want to see established to build a different kind of inclusive, egalitarian society.

“Once consensus is cemented, the key players need to come on board. We need to move to an agenda of saying people shouldn’t be paying triple or more for services in the private sector that can be provided at much lower cost in the public sector.”

The Red Cross Children’s Hospital has the best paediatric expertise in Africa. It and the Mowbray Maternity Hospital, also in Cape Town, are used and respected by middle-class patients in large part due to the social justice and community-oriented ethos of their staff and managers. These public hospital models can be replicated in provinces that are dramatically underresourced, such as Mpumalanga and Limpopo. 

The University of Cape Town’s head of the school of public health and family medicine, professor Leslie London, was instrumental with professor David Sanders, emeritus professor in the school of public health at the University of the Western Cape, in compiling the joint submission of health stakeholders in SA to the UN Committee on Economic and Social Rights.

Sanders is less optimistic about the NHI’s potential for integrating the fractured health-care system. “We are worried that the way the NHI is going to unfold is going to accentuate, rather than do away with, those divisions because it seems that the government is thinking it can build the NHI on the back of the existing medical-schemes environment, which is a huge problem,” he says.

“Once that gets built into an NHI it will be very difficult to ensure universal access for everybody, because if you have benefits under a system you are not going to be willing to give them up to enable other people to access care.”

London says the government should be building the NHI from the bottom up and focusing on capacitating the public sector “where the most uninsured and the most vulnerable population get care” so it is a real alternative to private health care.

He says this will make it possible for people to see that they can receive good health care in the public sector without paying astronomical medical aid fees.

“The costs of private-sector health care are unaffordable and serve the minority,” London says. Fewer people can afford private medical aid and their benefits are shrinking. “Why should you put into a medical scheme where benefits include discounted air tickets and movie tickets? It is a completely bizarre business, and it is profit-generating so the logic of it is unsupportable.”

Sanders says when he presented the interim arrangements in the NHI bill, health minister Aaron Motsoaledi described streams of funding for five groups. These are people formally employed by large companies; people working in small and medium enterprises; public service workers; the self-employed and the unemployed. He says there is concern that these funding streams will translate into different benefit packages, and that the medical schemes will be involved in deciding on this.

“The unemployed are likely to have a much slimmer package of services than those employed by large companies or in the civil service. This will entrench inequality, which is precisely what the NHI is supposed to overcome,” he says. 

Sanders says another concern is that public money placed in the NHI fund will be used to rescue medical schemes in crisis.