Dr Mpho Phalatse explores the current situation surrounding the National Health Insurance debate
On 12 June 2023, the NHI Bill was passed by the National Assembly, with the National Council of Provinces giving its concurrence a few months later, on 6 December 2023. This in spite of loud and deafening dissenting voices which continue to echo warnings of impending disaster should the NHI be implemented in its current form.
However, in its current form, the NHI will not see the light of day—not in our lifetime. From the point of view of its affordability to governance challenges and transitional mechanisms, there is no reason to believe that the South African government would be ready within the proposed timeframes to enable its implementation. Having just transitioned from healthcare governance in SA politics, to the patient-provider interface in private healthcare, I have no confidence that the NHI will succeed.
The idea of universal health coverage is a noble one and is something SA should aspire towards. As we commemorate 30 years of our democracy, this is an opportune time to reflect on progress made against all legal and constitutional provisions aimed at improving the lives of South Africans. If the signing of pledges and subscription to such noble ideals as universal health coverage were key performance indicators, South Africa would come out with flying colours. The proof of commitment must be in the lived experiences of its citizens. Public healthcare in SA has collapsed. The sick queue in a scramble for hospital beds. Hospitals have no medicine. Money that should be used for medical care is used for diesel for backup generators as loadshedding threatens to turn hospitals into valleys of death.
Volumes have been written with our commitment to universal health coverage. As a member of the United Nations and a signatory to the UN Sustainable Development Goals, SA subscribes to Goal 3.8 which seeks to “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. The World Health Organization defines Universal Health Coverage as “all people having access to the full range of quality health services they need, when and where they need them, without financial hardship”. The Freedom Charter, a vision upon which most support for the ruling party was premised in 1994, states that there shall be “free medical care and hospitalisation…for all, with special care for mothers and young children”. Section 27 of the South African Constitution also recognises access to healthcare for all as a basic human right, and urges the state to “take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of” this right.
Today, the majority of South Africans still aspire towards this ideal of access to quality, affordable healthcare for all, regardless of socioeconomic background. And while at face value the healthcare disparity seems to move along the public-private divide, the problem runs much deeper with private healthcare displaying its own internal dichotomies. In 2008, following the completion of my proverbial Zuma year of community service at Jubilee Hospital in Hammanskraal, an exciting new challenge fell on my lap. I was offered a job opportunity away from the dreaded and under resourced public health system I had known throughout my training and in-service years, to a private hospital in a mining town in Limpopo. My orientation at this mining hospital was quick and to the point, and while there was care to familiarise me with all the service points, a disturbing theme began to emerge. Patients were not equal, and the type of care given had to strictly align with this ethos. From the separate medicine cupboards in the casualty, to the distinct cubicles in the wards, the varying frequency of ward rounds, and believe it or not the time spent with each patient—the blue collar-white collar divide prevailed even at the point of preserving life. Disconcerting as this was, it was alarmingly characteristic of the South African healthcare situation where some animals are more equal than others.
According to a 2017 StatsSA report, medical insurance was only enjoyed by 17% of the population while the rest depended on the public system. If my years of serving as MMC for Health in the City of Johannesburg between 2016 and 2019 are anything to go by, rural communities are not unique in their lack of equitable access to healthcare, within the WHO prescribed 5km radius. Majority of people who live in informal settlements and townships in the big cities endure the same circumstances. It is only through innovative service delivery models such as the mobile clinics that we rolled out in the City of Johannesburg in August 2019 that some of our residents could have access to healthcare. Sadly, many other parts of the country still await their turn at a capable, caring government.
The public has lost confidence in the ability of government to provide services, let alone large scale reform programmes of the magnitude of the NHI. If anything, the public has become very suspicious and cynical about anything coming from government. The gross mismanagement of the COVID-19 relief fund and lack of real consequence management has sapped all that was left of public trust for government. How, for instance is the public to trust that under the NHI public hospitals will have adequate medical staff—doctors and nurses—when qualified and unemployed doctors are roaming the streets whilst hospitals are short staffed? What measures will the NHI put in place to incentivise doctors and nurses to stay instead of emigrating? There is no doubt that the proposed alienation of medical aid schemes and the concomitant erosion of patients’ freedom of choice will set the stage for constitutional court challenges. These are just but a few of the red flags pointing to a National Health Insurance that is dead on arrival.
Just a month ahead of the most highly contested South African general election to date, major opposition parties have denounced this looming health systems catastrophe. While we can all agree that access to quality, affordable healthcare for all is a non-negotiable, it is clear to most that we are still a far cry from achieving it—not with the NHI as the proposed pathway to change. Panic remains in the minds of many as they watch in trepidation the wheels of law-making turn in favour of this calamity. Yet we ought not to miss the opportunity presented before us. Two critical success factors surface as we ponder on what would secure our health. A capable state on the one hand, and a stable government on the other. Coalitions at local government level have been unstable at best, thwarting any vision of governance continuity in a political landscape that is increasingly becoming fragmented. Programmes are aborted in favour of unhinged power and illicit financial flows. Real growth is at risk, unless we choose wisely as South Africa’s electorate. This democracy that our predecessors have fought for, empowers us to be architects of our own destiny. Let us not abdicate our responsibility to design our fate and that of future generations. Our first responsibility is to show up at the polls. Our next is to be intentional to not prodigalize this charge. Parties should be assessed on capability and propensity to hold the forte in the face of contestation. We the people will govern, and we will choose universal health coverage. It is not the NHI—at least not in our lifetime.
Dr Mpho Phalatse is the former Mayor of Johannesburg.
