Apartheid built healthcare inequalities NHI must dismantle them

Author: Aaron Motsoaledi

LIKE birth, revolution is characterised by blood and pain. In a revolution or any radical change, there are two contesting forces – one fighting for change and the other for the status quo. It is understandable that the beneficiaries of the current order will fight tooth and nail to stop the revolution – and National Health Insurance is a revolution in the provision of health. The battle over the implementation of universal health coverage, a plan endorsed by the World Health Organisation, is not happening only in our country.

In the US, for instance, Obamacare, the US version of universal health coverage, is under attack by the new administration of President Donald Trump. We have our own Trumps in South Africa – those who are beneficiaries of a system that benefits the minority and excludes the majority oppose the NHI on ideological grounds. They do not want equity with regard to healthcare provision. They argue that the state should leave private healthcare alone and rather sort out the mess in public health facilities. They argue that the poor management and incompetence that characterise the public healthcare sector should not be exported into a private sector that works well.

It is true that the public healthcare system faces serious problems, but this is not a uniquely South African phenomenon. The UN and the WHO have identified the extreme inequities between the wealthy and the poor around the whole world as the cause of these problems. They prescribe universal health coverage as the remedy. The outgoing director-general of the WHO described it as an equaliser between rich and poor. But critics of the public care system deliberately choose to ignore the link between cause and effect. To them the problems faced by public healthcare are because of the sheer stupidity of those running it. They ignore the fact that the state of public healthcare is not an accident of history. It is a product of these inequities. Over the years, the public health system has been systematically stripped of resources – both human and financial – as these were directed towards the private sector. This was achieved by pooling funds to access good quality care for a select few South Africans in the form of medical aid. With medical aid, huge amounts were siphoned from the public purse through huge medical aid subsidies camouflaged as a condition of employment. It was also achieved through very generous tax rebates and credits directed at the few South Africans who were able to join a medical aid. These are the resources propping up the private sector, without which it would not be sustainable. This has the effect of compromising the efficiency, effectiveness and quality of the public health sector, because naturally human beings follow resources. So, it is logical that most of skilled health professionals followed the resources in the private sector, leaving the public sector all the poorer.

This subtle and stealthy re-allocation of resources to the haves started in 1967 with the proclamation of the first medical scheme. It started as a whitesonly system and was later extended to a few blacks, which is where we are today. Ironically, 1967 was the year that public healthcare demonstrated its supremacy when it delivered the world’s first heart transplant, where the recipient did not have to be a have or a have-not: it did not matter, he was just a patient.

Unfortunately, 50 years down the line, due to this movement of funds, we wake up with 4.4 percent of GDP supporting the health needs of 16 percent of the population on one hand, and 4.1 percent of GDP spent on a whopping 84 percent of the population on the other. Blaming the public healthcare system for poor performance under these conditions is no different from giving blacks an inferior education for 50 years – with most of the resources pumped into white education – and then turning around and blaming blacks for poor educational outcomes.

Democracy cannot reverse this because it only afforded us equality before the law, not equality with regard to resources. This analogy of the healthcare system with Bantu education is lost on many people because discrimination in this case is based not on colour and race but on money, and a few blacks have been co-opted to have access to private healthcare. NHI is designed to do away with any form of discrimination, subtle or obvious, regardless of colour, creed, or social or economic status. It has been rubbished as too expensive, a plan that will collapse the quality of healthcare in private and public hospitals.

Repeatedly, we are told we should rather focus on ensuring public hospitals are well equipped and have adequate staff, and leave private healthcare alone. The issue of NHI being too expensive is a fallacious argument. It is also morally bankrupt. Actually, the system that is more expensive is the current one that allocates 4.4 percent of the GDP to the healthcare needs of 16 percent of the population. No other country does such an illogical thing.
Because they are aware of the moral bankruptcy of their argument, opponents of NHI try to hide behind the interests of the poor to advance their argument. They argue that the labour movement would not accept NHI because this would affect their members’ medical aid benefits. Nothing could be further from the truth. In fact, Cosatu, the biggest labour federation with more than two million members, is on record saying we are moving too slowly on implementing NHI. They understand that the current situation is not sustainable. Medical inflation is more than double the rate of inflation every year but the benefits in medical aid schemes are shrinking. But as we argue for social justice in the provision of healthcare, we should also explode the myth that NHI wants to do away with the private healthcare system. NHI is a funding model that will ensure all South Africans have access to health in both private and public health facilities without regard to economic status.

Why should this be viewed as a bad thing? It is possible that those who see private hospitals as exclusively reserved for the rich may fear that poor people will “invade” their space. But how do we justify the status quo? It is time that we isolate those who want to perpetuate inequalities brought about by apartheid planning. It is time that we urge all progressive forces to join hands and push for the rapid implementation of NHI.

Dr Motsoaledi is Minister of Health

Source: Sunday Times