By Mark Heywood

The rich and middle class can purchase life and health through the private health sector. But the unemployed and poor must take their chances in the public sector…The Constitution gives everyone in South Africa the right to ‘access health care services’. But despite this, the harsh reality is that since the late 1990s the quality of public health care services in South Africa has declined dramatically.

In the same period, the need for health care has increased, primarily because of the AIDS epidemic.

The Constitution also says everyone has a right to equality and dignity. But, despite this, increasing inequality in access to health care has become a gross manifestation of class inequality in post apartheid South Africa. The rich and middle class can purchase life and health through the private health sector. But the unemployed and poor must take their chances in the public sector, which often not only fails their health needs, but can sometimes make an illness even worse because of poor hygiene and infection control.

Much of the blame for this crisis can be put at the doors of former Health Minister Manto Tshabalala-Msimang and President Mbeki. But they are easy scapegoats. Their denialism about the AIDS and health crisis masks a decade of systematic underinvestment in public health care. It also hides a largely laissez-faire attitude by the ANC government to most aspects of the conduct of private health care providers.

However, under the presidency of Jacob Zuma a wind of change has begun to blow into the health system.

For a start, the ANC leadership now admits that there is a health crisis. They no longer deny each new exposé of the intolerable and undignified conditions in which people are supposed to access health care. Similarly, the ANC also recognises that a crisis of epidemic disease rages in SA. Thousands die weekly of HIV-related illnesses, including TB; mothers die in childbirth; diseases of malnutrition stunt and kill infants, and a growing epidemic of non-communicable diseases (diabetes and cancer) has begun to further sap our health resources.

In this context, during 2008, the ANC developed a ‘10-point plan’ to address the crisis in health. In addition, the ANC has committed to the introduction of a system of National Health Insurance (NHI) within five years.

What is NHI?

There are various models of NHI, but the one being proposed by the ANC can be summarised simply as follows:

• It is a system of funding that will be introduced through a new law.
• It will create a single pool, called the National Health Insurance Fund (NHIF), for all money that is spent on health. Into this pool will be put the money that the government already allocates every year to health through the budget. The ANC has accepted that the public health budget must be increased to 5% of GDP (it is currently only 3.5%). Whether the Treasury does is less certain.
• But the crux of NHI is that this fund will not only include money from taxes. It will be supplemented by a ‘mandatory contribution’ that will be made by all people over a certain income threshold – an amount that will increase progressively according to a person’s income. Put simply, this means that people who earn more will pay more. People who are unemployed or below a defined income threshold will not have to pay anything at all.
There will no longer be user fees or co-payments for health care.
• It is intended that this fund will be used to pay for all health care services in South Africa. Every South African citizen and permanent resident will have an equal right to have his or her health care needs paid for from this fund. He or she will be permitted to use either a public or a private health facility to obtain this care.
However, NHI will not fund health care for undocumented migrants and refugees – this is a violation of the constitutional right of ‘everyone’ to have access to health care services. In a country like ours, where there are so many foreign nationals, it is also bad for public health, as transmissible diseases like TB do not discriminate on the grounds of nationality!
• The ‘comprehensive package of healthcare services’ that NHI will cover –and to which people will be entitled as a right – will be defined by the National Department of Health.
• Medical aid schemes may exist. But they can only register members for services over and above the NHI package of care.

What to do with the private health sector?

The government has a constitutional duty to create a health system that ‘progressively’ meets the needs of those who most need and can least afford health care.

There is nothing unlawful about the existence of two health systems. However, as they currently exist, the private health system undermines the public one by consuming an unjustifiable amount of resources. It seems to be oblivious to many national health priorities, including providing treatment to people with AIDS.

The aim of NHI is to knit the two systems together in order to make it possible to ‘progressively realise the right of access to health care services’. According to the Minster of Health, NHI will not do away with the private sector. Instead, it aims to create a single platform for health care that will utilise health workers and facilities from both the public and private sectors. It will pay each service provider for the services they provide.

However, making this possible does not just require that there is equal access to funding to pay for health services. It also necessitates equal access to health facilities that can provide a common standard and quality of care.

This is one of the most immediate challenges for NHI.

For activists to participate effectively in the discussion about NHI, a number of misleading ideological assumptions about health care need to be dispensed with. One is that only rich people access private care. This is not true. Thousands of trade unionists are members of medical aid schemes. In addition, because of the terrible quality of the public health sector, its queues and unpredictability, poor people often opt to pay out of pocket for whatever health service they think they can afford.

Another myth is that the private health system is large and that if it was opened to poor people it would resolve many of our problems with capacity. This is not true either. The private health system is expensive.
It consumes an unequal and large part of resources for health. But most of its facilities and professionals are in urban areas. So, access to health care is not only determined by class, but also by geography.

The reality therefore is that the success of NHI is dependent upon rapid reform and improvement of the quality and capacity of services in the public sector. This must be combined with price regulation of services and facilities provided in the private sector.
As we implement NHI, the initial aim should be to make it possible for more people to access affordable and quality private care. This would take some of the pressure off the public system whilst it is being upgraded and improved.

Should social justice activists support NHI?

Pro-poor civil society should support the principles of equity and equality that underlie NHI and campaign for the rapid implementation of a reasonable and sustainable NHI system.

The rights to equality, life and dignity justify the government’s intention to increase cross subsidisation by the wealthy to the poor within the health system. As a result of important legislation to regulate medical schemes, particularly the Medical Schemes Act, the fraction of the population who are on medical aid schemes cross subsidise each other. However, while all taxpayers contribute to the public system, whether we use it or not, the budget allocated to health is not sufficient. As Di McIntyre has pointed out, the result is an inequitable distribution of resources and benefits.

So the motive for NHI is a good one. The question is what should the plan look like and what needs to be done to make such a plan possible?

Unfortunately, so far, the debate about NHI has both excluded the poor and has raised unrealistic expectations about what NHI can achieve. It has also led to a polarisation between those who support NHI and those who are critical of it. Branding all critics of what is currently proposed as ‘class enemies’ (as the SACP has done) risks preventing a critical engagement with the policy that is vital to its success.

It is important to stress that NHI is not a panacea. It will not deliver quality in health care automatically. In fact – if the public sector is not rapidly improved – it could increase inequality because, although there will be a single funding pool, much of these funds will flow back to the private sector if the public sector is not able to compete in quality and access of services by the time it is introduced. The facts in the box below are telling in this regard:

A plan of action on NHI

We need a plan for NHI that is rooted in the Constitution and that is capable of providing quality health care for all people who are in South Africa, including foreign nationals. To achieve this, democratic, popular organisations, trade unions and all affected by issues of health should recommend:

• A call for government to publish the proposal on NHI and hold public hearings on the plan;
• A call for public hearings on the comprehensive package of care that all people should be entitled to;
• A call on communities to mobilise for a quality public health system by joining clinic committees and hospital boards, monitoring services, demanding sufficient funding and exposing corruption and mismanagement;
• A call on government to introduce legislation immediately to regulate prices and quality of services in the private sector;
• Mobilise communities, unions and churches to ensure the implementation of the national Strategic Plan on HIV/AIDS and STIs by 2012.

Mark Heywood heads the AIDS Law Project and is a social activist involved in the Treatment Action Campaign.