Health system reform is both necessary and possible. As The Economist magazine noted in 2018, “universal healthcare, worldwide, is within reach: the case for it is a powerful one — including in poor countries”.
Poorly run and exclusionary health systems undermine education, discourage entrepreneurship, reduce worker productivity and slow economic growth. As a result of sensible reforms, middle-income countries such as Thailand, Chile and Costa Rica now enjoy health outcomes similar to those of high-income states.
We know private care is no long-term solution even for its beneficiaries. Information asymmetries in the health sector mean we do not know what treatment will benefit us, and the incentives confronting treatment providers result inexorably in waste, spiralling healthcare costs and higher premiums.
However, despite the imperative and potential benefits of reform, there is little relief to be found in the National Health Insurance (NHI) bill that has finally concluded its tortuous journey through parliament’s legislative process. This is a deeply disappointing product for a decade or more of deliberation.
We should remember that the legislation does little to nothing to tackle the key determinants of SA’s poor health outcomes. It will not divert resources from ineffectual treatment programmes towards prevention and health-building initiatives. It will not dent growing obesity, cardiovascular disease and poor nutrition. It will not improve an education system that denies young people the knowledge they require to look after their own health and that of their children.
It will not bring the affordable electricity that is needed to end indoor coal and wood burning, and it will not resolve the epidemics of HIV/Aids and drug-resistant tuberculosis, reduce the toll of traffic accidents, or prevent violent deaths attributable to alcohol. In addition, it will not create social support systems to reduce the burden placed by the old and vulnerable on expensive health facilities.
Moreover, basic and appalling problems of mismanagement and corruption in the public health system will not be addressed by an NHI. Indeed, even many strong proponents of an NHI have noted that the proposed reforms are likely to invite further corruption.
Worse still, the NHI bill falls short of our most basic expectations of credible planning. First, it does not set out, even in broad terms, an implementation plan. How do we get from where we are today to where parliament intends we should be tomorrow?
Second, this is a financing scheme but it does not seem to be based on any credible plan for sourcing the revenues required for enormous new recurrent expenditures.
Third, SA discovered in the earlier years of the HIV/Aids pandemic that the key constraints on health system intervention are human rather than financial resources. The NHI proposes breath-taking changes in the organisation and everyday activities of health sector workers. Yet there is no credible strategy for securing support — or even acquiescence — from the extremely mobile health professionals on which the system will depend.
On the government side there has been much tedious self-righteousness, and a failure to accept that its own credibility has been lost. The ANC can scarcely complain when its promises about NHI are greeted with incredulity. This has been made worse by the implication that those who oppose the current bill are simply heartless.
Opponents of NHI sometimes appear selfish and uncaring, but they are mostly motivated by anxiety — and it is perfectly understandable to be scared of dysfunctional public hospitals and clinics. Moreover, such fears are evident across the middle class, black and white. This stubborn political fact will probably ultimately defeat the wearyingly dogmatic champions of the current iteration of NHI.
Hopefully, there is still time and space to return to more productive deliberation about how to realise the potential gains universal access can bring.
• Butler teaches public policy at the University of Cape Town.
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