President Cyril Ramaphosa recently signed the National Health Insurance (NHI) Bill into law, launching what some might call a grand leap into the unknown. Heralded as a panacea, the legislation is fraught with — to use a favourite ANC descriptor — challenges. But why let that stand in the way of a good idea?
Ramaphosa also signed the Basic Education Laws Amendment (Bela) Bill into law, only to halt its implementation after grumbling from the DA. It raised the question: if Ramaphosa is willing to pause the Bela bill, might there be room to also reconsider the far more significant NHI?
The UK faced similar questions when it founded the National Health Service (NHS). Its architect, Nye Bevan, declared that “no society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means”. Stirring words, but implementing those ideals has been daunting — even for a country such as the UK, where the system is creaking under the weight of its own expectations.
SA has spent about R3-trillion on healthcare over the past 30 years. But given the state of our public hospitals one could be forgiven for wondering where that money went. By comparison, the UK, with a similar population, spent £3.1-trillion during the same period. Adjusting for purchasing power parity, SA spent about £500bn in UK terms, while the UK’s spending would be about R18-trillion.
More spending doesn’t guarantee success. Despite the huge spend the NHS has become a byword for failure. If the NHS faces existential challenges, what are the chances of the NHI succeeding in a country in which mismanagement and corruption are comprehensively embedded?
Reconsider legislation
The question is whether the NHI has any hope of delivering the healthcare SA so desperately needs. With our government’s history of bungling large-scale projects — Medupi, Kusile and a parade of unfinished infrastructure white elephants — it is hard to be optimistic. The NHI could well become just another enormous state-driven project, bleeding funds with little to show for it. One might wonder whether the “I” in NHI stands for “Inanity” rather than “Insurance”.
Predictably, the DA has come out swinging against NHI, as it did with the Bela bill. But here’s where things get interesting. Ramaphosa’s decision to halt Bela’s implementation signals an opportunity, but the president, ever the tactical player, has shown that he’s willing to reconsider legislation when politically convenient. Could the DA nudge him into a rethink on NHI?
Alas, political agility is not exactly the DA’s strong suit. Despite its opposition to state overreach, the DA often finds itself entangled in awkward coalition politics. A bit of subtlety, or perhaps a well-timed proposal for a genuine healthcare alternative, could serve it well. But nuance and strategy are qualities the DA is still cultivating — often a tad slowly.
Meanwhile, Ramaphosa has demonstrated his uncanny ability to mollify opponents by giving them just enough room to criticise, while deftly maintaining control of the narrative. The DA faces a dilemma: rail against NHI from the sidelines, or offer firm alternatives and risk shaking the fragile GNU. If it chooses the former, it may find itself increasingly irrelevant; if the latter, it might just turn the tide.
No-one doubts that SA’s public healthcare system is in dire need of reform. With a government track record that hardly inspires confidence, many fear NHI may end up as yet another aspirational failure in the making. And yet, here we stand — on the edge of another sweeping reform, gazing into the abyss of state-driven utopian promises.
Ramaphosa’s careful dance through these legislative hurdles reflects the fine art of political manoeuvring in a coalition-dependent democracy. The DA, for its part, must decide, especially as it sits on the brink in Tshwane — but that’s a story for another time.
As always, the pigeons, metaphorically speaking, will have the final say — whether they’re perched on statues or hospital roofs.
• Cachalia is a former DA MP and public enterprises spokesperson.
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