*This article is jointly published by Amandla! and the Daily Maverick

A Puzzle

Bad faith is involved when the billionaire President of South Africa and the ANC, who presides over the world’s most unequal country, dismisses the objections to the NHI Act on the basis that “the haves don’t want the have-nots to benefit from what they have been having”

(While economists and many politicians claim that the R370 per month paid to those people who otherwise would have no income, the highest paid mine CEO, from BHP Billiton, receives R685,000 a day.)

Bad faith is involved when (virtually) everyone involved in the provision of private health shout NO! while proclaiming their support for the idea of an NHI. This is particularly so when they use the same arguments, whenever the need arises, over a 20-year period.

Much more than bad faith – as we shall be seeing – is involved in the 76-year-old failure to recognise health as one of the fundamental rights of the Universal Declaration of Human Rights (UDHR) or the older 78-year-old constitution of the World Health Organisation. 

Article 25 of the UDHR declares:

1. Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care.
2. Motherhood and childhood are entitled to special care and assistance.

That the right to health is an “inclusive right” is further elaborated by the WHO in its subsequent document quoted above.  This make clear that the right to health is much more than formal access to health care and hospitals.  The right to health, it notes, “includes a wide range of factors that … help us lead a healthy life.”  Drawing on the UN’s International Covenant on Economic, Social and Cultural Rights, of 16 December 1966, these “underlying determinants of health” involve safe drinking water and adequate sanitation; safe food; adequate nutrition and housing; healthy working and environmental conditions.

Much more than bad faith is involved in the contempt show to the guarantees in our own Constitution. Besides Health, our Bill of Right guarantees everyone 

• “adequate housing” (S26.1) 
• “sufficient food and water” (S27.1.b)
• “Equality …includes full and equal enjoyment of all rights” (S9.2)
• “Environment.  Everyone has the right to an environment that is not harmful to their health or well being”  (S24.a)
• “Human Dignity.  Everyone has inherent dignity” and the “right to have their dignity respected and protected (S10).  

Adding to the contempt is that all these rights are subject to the mandate to the state to

• “respect, promote and fulfil the rights in the Bill of Rights” (S7.2)

and, more specifically,

• “that state must take reasonable legislative and other measure, within its available resources, to achieve the progressive realisation of these rights (S26.2 & S27.2).  

Rather than any expected progress, the 30-year-old and counting neoliberal policies of our government (see here, here and here) have taken us galloping backwards. Moreover, the qualifications of Sections 26 & 27 don’t apply to children.  They have the absolute guarantee of “basic nutrition, shelter, basic health care services and social services” (S28.1.c).

These widely and long-recognised social determinants of health, along with the omnipresence of inequality in all aspects of contemporary South Africa, makes one wonder whether it is cynicism, opportunism and/or wilful blindness that lies behind neither the government nor its many NHI adversaries saying nothing about any of these multiple inequalities that deform our society.  They all solemnly act as health specialist having to decide on the particular cancer cell to treat on a patient riddled with cancer cells.

So, what’s really going on?  A simple answer to a small part of the question is: 

Electioneering

Never mind the cynicism of Ramaphosa’s attack on the rich, including its racist innuendos against the White rich in particular.  The NHI has succeeded in being a temporary diversion for the ANC and its 30 years of failure.  

It was left to the ANC’s Gauteng Premier, Panyaza Lesufi, to be explicit about the rushed timing the reintroduced NHI: 

“After 29 May, if the ANC wins the election, you can go to any hospital of your choice, whether it is a private hospital, public hospital, or private clinic. You can go to a private hospital and get the best experts to treat you. After you have been treated, the government will pay the bill free of charge. That is why we are telling our people to go and vote for the ANC. Gone are the days when, if you don’t have medical aid, you must die.”

The DA’s Gauteng premier candidate was a little more restrained.  He told his audience:

With Gauteng residents’ support in the upcoming elections, we can work towards creating a healthcare system that truly puts people’s needs first and provides the best care possible.  

Opposition to the NHI is more sophisticated than crude electioneering. 

The NHI is a great idea, but…

Business Day’s Editorial – yes, Business Day – speaks for multitudes when it writes:

Access to the generally high-quality healthcare services offered by the private sector is largely the preserve of those with the means to dig into their own pocket or pay for medical scheme membership. No-one in their right mind would argue that this is acceptable. The trouble is the NHI Bill is not going to fix any of it (Emphasis added).

The ‘But’ includes, in no particular order:

• Inadequate, if any, consultation
• Corruption
• Seriously exacerbating the debt problem 
• Undermining the quality of health provided by the private sector
• Incompetent administration and enforcement 
• Ideologically motivated attacks on the private sector
• Detering foreign investment
• Infringing of constitutional rights 
• Flight of doctors, nurses and other health professionals
• Huge tax increases, with no VAT exemption for the poor 
• Unaffordable
• And, in any event, Public Private Partnerships (PPPs) between the State and private sector make the NHI achievable.

This is a formidable list, which is why so many organisations are – or threatening to – go to court.  

Yet, all these ‘Buts’ have been voiced before, some as long ago as 22 years, when the first HNI Bill was introduced.  They were repeated again in 2013 when the NHI Amendment Act was introduced and on other occasions, as we shall see.

The previously quoted Business Day article was from 13 December 2023.  They recently did another editorial on the NHI.  This one makes me wonder how much wilful blindness of the past is involved.  Under the significant headline of “NHI: good politics, bad law”, it writes:

There is no question that SA’s health system needs reform. It is entirely unacceptable that the services people obtain hinge so heavily on their income. Only 15% of the population belongs to medical schemes …, while the rest of the population relies on over-stretched and increasingly decrepit public health facilities or must pay out of pocket to see a private doctor or dentist. Nor can one take issue with the ANC’s commitment to the principles of universal health coverage, in which all patients receive care without fear of financial hardship.

 

Under NHI, the government intends to replace SA’s two-tier health system with a single service that provides care that is free at the point of delivery, with the rich and healthy subsidising the poor and the sick. The trouble is, as has been repeatedly pointed out by economists, healthcare professionals, organised business and civil society, the act will not achieve this noble goal.

The incompatibility of “this noble goal” and private health

Professors Louis Reynolds, Leslie London and the late David Sanders of the Red Cross Children’s Hospital, UCT and UWC, respectively, provide a succinct outline of this incompatibility in the South African Medical Journal of October 2005:

Private ownership implies a fundamental conflict of interest between meeting the needs of people’s health on the one hand, and having to provide profits for shareholders and owners on the other.  This market-based approach, by its very nature, commodifies health services, creates and widens inequities in access between rich and poor, and is anathema to the ideal of health as a fundamental human right.

The Government’s own Draft Health Charter of 2005 – to which we will be returning –complements this outline with 3 fundamental health challenges:

• “The most significant challenge facing the South African health system is to address the inefficient and inequitable distribution of resources between the public and private health care sectors relative to the population served by each” [2.2.7(a)]
• “In the private sector, membership of medical schemes has become increasingly unaffordable, thus widening the gap between the high-income group and the middle-income group in terms of equitable access to health care.” [2.2.7(d)]
• “The challenge is to control the rapid spiral of medical scheme contributions and expenditure.  It is significant that direct out-of-pocket payments, the most regressive form of health financing, account for almost a quarter of private health care financing.  The majority of such expenditure is by medical scheme members (for instance, for co-payments and services not covered by the scheme)” [2.2.7(e)].

Nothing substantial has changed since 2005.  Section 33 of the just published NHI Act, which prohibits medical schemes from covering service proved by the NHI, is the fundamental reason for the private sector’s strident opposition. 

Rather than Section 33, a “partnership” between the public and private sectors is proposed.  Craig Comrie, who chairs the Health Funders Association, and is a proponent of such a partnership, reveals the kind of partnership he has in mind.  For him, it means: 

“Bringing the public health system closer to the private system to improve access to quality healthcare for everyone …”

Doubtlessly, low-cost medical schemes are part of this envisage transition from public to private medical health.  The Health Department, however rejected these schemes 19 years ago, in its previous mentioned Draft Health Charter challenges.  One of them being that: 

“low cost options should not be perceived as, or become, low quality options.  The quality of health services that are offered by low-cost options must be the same as that offered by other options.”  [2.3.5(a)]”

Making private health the sole – or, at least, dominant – party is a common theme.  According to Business Unity South Africa’s CEO designate, Khulekani Mathe, the transition from public to private health requires nothing more than a “minor tweak”.  

Asked by Daily Maverick journalists about the “significant profiteering and overpricing” in the private sector, as revealed in the Competition Commission’s health market enquiry of 2019, Mathe said he was not able to answer the question!

It was a wise decision not to answer the question, even though he was probably unaware that monopoly – or a highly concentrated industry – is capitalism’s natural state.  A state, moreover, that normalises “profiteering and overpricing” everywhere.  

According to a Mail & Guardian article headlined “Hospitals – they’re making a killing”, 3 hospital groups constituted almost 80% of the private hospital market.  The result, according to the Council for Medical Schemes, is that hospital groups are in a position to dictate prices to medical aid schemes. Medical aids, in turn, are becoming less and less willing to cover the inflated amounts.  

The Mail & Guardian article is from 2013.  Surprisingly, little seems to have changed on the hospital front where the “nearly 80%” dominance of the big 3 is now listed as 80% according to the most recent information. There are, however, changes in the medical aid market.  A BusinessTech article from October 2022 notes the “consistent consolidation” in that market has left only 73 schemes compared to the 144 in 2000.  The gap between what hospitals charge and medical aids are prepared to pay is still there, but the gap has subsequently been filled by yet another lucrative health insurance market.  This is further good news for capitalism, and our GDP, which measures the gap market as growth.

Most importantly, for understating the hostile response to the NHI Act is that the profitability of private health – for both hospitals and schemes – remains robustly healthy.  Netcare and its investors have much to cheer about.  Although a single year’s results tells little, it is indicative that FY 2023 profits were up 27.2% to R1.336 billion, Group revenue by 9.5% to R2.3699 billion and a preference dividend of 426.34418 cents, in an economy with a 2023 growth rate of 0.6.  The same – if not more so – applies to Discovery, the largest health scheme.  Its profitability is such that it has branched out into care and life insurance and, as the ultimate expression of financialisation, now has its own successful bank. 

The constraints on this article preclude any mention of the state of (ill)health in the US, other than to say the South African situation is easy by comparison.  This, however, doesn’t diminish the double health whammy in which we are caught:  an unjust private health system alongside the shame of public health after 30-years of post-apartheid democracy. 

Before addressing a possible way forward, brief attention on another related matter is warranted.

Storm in a bedpan 

Both the government and private health interests know that the NHI Act is not to be taken seriously.  The neoliberal policies to which the government seems to be committed in a non-divorce Catholic wedding not only ensures the perpetuation of health inequality but all the other inequalities of a capitalism addicted to neoliberal steroids.  The antagonists to the Health Act, on the other hand, are most able scare mongers.  Even when some of them acknowledge that Section 33 is some 30 years away, all of them beat the drum of the Act’s near-instant implementation, made worse by the horror stories of the additional heavy taxes with which they will be burdened to pay for a decent health service for the poor.

Both sides presumably are well aware of previous court cases against similar NHI proposals that have gone all the way to the Constitutional Court before being finally thrown out.  

Besides the obvious electioneering behind the government’s the Act signed, it also sort of feels duty bound to carry out the decisions of the ANC’s National Conference, this time of 2009, which called for an NHI.  

The defenders of private health know that the leaders of all political parties contesting the May election are, by a common class interest, ultimately on their side.  My guess for their nonetheless hysterical reactions involves two considerations.   First, to reassure investors and, second, to remind the government – if such reminding should be necessary – that they will use all avenues to protect their precious vested interests.

The disappearance of the previously mentioned Draft Health Charter of 2005 is but one of the reassurances available to the private sector. (See below for the mystery surrounding the Health Charter).  It is almost certain that this Health Charter is unknown to most people.  I know it only because I happened to be working for the South African Municipal Workers’ Union (Samwu) at the time and Samwu received an official invite to comment on the draft.  Samwu did.  Its formal submission of August 2005, noting that the Draft contained two incompatible parts, continued:

“The first part is a sustained and incisive critique of privatised health.  The unambiguous message of this part … is that making money out of health is as exceedingly profitable for the few as it is harmful to the many.  The Charter is clear that the nation’s health is impoverished by the wealth of the business that thrives on sickness.  

 

“Yet, incredulously, private health has nothing to fear from the Charter.  The Charter’s 2nd part simply ignores its own critique of the mixing of profit maximisation and health.  Wealth, not health, ends up as the Charter’s raison d’etre.  The honeypot of private health remains secure provided only that some space is made for black spoons.  The Charter’s concluding preoccupations with black elite enrichment obliterates its own exposure of how the nation is made sick by private medicine”.  

The unamended Draft was adopted to become the “Charter of the Public and Private Health Sectors of the Republic of South Africa” of 2005.  Mysteriously, this Charter is not to be found on Government websites.  It is preserved thanks to the invaluable Parliamentary Monitory Group.  However, it is not clear whether the PMG preserved the Draft or the actual Charter.  Shorn of its many provisions promoting black private wealth, the reason for the effective disappearance of the Charter is likely to be its utter reasonableness. It’s provisions likely to have been too challenging to both public and private health, the former recognising that government policies were inimical to the Charter provisions and the latter unwilling to be anything more than a healthy recipient of profit.

Nineteen years later, in 2024, the challenge to those of us not in government or the private sector is even more pronounced – and urgent.  

A way forward

The Charter (without its promotion of BEE) provides the blueprint of what still needs doing in the public sector, as minimum preconditions for a single-tier, universal public health system, whether or not in the form of the current NHI.  Tackling private health without a reasonably adequate and functioning public health would be to ensure the active opposition of many health professionals and members of private schemes who would otherwise be supporters of a single-tier free health system.   

The best expression of the Charter’s guiding principle is the previously quoted utilitarian one about being the most effective and efficient use of both natural and human resources to meet the health needs of the great number of people (S1.1). 

The continued existence of the private sector and its important role in providing health care is recognised throughout the Charter.  This includes the government taking the “interests and views” of the private sector into account when introducing “legislative and other reforms”.  

Equity is a connecting theme of the Charter, which it defines as

“the fair and rational distribution of an affordable package of quality health care services to the entire population of South Africa, irrespective of patients’ ability to pay for such services” (S1.2)

Integral to equity is to

“develop a minimum defined basic package of health services … available as the health care safety net for all … irrespective of their ability to pay” (S2.2.1, 2.2.2, 2.2.5a)

Quality of service is another major objective.  To this end, the public sector resolves to improving the quality of its service by

“Implementing comprehensive Employee Assistance Programmes to support and assist the health care personnel employed by them (S3.3.2)

 

“The implementation of benchmarked quality assurance programmes that include a quality monitoring system and the measurement of health outcomes” (S3.3.4)

All the above depend on trained staff in adequate numbers.  The Charter fully recognises that this is not the case, in 2005! (S2.2.6.a).  It specifically identifies specialised nursing, general medical practice, specialised medical practice, clinical technology, pharmacy, radiology and pathology.  Moreover, it notes:

If the skills necessary to ensure access to a basic minimum package of care and services are not maintained throughout the national health system, then access is not achievable. (S2.2.4.b)

Additionally, acknowledging that proper levels of staffing is “central to the question of equity in health”, it concludes 

“appropriate numbers of suitably qualified and trained health care personnel must be assured throughout the national health system” (S2.2.6.a)

With finance being central to equity, the Charter calls on private health to “contribute to promoting equity” by “commit[ing] a fixed proportion of their annual income” on public health and related initiatives (S3.4). (This ‘fixed proportion’ appears in the Charter under BEE.  I’ve retained the idea because of its importance.)

No way forward without changes to the political economy 

The social determinants of health mean that even if a government were to pick on health amongst the plethora of inequalities plaguing South Africa, it couldn’t do so without also and equally addressing water and sanitation, housing, food insecurity, and levels of social benefits as priority areas all contributing to poverty and its reproduction.  

This government-from-the-future would, unavoidably, have to address the cause of the many faces of poverty.  Capitalism is not the immediate answer.  The government need only be committed to removing the neoliberalism embedded in so much statute and policy.  

“Only” is a single word, but so much depends on it. This is the challenge facing those readers who agree with much, if not all, of what I’ve written. 

I write just days before the national election that will change nothing.  

Jeff Rudin works at the Alternative Information and Development Centre and is a member of the Amandla! Collective.