Just 15% of us enjoy first class private healthcare while the rest of the population must rely on an underfunded and poorly resourced public healthcare system. It concerns me that this may be just another aspect of our very unequal society that we have learned to see as ‘normal’ or ‘natural’? Perhaps (privately) readers of this article believe they deserve better healthcare treatment because they can afford to pay for it? Or perhaps you believe it is a great pity, but inevitable, that poor people will get sick and sadly die younger as they can’t afford to look after themselves. If there is a fundamental reason NHI is needed in South Africa, it is to jump-start the idea that basic healthcare is a moral obligation rather than a financial opportunity.
So how unequal is our healthcare system? Consider this: 60% of funds for health services are directed at the 15% of the population which is covered by private health insurance. Only 40% of the funds are used to pay for the public sector that serves 85% of the population. In more concrete terms, less than 30% of doctors, dentists, pharmacists, physiotherapists and psychologists and only 40% of professional nurses work in the public health sector. Added to this, vacancies in the public sector remain alarmingly high, and appear to be on the rise again. Currently, just over 42% of health professionals’ posts in the public sector are unfilled, up from 34% last year. Almost 60% of professional posts are vacant in the Eastern Cape and 70% in Limpopo.
Indeed, government’s Millennium Develop Goals (MDGs) Country Report presented at the UN in New York last month painted a very bleak picture of our maternal and child mortality rates. It says the MDGs aim to lower infant mortality rate to less than 18 deaths per thousand live births, is “unlikely to be reached” in South Africa. Equally distressing is the fact that the maternal mortality ratio has actually got worse. The MDGs call for a ratio of 38 deaths per 100 000 live births by 2015. But in South Africa in 2001, 369 mothers died giving birth and alarmingly, the figure went up to 625 in 2007.
This may have come as a shock to some but most people in South Africa continue to experience the devastating effects of poverty, unemployment, a maturing HIV/AIDS epidemic and the global economic recession. If only, one might argue, everyone could be on a medical aid and benefit from our wonderful private healthcare. But as UCT research has shown, medical scheme cover is becoming unaffordable for an increasing number of families. In the early 1980s, medical scheme contributions for a family took about 7% of average wages and salaries across all formal sector workers. This had increased to 14% by the early 1990s, 20% by the early 2000s and a staggering 30% by 2007. The serious failures by both the public and private sectors to address our health crisis and the well-being of our nation is a daily reality for most of us, experienced in different degrees of crises or levels of concern. It remains an increasingly threatening trend that can reverse the chequered but real gains we have made as a nation since 1994.
According to the ANC’s discussion document, the NHI is aimed at providing affordable, universal health coverage to all and will be implemented in phases over 14 years, starting in 2012. Business has been quick to express its concerns over the affordability of a NHI scheme. Government has stressed the importance of revamping our hospitals and civil society organizations, such as ourselves, have underlined our Constitutional commitment to health. We hope this all signals the beginning of a robust debate on the principles at stake as well as much deeper public engagement with the (until now undisclosed) policy work of the Minster’s Advisory Committee on NHI which was formed in December last year.
Questions of the appropriateness of different healthcare systems cannot satisfactorily or comprehensively be addressed, however, until there is clarity on the values that should drive the system – and these values should be determined by the citizens of the country. Some experts are cynical of public involvement, saying the narrow interests and limited expertise of the public shouldn’t be considered when it comes to health policy choices and preferences. But we would argue that if you want the public to pay for it, then they should be consulted and their preferences should count. Besides, to propose that citizens get more involved in health system decision making is not new – more than 50 years ago, the World Health Organisation (WHO) proposed a move to have the values of citizens drive decision making when it comes to health systems.
There is an urgent need to develop an effective way of eliciting public opinions on health policies so that “what the people want” can be fed into the policy development process at an early stage. The Black Sash, in partnership with the Health Economics Unit (based at UCT’s School of Public Health and Family Medicine) and Health-e began a series of provincial consultative workshops in May this year in an effort to understand public preferences on the principles that should guide a reformed national health system. We asked people to consider how they would fund a healthcare system in South Africa and prioritise spending. For example, at our workshops in the Eastern Cape, KZN, Western Cape and in North West, we asked people to consider which of the following options their community would choose:
A. If a person tends to be more sick than others, they should pay more towards health care.
B. If a person has more money than others, they should pay more towards health care.
C. Everyone who is able to pay should pay the same amount towards health care.
Delegates considered these questions seriously, taking note of a range of demographic, economic and health information, and weighing the implications of different choices with care. Interestingly, most of the participants so far have promoted some form of social solidarity when it comes to funding our public healthcare. Participants who themselves came from struggling and poor communities said they would be willing to contribute financially to ensure that the sick are subsidized by the healthy and the poor by the wealthy. Participants were also of the view that regions in need should receive more funds, and that this allocation of monies should not be based on their region’s economic output. Importantly, delegates also highlighted other critical factors to support healthcare spending such as infrastructure development and transportation services.
It has been heartening to see how the spirit of “ubuntu” is still alive and well in South Africa. In our provincial workshops, we believe we are seeing emerging evidence for a social contract that benefits all. And let’s face it, when it comes to the health of a nation, we are all in this together. Pooling the risk and the cost must be the most efficient way to create a healthier society. It’s depressing that many privileged high-income earners don’t share this view and worry only about whether or not someone receives more than his or her “fair” share or more than what they’ve paid for. In other developing countries, the rich and poor have to share resources, where they live and work, how they travel and have more equal access to healthcare services. Perhaps one long term additional benefit of the proposed NHI scheme would be an end to persistent separation between rich and poor in South Africa. It may just help heal our aberrant psyche of enforced separateness.
In the ensuing discussion around the proposals put forward by the ANC, the country must find a workable formula to fund this policy in a way that benefits all of us equally. Public debate, therefore, should focus on creating a “healthy” nation. Instead of saying health system change is unaffordable, let us focus our energies on how we can achieve a sustainable, integrated healthcare system – one that results in improved health status for all South Africans and one that brings our nation together rather than dividing us even further.
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