Healthcare that is accessible to all is the foundation on which an equitable and efficient system must be built.
The People’s Health Movement of South Africa notes with concern that some criticisms of the National Health Insurance (NHI) fail to acknowledge that public healthcare in South Africa has been critically underfunded.
Private healthcare consumes over half of the total healthcare spending in South Africa, which only covers about 15% of the population, leaving it inaccessible for most of the population. The public health system is therefore under pressure to deliver services to about 80% of the population.
In a recent article, the Helen Suzman Foundation’s Kate Francis and Michael Edmeston point out that “South Africa spends more on healthcare than our peer countries and yet our health outcomes are far worse”.
This is true.
But the article fails to provide an account of the impact of the current inequity in spending in the public and private healthcare sector. It also fails to offer a solution for how to improve the situation.
The root causes of our poor health outcomes lie in the material conditions under which most people in South Africa live, including socioeconomic inequality, poverty and unemployment; social exclusion; the exploitation of workers; poor education; and overly slow progress in meeting the basic needs of the poor and marginalised through effective service delivery. Such conditions have a profound impact on the lives and health of people: they are known as the social determinants of health.
If we, as a nation, are to reduce our massive disease burden (as well as reduce the load on the health system), we have to address the problem effectively. This requires concerted action by all sectors of government as well as business, civil society and an active, critically aware population.
Health sector reform
But to achieve health for all we also need an affordable, equitable, well-functioning and efficient health system that sees health as a fundamental human right and an essential public good rather than a privilege or a commodity, subject to the whims of the market.
The People’s Health Movement believes that significant and radical health sector reform is necessary and consequently requires public funding. The current health system is unfair and inefficient. It doesn’t have to be. We therefore welcome the move by the government to initiate change within the health sector as outlined in the government’s 10-point plan to improve health.
The success of this initiative depends on whether its primary and central focus is on addressing the health needs of people and that it rejects healthcare as a commodity for profit, which is anathema to good, affordable healthcare.
For-profit healthcare entails perverse incentives, including expensive overservicing and the use of expensive technology often unrelated to genuine medical needs.
It reduces people to “clients” and denies their right to healthcare when they are unable to “purchase” it. Healthcare should be free at the point of delivery to those who need it, rich and poor alike, with no out-of-pocket payments.
The health system, including the NHI should be funded from progressive taxation. Those who can do so must be prepared to make a larger contribution in the interests of social solidarity, recognising that health is a public good that no one can enjoy fully unless everyone has at least basic health.
The NHI should be administered in an open and transparent manner, avoiding the establishment of a costly parallel bureaucracy. It should be accountable and there should be meaningful community participation in the affairs of health facilities, whether public or private.
Move into communities
To be successful, the NHI must ensure a more equal distribution of appropriately skilled and motivated health workers through the re-engineering of primary healthcare. At present, 47% of South Africa’s children live in rural areas where only 12% of doctors and 19% of nurses work.
There needs to be a far greater emphasis on community health workers supported locally by nurses and appropriately trained doctors who have the necessary skills to operate in poorly resourced districts, address health needs comprehensively (including health promotion, prevention and treatment of disease, rehabilitation and chronic care) and to support community-based health workers.
The centre of healthcare excellence should move out of hospitals and into community settings. To achieve universal coverage of essential healthcare and equity, the system should prioritise those most in need, with a particular emphasis on rural areas and marginalised and vulnerable groups.
Efforts to re-engineer primary healthcare depend on the public sector having sufficient, appropriately oriented specialists and doctors as well as nurses who are central to the operation of the outreach teams.The primary healthcare approach entails not only healthcare but a broad developmental approach that addresses the social determinants of health.
This lies beyond the ambit of the department of health and the NHI; it requires close collaboration between virtually all state sectors. But the department of health should play a leading role and ensure that health is a central concern in all development policies and plans.
We realise that achieving such a system faces enormous challenges. The government can and should implement free healthcare for all.
While corruption, lack of accountability and poor management persist in the public sector, these must not be used as an excuse for not delivering free publicly provided healthcare, a proven way to save millions of lives.
Of greater concern is the fact that there are powerful vested interests which seek to profit from the NHI and the health system reforms taking place.
There is considerable and increasing evidence worldwide, however, that there are serious failings inherent in private healthcare provision.
While the private sector may be playing a critical role in access to healthcare in South Africa, there is evidence that private healthcare providers tend to increase inequity of access because they have naturally favoured those who can afford treatment.
Lastly, there is no evidence that private healthcare providers are any more responsive or any less corrupt than the public sector. With this in mind, the People’s Health Movement and a range of other key civil society organisations are in the process of building a broad public campaign for a “people’s NHI”, to ensure that the NHI leads to health for all, rather than profits for the few.
Dr Louis Reynolds is a retired paediatric pulmonologist with considerable work experience in the public health sector. He is an associate professor at the University of Cape Town’s paediatric and child health department and a member of the social justice organisation, People’s Health Movement of South Africa.