The passage of the National Health Insurance Bill by the National Assembly brings South Africa a step closer to introducing the government’s plans for a sweeping overhaul of health funding.
This will, in essence, bring almost all health funding under state control, establishing a monopsony – a single buyer – for all healthcare goods and services. It’s fair to say that this would be one of the most fundamental changes to South Africa’s political economy since the transition to democracy – and one of its most hazardous.
The keystone of the NHI concept for its proponents has been articulated by the deputy director general of health for NHI, Dr Nicholas Crisp: ‘every person getting the help that they need when and where they need it, without financial hardship.’ In conceptual terms, this is expressed as ‘social solidarity’, meaning that everyone across society would take responsibility for the wellbeing of each individual: the more affluent would fund the poor, and the state would ensure that all resources are used prudently and equitably.
It’s a compelling appeal, but on the last point, in South Africa, unconvincing. On the basis of bitter experience, there is very little reason for confidence in the capacity of the State to manage anything. The scale of malfeasance that accompanied the Covid pandemic highlighted the venal opportunities that the transformation of the healthcare economy into a state monopsony would offer.
That, incidentally, is a response to Dr Crisp’s rhetorical comment: ‘We put about R50 billion into employees’ medical schemes. Why put it in medical schemes instead of putting it into the NHI?’ Precisely because NHI will be overseen by the State. And with health expenditure running at 8.6% of GDP (2020 World Bank figures), there is an enormous incentive for looting.
Lucre
The government has itself undermined the very social solidarity (at least its own role in it) on which the proposed system is premised. NHI itself would be a new State-Owned Enterprise whose explicit function would be to collect and spend money. Neither Eskom, South African Airways nor Transnet would present comparable lucre.
All of this poses a particular threat to South Africa’s hard-pressed middle class. The ability to access excellent care – whatever its limitations, and there certainly are many of these – is one of a diminishing set of quality-of-life factors for them. Take this away, as care is dependent on resources husbanded by a rapacious and inept state, and it would fatally compromise the ability of the middle class to maintain a middle-class lifestyle. This would be a major impetus for those who can (and those on whom a functional society depends) to head for the exit. Expect medical practitioners, now directly dependent on the state for their living, to be disproportionately represented among them.
With some irony, major losers in this scenario would be one of the key beneficiaries of ANC rule: government employees, whose state-backed medical aids would presumably be abolished as NHI provided ‘universal’ coverage.
The response might be that the above is alarmist, and besides, since everyone from the President down would depend on NHI for their care, every incentive would exist to make it work.
This is unconvincing. In any circumstance, people can be expected to act to satisfy their own interests. This is what South Africa’s middle class has done by buying themselves out of dependence on state healthcare. (It’s also what they’ve done, as far as they are able, to provide themselves with a high-quality education, with physical security, and increasingly with a supply of electricity, all of which they also pay the state to provide.)
It’s something that elites the world over are adept at. For the personally wealthy, it’s a case of buying oneself into a quality of life or a quality-of-service superior to that of the larger society. This explains why the well-resourced from the developing world will frequently seek medical treatment from facilities in the so-called global North.
Scientific innovation
The United States is often criticised for its market-driven healthcare sector, and with some validity. But it’s also a global hub of scientific innovation, and a destination of choice for cutting-edge treatment, not only from the developing world, but also from affluent Canadians and Europeans seeking what the universal healthcare systems of their own countries may not be willing to provide. (The Norwegian thriller series Occupied references this, with a subplot involving a cabinet minister looking for cancer treatment in the US.)
Personal wealth is not the only means to secure oneself privileges inaccessible to others. Political power and influence can do so equally effectively.
Sometimes this is simply built into the system. Special facilities may be available for the politically connected, say a hospital attached to a ministerial compound or a clinic attached to the Parliament building. One obvious means to providing special treatment is to use military facilities – as PW Botha did on occasion. These are not available to the public, and can operate with restricted scrutiny. The NHI Bill explicitly excludes military facilities from its purview.
During the Soviet era, nominal free, equal and universal healthcare was in practice qualified by the political elite’s access to special facilities and advanced Western medicines. The corollary of this is that even ordinary treatment could be subject to political preferencing. Displeasing the authorities could in a very real sense be hazardous to one’s health.
Treatment abroad
Another is for the politically powerful to seek treatment abroad. Here again, there are a variety of mechanisms. Some countries offer medical care to foreign allies as a tool of diplomacy. For example, the late Hugo Chavez underwent cancer treatment in Cuba.
Others might be able to tap into foreign services through some combination of state support, political connections, personal fortunes or the patronage of benefactors.
This is a sore point in Africa. It is far from uncommon for African leaders to seek the treatment abroad that their own health systems cannot provide domestically. The website africanews.com ran a piece on this sardonically entitled ‘Africa’s “health tourism” presidents.’
The list of those going abroad to address their health maladies is long. Former Nigerian President Muhammadu Buhari did so in London. In 2017, two medical stays took up a cumulative 153 days. Merely parking the plane cost Nigeria millions of pounds.
Robert Mugabe of Zimbabwe chose Singapore for treatment, and ultimately died there. Even after he was deposed as Zimbabwe’s president, the country’s Reserve Bank was reportedly doling out millions in hard currency to support his medical stays abroad. He died in a hospital in Singapore.
Several others died abroad: Zambia’s Levy Mwanawasa in France in 2008; Gabon’s Omar Bongo in Spain in 2009; Ethiopia’s Meles Zenawi in Belgium in 2012; Guinea Bissau’s Malam Bacai Sanhá in France in 2012; Zambia’s Michael Sata in Britain in 2014; and the former President of Angola, José Eduardo dos Santos, in Spain in 2022.
Julius Nyerere, the iconic founding leader of Tanzania, ardent socialist and the ‘the Conscience of Africa’ passed on in St Thomas’ Hospital in London in 1999, a far cry from the community health centres he might have championed as head of state.
Straight corruption
Then there is straight corruption. Those with political connections can bargain their access and influence for benefits. In the NHI context, it presents the prospect of senior politicians being offered medical ‘inducements’ by firms hoping to cash in on tenders: sponsored internationally-accepted health insurance, regular treatment on the company’s coin, a supply of cutting-edge medication. The potential is endless.
Leveraging political influence is, by its nature, an option open to a small circle of people. There may simply not be enough to go around to give everyone who hopes to benefit the opportunity to do so. So, imagine a situation in which a very small elite can enjoy world-class services, while even those in Parliament face deteriorating conditions as NHI becomes a cash cow, and medical skills depart the country.
Social solidarity in these scenarios is not likely to be applicable to the more prominent in society.
What is certain, however, is that South Africa is not at present in any condition to execute NHI. Central to the problem is that the trust needed for the social solidarity that would secure the cross-society buy-in simply does not exist; nor is there any reason to imagine that it would develop given the likely trajectory that its implementation would follow. No convincing argument has been made as to why NHI would function differently from any of South Africa’s other corruption-prone state endeavours. The country has, after all, heard ad nauseam how lessons have been learned and a new era opened.
This is not necessarily an argument against the concept of universal healthcare – that is a different conversation – merely an analysis of what makes NHI implausible. Appeals to social solidarity will not be an adequate substitute for the realities of present-day South Africa. Indeed, the predictable path that it will follow stands to damage rather than encourage social solidarity.
[Image: Stefano Ferrario from Pixabay]
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