South Africa: Healthcare in a hurry

The sign ‘Leading innovative healthcare’ greets visitors to Hospital Street, the main entrance for patients, doctors, nurses and anyone using the services of Groote Schuur in Cape Town, one of South Africa’s oldest hospitals. The street, located inside the hospital, is a busy exchange – here patients who are strong enough are walking with family members, nursing staff are buying snacks at the local cafe and doctors are rushing to various wards. With the economy in recession and national elections on the horizon in 2019, issues like National Health Insurance (NHI), education and land reform are high on the agenda for the governing African National Congress (ANC) to mobilise its grassroots supporters.

The NHI is a health-financing system that will pool funds to provide access to health services for all, based on health needs and irrespective of socioeconomic status. The NHI bill has been gazetted and is now open for public comments. Critics of the scheme say the country cannot afford universal healthcare and that the NHI will hurt the private healthcare sector while doing little to improve poor service provision in the public sector. The government wants the NHI scheme to be operational by 2025.

Groote Schuur is the hospital where the world’s first heart transplant took place 51 years ago. It has long been a beacon of healthcare for millions. “We have had to improve our standards – the national core standards mean all hospitals will have to follow what we are doing here,” says the head of engineering and deputy director at Groote Schuur, Denton Smith. He, and others like former hospital administrator Beth Adams, is enthusiastic about the NHI. “It will be challenging, but it’s exciting,” says Smith.

And this is the passion that is driving health minister Aaron Motsoaledi to ensure that the NHI becomes a reality. On the steps of parliament, Motsoaledi told The Africa Report his favourite idea – from the German philosopher Arthur Schopenhauer: “Health is not everything, but everything else without health is nothing. You can’t have education if people are not healthy, you can’t expand the economy, you can’t take advantage of free education if you’re sick, you simply can’t.”

The statistics on healthcare access do not paint a pretty picture and Motsoaledi says the inequality in access to healthcare is unacceptable, with half of the doctors serving the roughly 16% of the population who are medical scheme members or who can afford to pay for medical services themselves. He adds: “As far as specialist healthcare goes, 80% of specialists are to be found in the private sector and only 20% in the public sector.”

Outside Hospital Street, an unemployed father of one, Mark Booysen, doesn’t know about the NHI debates and says he is alive today because of the care he received at government-funded Groote Schuur. The 54-year-old says he has been given a new lease on life because of the care he’s received at the hospital. “I had a spinal operation and I have been given good care. The doctors are helpful and I have never paid a cent in my life.” Ragmat Dollie, 82, agrees: “I know people sometimes complain about the care they receive at Groote Schuur but I have only been treated well,” she tells The Africa Report.

There is a lot of confusion in public debates about how the NHI will work and how it will be funded. According to the White Paper on the NHI, adopted in June 2017, it will be funded through a combination of current sources of government health spending, including the removal of the tax subsidy for medical schemes, and mandatory employer-­employee contributions. All these funds will be placed in a single pool that will be available to fund all healthcare in the public and private health sector.

The NHI is going to cost the government more, but it says it will improve access and incentivise healthcare providers to operate more efficiently. The treasury predicts the full implementation of the scheme will increase public health spending from 3.9% of gross domestic product (GDP) in 2017/2018 to 6.2% of GDP by 2025/26.

It’s about priorities

The Democratic Alliance is one of the parties that oppose the NHI. They feel it would create an overly bureaucratic system and will only support some of the country’s health priorities. Shadow health minister Lindy Wilson says: “We believe that maternal and child health, emergency services, fixing broken, dysfunctional and mismanaged hospitals, building more fully operational clinics and training more doctors and nurses are priorities, as these address the real needs of the majority of South Africans.” Wilson says mismanagement and corruption are rife in the health system and ploughing money into a broken system will not address the plight of the poor and vulnerable.

South African Medical Association (SAMA) vice chairperson Mark Sonderup tells The Africa Report that SAMA supports universal access to healthcare but worries that health minister Motsoaledi has not answered the basic question: “How will we do it? We cannot talk about the NHI and we need proper leadership, the proper debate on policy.” Democratic Nursing Organisation of South Africa spokesman Sibongiseni Delihlazo takes a similar view: “The NHI is a big elephant – we need to eat it bit by bit. The pace we are eating the elephant is very slow, and right now our members are overworked and underpaid, but despite this we fully support the NHI.”

The government seems to be losing the communication battle, and for many health activists, there are still too many questions unanswered: there is a lack of clarity about the funding, how medicines will be procured, infrastructure and staffing. But with health minister Motsoaledi’s passion and the World Bank calling on governments to invest in health to boost the economy and human capital, South Africa is on the path to expanding access to health services with or without all the stakeholders on the same page.

This article first appeared in the November 2018 print edition of The Africa Report magazine