South Africa is no stranger to cognitive dissonance. Our politicians, eyes averted from reality, speak loftily of smart cities and bullet trains, even as our freight trains have ground to a halt, their routes stripped of the cables needed to function.
Or as outgoing health ombud Prof Malegapuru Makgoba put it last week: “As a country, we have strange priorities.”
Makgoba provided an eviscerating diagnosis of the state health-care sector as he stepped down, labelling it a “shambles”. The Eastern Cape health department was “embarrassing”, while Gauteng’s hospitals are run by “Mickey Mouse CEOs”.
It’s an unflattering assessment that ought to catalyse a raft of resignations.
“What you observe at the Gauteng health department and at Eskom are similar problems. No leadership, no capacity, no vision,” he said. “Of course they’ll blame someone else — apartheid, I think.”
Yet in the same week, the ANC majority on parliament’s health portfolio committee blithely voted to approve the National Health Insurance (NHI) Bill — legislation on which a new “universal health-care” system will be built.
But the way NHI has been designed leaves so many questions swirling, you wonder why those MPs didn’t believe some answers were needed before pressing “go”.
In particular, that bill leaves the “shambles” that is the state health-care system entirely untouched, and instead promises that everyone will be able to visit any doctor, specialist or hospital free of charge. It does this by creating a single pool of savings to pay for this — a fund to be run by the state — which will make the government the sole buyer of health-care services.
Philosophically, it’s fabulous. But gosh, it does sound like it’ll cost an awful lot; where will this money come from?
Well, that’s a question those ANC MPs never got a real answer to.
Most MPs are economic illiterates who’d struggle to balance a G&T on the bench in front of them, let alone a budget
Which underscores what any vaguely finance-savvy person who’s appeared before parliament will tell you: many MPs are economic illiterates who’d struggle to balance a G&T on the bench in front of them, let alone a budget.
The truthful answer is that NHI can only be financed by a spectacular tax hike. Nicholas Crisp, the health department’s deputy director-general, told parliament last year that new payroll taxes, a hike in VAT or new general taxes might be needed. His department says on its website: “Every person earning above a set amount will be required by law to contribute.”
If that sounds benign, it’s only because they’re not saying how much you’ll pay. In 2017, a government white paper put the cost at R256bn a year, using outdated 2010 figures. Economists say it’ll cost far more. The Institute of Race Relations puts it closer to R700bn a year, saying “major tax hikes will be needed”.
Now, given Makgoba’s assessment, and that 85% of our municipalities can’t publish “clean” accounts, what do you think is likely to happen when the government is given a giant pot of money to finance all health care in the country? If that doesn’t send digital vibes down your spine, it should.
This week the CEO of Business Leadership South Africa, Busi Mavuso, flayed NHI in its state-designed format, saying it would force out the private sector while failing to improve health care. “Business would benefit from an environment in which everyone had good-quality health care — but one in which no-one had would be catastrophic,” she wrote in the BLSA newsletter.
The business sector, she said, has every interest in seeing universal health coverage, but it must be sustainable. “NHI, as it is conceived in the bill … is not that. Indeed, [this version] would leave all South Africans worse off, in a system in which state provision becomes impossible, and private health provision is effectively closed down,” she said.
Just about every medical association agrees. Last week, the South African Private Practitioners Forum said it was worried about the “sustainability” of private health care, since medical aids will become redundant, limited to covering “complementary services” outside the ambit of NHI. This infringes people’s right to “make choices about how and where they access health care”.
Mvuyisi Mzukwa, chair of the South African Medical Association (Sama), said the “misappropriation of funds in various state-owned entities casts doubt on government’s ability to handle the health-care budgets responsibly”.
Mzukwa asked how anyone could entrust their lives to a state “with an established history of financial mismanagement”.
One group not complaining are emigration consultants. Three years ago, insurer PPS said a survey of its professionals showed that 72% will emigrate if NHI is implemented in its current form
One group not complaining are emigration consultants. Three years ago, insurer PPS said a survey of its professionals showed that 72% would emigrate if NHI was implemented in its current form. This underlined earlier polls — including one from Sama — that found 38% of doctors were planning to leave due to NHI, and another from the Radiological Society of South Africa, which said 20% of radiologists would emigrate.
Makgoba himself is an advocate of universal health care. That’s unsurprising since he worked in the UK’s National Health Service for 15 years, before returning to South Africa. But even he said, speaking to 702 last week, that he doesn’t think “the system is ready for it” in South Africa.
He pointed out that universal health care can transform a nation — the UK has been largely free of malnutrition since 1948. “The philosophy is not in question, but it’s the implementation process that has been proposed — I think it has lots of defects that need to be corrected,” he said.
Last year, Makgoba said: “As things stand today, we couldn’t go into NHI with the level of inspections and certification we have done so far, because I suspect most of the hospitals will not meet the high standard required of NHI.”
Yet, silver bullets are catnip for ANC lawmakers. Rather than the more difficult job of fixing the existing public system — one in which staff at Mahikeng Provincial Hospital put newborn babies in cardboard boxes for two days, undetected by management — they’re seduced by the magic potion of NHI.
Now, even before figuring out how to pay for NHI, they’ve given it the green light. Is it any wonder the country is in a fiscal bind?
Strange priorities indeed.
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