Strengthening the weak by weakening the strong

Marco MacFarlane

This week has seen the leakage of an internal African National Congress (ANC) discussion document outlining plans for a proposed national health insurance (NHI) scheme. Unfortunately the plan in its current state looks set to destroy private healthcare, and consequently cause a flight of skills from these shores that will cause untold damage to the economy.

The details of the plan are sketchy, and most stem from a speech given to the Hospital Association of South Africa (Hasa) by Mr Alex van den Heever, a health economist. Some of the proposals said to be contained in the discussion document include a 5% tax on earnings of those who are not members of medical aid schemes. For those who already have medical aid, some 85% of their contributions would go directly to a newly- created national health insurance body. Finally, all services that could be provided by the public sector could not be insured under a private medical aid. Thus if public hospitals offered cancer treatment, individuals would not be able to have health insurance that covered cancer, and essentially would have no choice but to obtain treatment through the public system.

If the choice is between public health care for a chronic disease, or emigration, many South African professionals will answer with their feet. Without a private health care system, it is doubtful whether South Africa can sustain a professional class.

The public health sector is floundering, however, and years of bad planning and poor management have taken their toll on a once well-regarded public health system. In 2006, some 32% of all professional nursing posts in the public sector were vacant. By 2008 the proportion of vacant nursing posts had risen to 40%. In the Free State and the Eastern Cape, more than 50% of all public sector nursing posts stand vacant.

The story is the same for doctors, as vacancies in the public sector rose from 30% in 2006 to 35% in 2008. In the Northern Cape, 60% of public sector doctors’ positions stood vacant in 2008. The situation has become so dire that public sector health professionals have now engaged in protracted (and illegal) strike action. It is an indictment of the Government that it has allowed the public health system to deteriorate to the point that it has.

In light of this, it seems as if the Government is trying to deflect criticism of its poor management of the health sector on to the well-run private health system. The reasoning seems to run as follows: the public sector has been managed to the brink of collapse. The private sector continues to provide top-quality medical care, so much so that South Africa even receives a significant amount of ‘medical tourism’, with foreigners coming to these shores for the high-quality care they can expect in our private hospitals. Despite the fact that taxpayers fund the public health system in its entirety, and despite the fact that they also fund the private sector out of their own pockets, the private sector represents some sort of ‘threat’ to the public sector.

The ANC Government has a long history of attacks on the private sector. We need only look back at the last few years to see evidence of a sustained campaign to weaken or perhaps even eradicate private healthcare. Doctors have been subjected to the (unimplemented) ‘certificate of need’ fiasco, which sought to put obstacles in the way of private practitioners when opening their practice in an area of their choice. Next the minister seized control of drug pricing. Then the dispensing fees of pharmacists were controlled to the point that smaller pharmacies could no longer turn a profit. When a private hospital group wants to build a hospital it needs permission from the minister. Somehow the question, “Why has the public health system collapsed?” is being answered with, “Because the private sector is too expensive”.

It seems to have escaped the Government’s notice that the money spent on private health care is in addition to the money that taxpayers already spend on the public system. If the private sector did not exist, the public health care system would have the same resources it does now, but would have to take care of 20% more people than it currently does. Thus the hostility towards private health care seems not only misguided, but also lacking in logic.

Although the plan at this stage is merely a discussion document, the very fact that such ideas could be entertained at all should cause uproar. Little noise is being made about it, however. There have been some timid comments from the private hospital groups and medical aid schemes. The public has been very quiet about it, possibly since public participation and comment on the process has thus far not been sought. Unions like the National Education, Health, and Allied Workers’ Union (Nehawu) have stepped in and said that the NHI will ensure that, ‘the poor access free healthcare at the point of delivery whether they are employed or not’, ignoring the fact that this is already the case.

The debate about health has been hijacked so that it has become about costs of private care, instead of the ever worsening quality of the public health care system. Before such policies are considered in future, the ANC would do well to heed the words of Abraham Lincoln: “You cannot strengthen the weak by weakening the strong. You cannot help the wage earner by pulling down the wage payer. You cannot help the poor by destroying the rich. You cannot help men permanently by doing for them what they could and should do for themselves.”