Crisis is a catalyst for rethinking how SA delivers health care
President Cyril Ramaphosa has been praised for his leadership during perhaps the most severe threat to national public life and law and order since the assassination of former SA Communist Party general secretary Chris Hani 27 years ago.
SA, recording its first case of Covid-19 a few weeks after Europe and the US, has had the benefit of their experience. The overwhelming lesson from all interventions across the globe is that a complete and severe lockdown of between 14 and 21 days is the only way to stop an exponential wave of infections.
In his address to the nation and in one of the few moments when the president has spoken in the first person and disposed of the royal “we”, he said: “I am concerned that the rapid rise in infections will stretch our health services beyond what we can manage and many people will not be able to access the care they need.” This was a very telling sentence.
The 2020/2021 budget tabled by the finance minister a little more than a month ago allocated R229.7bn towards health, roughly the same amount as the R229.3bn set aside to service debt. The Treasury’s own projections show that debt service costs will consume roughly 20c of every rand we collect in tax revenues by 2022.
These are pre-coronavirus pandemic forecasts, so the picture will be all the more horrific. Business Unity SA suggests the pandemic, together with the credit rating downgrade by Moody’s Investors Service, will trigger a deep structural depression that will severely weaken our fiscal position. The ultimate impact is that debt service costs are likely to outpace health expenditure this year.
In effect, we will be paying more to the fund managers and bankers than we do to care for the sick and frail and buy the vaccines that prevent the healthy from getting sick. In this context, it is no wonder that the president was concerned about the ability of our health-care system to manage a spiralling and exponential disease burden.
While the countrywide lockdown may be a necessary solution to the crisis, it should also be seen as a call for the government to rethink its health-care delivery model in the context of a highly constrained fiscal envelope.
When the UK began aggressively expanding its National Health Service (NHS), its leaders had the foresight to understand that even within the health-care sector it was faced with many competing priorities: establishing and capitalising the NHS, enrolling the population, buying and stocking medicines, and paying and incentivising nurses and doctors. If there were to be any chance of a successful national healthcare system, it would need the full co-operation of the private sector.
The UK pioneered public finance initiatives; what we in SA call public-private partnerships. The ideal of a national health insurance scheme is a noble, aspirational developmental goal that most developing, and indeed developed, countries aspire towards. However, in the practice and discipline of public policy, such lofty subjective goals should always be tested against the hard surface of objective reality. Unfortunately for SA, that reality communicates a hard and clear message: we and our government are broke. If you don’t appreciate how dire our situation is, a cursory look at the latest Moody’s report reveals that without something short of a miracle, we are headed into a deep and potentially crippling fiscal crisis.
WE WILL BE PAYING MORE TO THE FUND MANAGERS AND BANKERS THAN WE DO TO CARE FOR THE SICK AND FRAIL
However, the government must govern and it ought to think more creatively about our health developmental challenge and the goal of universal health care. Our reality is that the government has no money to build new hospitals. Indeed, we are struggling to maintain the ones we already have.
Perhaps the time has come for the government to seriously consider and launch a transformative health-care private finance initiative. In this way, it could dramatically expand the number of available hospital bed nights and access to primary care without incurring the upfront capital costs.
SA already has all the “secret” ingredients — relevant public-private partnership experience, a world-class health-care professional cohort, a strong higher education research ecosystem, and the health infrastructural foundation. What has been missing thus far has been the crisis to catalyse all these into a powerful force for good.
Brazilian lawyer and politician Roberto Mangabeira Unger, in a paper written in response to the 2008 financial crisis, “Using the Crisis to Remake the Market”, said: “The task of imagination is to do the work of crisis without crisis.” Ramaphosa need not imagine much, for the crisis is already upon him.