Dr Tlaleng Mofokeng
The NHI lets women down badly
● A few weeks ago, I got a frantic message from a young woman in Johannesburg who had gone to the local clinic for her contraceptive pills. She was told the pill was out of stock, and that her options were the male condom or the intrauterine device, both of which were inadequate to meet her needs.
It is not uncommon in Gauteng for contraceptive supplies to be out of stock, and then for there to not be enough diversity in the alternatives. It is most frustrating that in 2018, women’s primary healthcare needs are still inconsistently delivered. The woman left the clinic without her contraceptive pill supply, and is uncertain when next she will get time off work to return.
In his state of the nation address in 2009, president Jacob Zuma announced the National Health Insurance system, and whenever a system overhaul is promised, especially if it is of a broken and ill-functioning system, one is filled with hope.
When the recent announcement was made about a revised white paper on the proposed NHI, I thought back to the optimism healthcare professionals once had; however, much of that optimism has been eclipsed by the difficulties faced by healthcare workers and the many South Africans who seek care within the system. The principles of the NHI are good, but unfortunately that is where the good now ends.
The deterioration of infrastructure, lack of supplies, unsanitary conditions of wards, poor nutrition and human resources that are overworked do not have time to wait for the NHI, yet it is sold as a future magic pill. The question of poor and sometimes corrupt implementation of healthcare is often put to the health minister and the answer is always the same — that he does not have power over provinces. Yet in all these years, one has never heard of his writing to the president, to let him know that he cannot do his job.
Nor has the minister canvassed public support to assist him. Neither has he used the courts to assert his authority or get the provinces to fulfil their mandates.
In a recent interview, he said the health system was seriously “distressed”‚ with shortages of medical and nursing staff in state hospitals and a huge number of patients with HIV‚ diabetes‚ TB or cancer. This has been his assertion from day one in office, and we ought to ask, where is the sense of urgency?
Early this year, the national Department of Health paid for a series of print and radio adverts in which the Phila campaign highlighted the many women dying due to unsafe abortions. The radio ad asserted that “every eight minutes a woman dies in South Africa”, but what was worrying was the nonchalant manner in which the ministry and directorate accepted the statistic as a natural state of affairs.
Even more disturbing is that the department cannot provide the source for that statistic. Although I doubt that this was the plan, it is an acknowledgement that under the minister’s two terms, the department has failed to provide healthcare to people who do not want to be pregnant, so much so that many are dying preventable deaths. What an indictment.
The state’s failure to comply with its own law, the Choice on Termination of Pregnancy Act, is an example of the brokenness of this system. The influence of foreign aid donors and of partnerships the department has formed with anti-choice faith-based organisations in the delivery of healthcare has debilitated it, even though there is legislation to guide implementation.
In the proposed NHI model, it remains unclear what will become of the department’s partnerships with NGOs that are its major partners in the delivery of HIV, TB and adolescent health programmes, which continue to be constrained, unconstitutionally so, by the “global gag” rule, that organisations receiving US aid not have anything to do with abortion.
Many months after the Phila campaign, the memorandum outlining an urgent plan of action regarding the preventable deaths the minister had spoken of is, unsurprisingly, nonexistent.
Unfortunately, for many women and girls, his legacy continues to be non-affirming of our bodily autonomy, and carries a paternalistic outlook that informs programme designs and implementation. If you need modern contraceptive choices beyond injectables and high-dose triphasic pills, non-stigmatising abortion care, medical and surgical gender-affirming care, the NHI is not the answer to your sexual and reproductive health.
Many transgender folks are self-medicating due to stigma and alienating experiences when seeking medical care. The hormonal treatment is not available and health workers have not received in-service training in this regard. The waiting list in state hospitals for surgical care can be as long as 15 years.
This is a hurried, inadequate form of NHI. The money spent on the current health system is not yielding the equitable care South Africans deserve, and throwing more money at porous leadership and more machines will not turn this system around.
Is the NHI the minister’s second attempt at a legacy? The first was the inquiry into private medical insurance. Despite all the energy and attention from the minster himself, we are still waiting for tangible yields from that lengthy process. There are more questions about the NHI’s relationship with private medical insurance and those private medical professionals who do not sign up to the NHI.
We need a health system that enables people to make informed choices, and that sees women as being about more than our ability to get pregnant and give birth. The reproductive healthcare guaranteed in the Bill of Rights will not be a reality with this continuation of expensive, paternalistic health delivery that chooses for people what is most important for them, and leaves one without care if, at the time, you opt out of motherhood.
The minister has failed to act in two conservative terms; he has failed to inspire confidence in health workers, the human resource on whom the delivery of his NHI falls. Yet again, South Africa is going to learn a very expensive lesson that legislation and emaciated plans alone do not lead to better health outcomes.