‘Private healthcare heavily subsidised by public’
In an interview, Health Minister Dr Aaron Motsoaledi tells Khathu Mamaila that his biggest risk in the implementation of NHI is fear and lack of political will on the part of the state
hathu Mamaila: The health ombud paints a very gloomy picture of the healthcare system in the country. Under the current circumstances, should we really be even talking about the implementation of the NHI? Minister Aaron Motsoaledi: It is true that I pronounced publicly that the healthcare system is under extreme distress. You may call it a crisis but there are those who prefer to call it a collapse.
I am the one who came up with the idea of having a health ombud, a position that never existed in the past. Some people who did not understand what we were trying to do asked me what is a health ombud, and my explanation was that the health ombud is a public protector in our health system.
Everybody is now familiar with how the health ombud dealt with the Life Esidimeni tragedy.
Actually, your main question is whether under the present circumstances we should be talking about NHI. I am very worried why it is not clearly understood that NHI is not a luxury which we implement when everything is going right. If everything was going right, then you do not need NHI. You need NHI precisely because you want to use this universal health coverage plan to correct the wrong things in the healthcare system.
Remember that we are not the first country in this planet to implement such a system. Many countries have done so for more than half a century. All the countries who implemented it had something in common. They were prompted by very serious problems in their healthcare system. Those problems were created by the prevailing economic conditions at the time. A prime example is that of Britain. When the British started their National Health Service, a similar plan to NHI, it was three years after World War II. Their healthcare system was in tatters, with high mortality and morbidity. They had a high rate of unemployment and many poor people. That is when the government of the day decided that to save many people from death, let’s start a health system that will not only cater for the rich but will help everybody.
Since NHI is the equaliser between the rich and the poor, to quote Margaret Chan, the former World Health Organisation director-general, then we should accept that this is the only system that is appropriate to address the problems in healthcare in our country, which is reported to be the world’s most unequal society.
KM: Perhaps before we get into the details of NHI, ordinary people are saying that what the health
This might not be an unfair comment, to be frank. But the point of dispute among many people is what brought this situation about. A number of commentators believe that it is just because of corruption, poor management, incompetence and unskilled officials as well as under-budgeting in the public healthcare system. This sounds like a powerful argument, but in reality this is too simplistic. These issues that many people argue are the causes are actually the consequences of a deeply fragmented system. Apartheid was fragmented along colour lines, but both groups were treated in the public hospitals, which had most of the resources even though they were not equal. Nobody was getting treatment in an exclusive and extremely expensive private hospital which was also heavily subsidised. All the human resources, skilled professionals, were accessible to all.
For example, Johannesburg Hospital, now Charlotte Maxeke, was an exclusively white hospital, but in terms of specialised skills that served this hospital, they were available to serve Baragwanath Hospital, which was exclusively a black hospital. But in today’s economic fragmentation, as opposed to colour fragmentation, the situation is much more brutal.
In this brutal system, 4.4% of the GDP is spent on only 16% of the population, while the remaining 4.1% (of a total of 8.5% of the GDP which is spent on healthcare) is shared by a whopping 84% of the population. No other country in the world spends so much money on so few people. I have heard some arguing that 4.1% is sufficient for the poor majority. But for how long do we expect the poor majority to keep on absorbing insults like this?
There are people who are propagating a misleading notion to the country that private healthcare use strictly private health money from rich people. This is an outrageous lie. The private healthcare system is heavily subsidised by the public. There is enough money for health for everybody in the country. The problem is that it is used on too few people.
But this does not mean that we are intending to ban the private healthcare system. We just want to make the healthcare resources in both private and public to be available to all people in the country.
I want somebody to stand up and tell me how it is wrong, morally, politically, legally and constitutionally, to give equal treatment to people without regard to their economic status.
People can gloss over the facts to maintain a particular narrative. But one fact that nobody can dismiss is that in 2004, only 400 000 people were receiving antiretroviral drugs from our public healthcare centres. That number has increased more than 10 times. Today just over 4.2 million people are getting antiretroviral drugs from our hospitals. This explains the longer queues that are a familiar sight in our hospitals and clinics. In a way, we are victims of our own successes. Yes, people may complain about the long waiting periods, which we try our best to reduce, but what is not often said is that we run the biggest ARV programme in the world. We are saving millions of lives. People need no longer die of HIV and Aids. We have turned the corner. Statistics support the view that fewer people are dying of HIV and Aids. Life expectancy has also increased. And all these are supported by the current healthcare system.
I wish to remind the public about the white paper. In that document we clearly said that NHI is a substantial policy shift which needs a massive reorganisation of the health system, both public and private. Without this massive reorganisation you can’t roll out NHI.
The reorganisation and the rollout must happen simultaneously, and the NHI bill indicates how this will happen.
Of course the issue of the allocation of resources is important. The shortage of doctors, nurses and other health specialists has a lot to do with how health resources in the country are distributed.
Under NHI, all South Africans will be able to access quality healthcare in both the public and private sectors. In other words, health expertise, which is currently reserved for the few who have medical aid, would be made available to all.
That scenario you are describing assumes that we are going to leave the public health system as it is and just impose NHI on it. This would not be the case.
The fear of the long queues in private hospitals is the same fear that certain people had regarding democracy. Some people feared that the blacks will dominate the public space that they used to enjoy exclusively.
Actually, NHI’s objective is to eliminate the queues, not to extend the queues to other places which had no queues in the past.
Part of the reorganisation would be to make primary healthcare to be the heart-beat of our healthcare system. We want to move away from a curative approach to a preventive approach. In other words, with early detection, we believe that fewer people will need to come to hospitals and many of their problems can easily be dealt with at clinics.
We have already started with some of the campaigns to reduce the number of people who will need to visit hospitals. We have been actively campaigning against smoking and tightening the regulations on smoking. And we have done the same with regard to sugar and salt.
Everybody knows that the public health workers have to break their backs to serve the majority. About 80% of the specialists are found in the private sector and 20% have to serve a huge population of 84%. Which one is inefficient? Under NHI we are not going to pour any money, we just want sufficient allocation to serve the entire population.
That would be lack of political will on the part of the state to implement NHI. Really, I see the biggest risk as fear by the state, when the state gives in to scare-mongers and their total onslaught on NHI.
There are many other obstacles in our protracted journey to implement NHI. In my view, the second biggest hurdle is poor understanding of what NHI is and what it intends to achieve. There are many people who are opposed to it, but when you listen to them attentively, you realise that they actually do not even understand the basic tenets of NHI. I think we should not take things for granted that our people know enough about NHI and how it will affect their lives.
There are those who believe that I am on a mission to destroy private healthcare through NHI. Of course this could not be further from the truth. We want to free the resources that are locked up in the private sector so that we use all the available resources in the country to deal with our health challenges. But we have to increase our public education campaign of NHI. If we can get the various stakeholders, policy-makers and the general public to understand the theory of NHI, I think we would have won a huge battle in the implementation of NHI.