Legislation won’t fix poor management of Health

As we mark 100 years of Albertina Sisulu and Nelson Mandela, it’s a tragic irony that the Eastern Cape, known worldwide for its great leaders, has become known at home for incompetent corrupt leaders.

Senior leaders of a municipality stole from the funeral of the Eastern Cape’s most influential and renowned leader. Our great storytellers would struggle to imagine a more poignant allegory for our terrible misfortune. But moralism is an ineffective and counterproductive response. In the great battle between Ethics and Politics, we cannot pretend Ethics comes first. We cannot impose the right ethical principles on unreceptive political conditions.

The South African state has been an instrument of domination and exploitation since its inception. We’ve developed toxic political institutions, practices, traditions and norms alongside it. We can’t invent a new ethics). It’s no good coming with revolutionary policies, regulations, legislation and ethical guidelines which are not enforced. We must nurse this creature back to health.

In this sense, there is a striking analogy between the Health Question and Land Question. In the chaos and confusion, one senses a familiar fishy smell, a red herring: moralistic political ideology. Expropriation Without Compensation and National Health Insurance are the latest policy acronyms, after last year’s Radical Economic Transformation. From RDP to GEAR to RET to NHI and EWC, have faith, loyal followers, we’re heading through the wilderness to the promised land.

The letters may change but method is always the same: Identify a grievance, moralise the situation (eg blame it on apartheid) and then promote a magical policy formula for the same people in charge to implement. Leave aside what’s happening on the ground, what can we do to work up everyone into a moral frenzy?

Last month the first of a long series of forthcoming legislative amendments was put forward to start the roll-out of a NHI scheme to bring free universal healthcare to us all. The ethical credentials of this noble objective are impossible to deny. Moreover, this is no utopian ambition. Many countries, from capitalist Britain to communist Cuba, have free universal healthcare. There is no debate that cross-subsidisation and collective solidarity makes for a more efficient, effective and ethical healthcare system than a private one.

A private system incentivises unnecessary costly intervention from doctors over-catering to the elite to the detriment of the health of most citizens. Costs escalate, patients are addicted to medication. You end up in an American nightmare.

Few in SA disagree with the objectives of NHI. What is missing from the justification from the state for implementing this very expensive scheme is the fact that we already have free universal healthcare in this country. What we are being asked to do is to overlook the actual material conditions of public health services, to imagine there is no such thing and that it still needs to be implemented, with the same people in charge, 15 years hence.

Moreover, the public must cough up R250-billion a year to make this happen. The ethical principle of free universal healthcare is already endorsed by most citizens and our constitution. Unlike the land question, there is no question of having to amend the constitution. But it’s no good discussing ethical principles, policies or regulations and creating another managerial structure with overlapping duties, when political conditions don’t support it. You cannot impose ethical norms without enforcement by state officials.

Funding is by no means the only factor plaguing public health; and more money may only inflame these other factors if they are not dealt with first. In every report on the problems facing healthcare, the same issues are always flagged: bad leadership, financial management and controls, oversight, accountability, planning, maintenance, supply chain management, human resource management and chronic understaffing. Can we believe an extra R200-billion a year this will address these challenges? How will the NHI solve inept strategic planning and payroll management?

And it’s not just health. It’s education. It’s every single stateowned enterprise brought to its knees by political mismanagement and corruption. No matter how much funding goes to SAA it cannot fly. We paid for an eagle, but procurement bought a chicken.

The latest SAMA Insider report claims, “there’s a deeprooted leadership problem in the health sector which is gradually collapsing the medical profession”. The association chair Mzukisi Grootboom writes: "As far back as 2016 we warned about the creeping instability in the management of our hospital services and unfortunately SA has had the misfortune of a dearth of leadership across the board”.

The public services action monitor report on the Eastern Cape health services in 2013 described a crisis of management and political oversight, corruption, chronic vacancies, poor planning, poor leadership, cadre (re)deployment, fraud, mismanagement; in sum, “a broken, inhumane and collapsed health system where accountability is non-existent”.

Our president is criticised for keeping so many of the same smallanyama skeletons in the cabinet with his unity line. Nothing functions without support from those who manage the system. South Africa must soldier on with the same old soldiers. But, how can we turn them around? Not by backing down on accountability. Across the patronage network, disciplinary enforcement must follow through.

The underlying assumption of the NHI Bill is that financing is the main problem in public healthcare, but most reports emphasise poor management.

Unless the state addresses failures in public management of the health system, NHI will drive more skilled professionals away. We already have too few skilled providers and administrators, even in private healthcare. We already have free, public healthcare. With no reference to financing from the minister of health, we are going to add a costly, complex health insurance scheme to a free public health system, which is already poorly managed.

All the effort going into the NHI looks to the future while acute health system reforms are delayed and responsibility is shelved. But you can’t legislate your way out of bad management and poor accountability if regulations are not enforced. The NHI will not function unless public health is fixed with immediate, substantial funding and curbing of corruption. Alternatively, the government is guaranteed a backlash that will dwarf e-tolls and brewing unrest over VAT and the fuel levy when functional private healthcare is taken from the middle classes in exchange for a giant tax hike.