Ramaphosa is head-in-the-clouds over NHI 

One of President Cyril Ramaphosa’s more underrated skills as a politician is his ability to spin a story.

He has, of course, always been able to weave a great narrative that lavishly plasters heaps of lipstick to the African National Congress, but to truly twist facts to suit himself is the sort of thing we’re more used to seeing from the likes of Donald Trump or Jacob Zuma.

But to hear him speaking in Parliament last week, solemnly making a slew of promises around National Health Insurance (NHI) that he must know he can never keep, was still an arresting sight.

Given the importance of NHI — a policy in which all healthcare professionals will be required to contract with a single state-run fund from which all healthcare services will be distributed, but which experts say will cost anything from R600bn to R1.3-trillion a year — it was no surprise that the President faced a cascade of queries over the policy.

Questions like: is NHI still on the table since the government agreed to “pause” implementing it until the slew of court challenges have been sorted out? Questions like, in a month in which the health department’s director-general Sandile Buthelezi was arrested on fraud allegations, how will you protect this fund from being looted like just about every state-run fund?

Not prepared to budge

But Ramaphosa, oozing stoicism and confidence, replied that South Africa almost has no option but to push ahead, given how the Freedom Charter and resolutions passed by the United Nations demand that this happens. “In the end, we’re determined to ensure every SA has access to quality health care, regardless of their ability to pay. This is a commitment we’re not prepared to move away from,” he said.

There is, of course, no little sophistry going on here, since neither the Freedom Charter, nor any UN Resolution speaks about a National Health Insurance like South Africa’s government want to implement

Actually, what the Freedom Charter says is: “A preventive health scheme shall be run by the state”, and “free medical care and hospitalisation shall be provided for all.”

Well, what about the UN resolution in October 2023? That resolution says “universal health coverage is fundamental for achieving the sustainable developments related not only to health and well-being, but also to eradicating poverty in all its forms and dimensions”, but adds that it is the “responsibility of governments at all levels to determine their own path towards achieving universal health coverage, in accordance with national contexts and priorities.”

So, it’s pretty clear that neither the Freedom Charter nor the United Nations say that in an effort to achieve universal health coverage, there has to be just one monopolistic state-run fund doling out all healthcare services. Neither say that to do this, private medical aids should be squeezed out of existence, as this NHI would do by mandating that all healthcare providers only contract with one national fund. And neither say that this particular version of NHI is the only way in which medical services can be provided to a country.

Conversely, the UN speaks of how the route to universal health coverage has to take into account “national contexts and priorities”.

Utterly unaffordable

You would imagine that any policy that is utterly unaffordable — the lowest estimate of R600bn is far more than is currently spent on healthcare, and would necessitate VAT hikes of up to 21% or new income taxes — would be precisely that sort of “national context” that would mitigate against this NHI.

As for “priorities” like securing investment, let’s not forget the warning signs from foreign investors that it would make them think twice about setting up shop in a country where they couldn’t guarantee good quality care for staff would.

And perhaps most critically of all, there already exists a system in which “free medical care and hospitalisation” is provided; it’s just that this capacity sits squarely in the public hospitals, which the government has run into the ground, by allowing shocking mismanagement, zero oversight, and a misallocation of resources.

The facility is there for medical care for all — it’s just that this public system does not provide quality care anymore because the money allocated to it is wasted and there is pretty much zero management or oversight.

Universal access already

As human rights activist Mark Heywood put it during a radio discussion earlier this year: “We are a country where we have universal access to healthcare services. Nobody gets turned away because they have no money – but, there’s a vast difference in the type of quality of care.”

This underscores the views of Wits University professor Alex van den Heever who, in today’s edition of Currency, eviscerates the argument that the country can only get “universal access to health care” through this version of NHI.

So, what Ramaphosa could have said, if he wanted to be accurate, was:  ‘there is already a free medical and hospitalisation plan, but it is run so appallingly that what we’re going to do with NHI is find a way to redirect more money from the private sector to the state in the hope that throwing money at the problem will fix our delinquency.’ And he could have added: ‘Don’t worry, despite all evidence to the contrary, this is the one fund we’ll actually run properly.’ 

As it is, the NHI has actually been piloted in a couple of specific sites since 2012, but the results were anything but convincing.

Asked about these pilot studies, Ramaphosa’s response was a masterclass in spin: “those weaknesses that were identified in some of those [pilot] clinics or health centres, is something that was good in that we identified weaknesses which we now need to strengthen. It’s been a good process — we are ready, we are truly ready for the NHI roll out.”

Unconvincing

The President was equally unconvincing when asked how he would protect the NHI from corruption, in light of Buthelezi’s arrest.

“As you deal with major processes like NHI, there will be challenges that we will come across. Now if the system is well structured, and the processes need to be executed, if the people who are supposed to do so are not good, you get rid of them,” he said.

Well sure — only, by then, you’ll have no medical aids left, and you’ll have done your best to dismantle the back-up system.

To be clear: this form of NHI is an invention of the ANC and, in reality, threatens to be the straw that will break the impressive progress of Ramaphosa’s other economic reforms, causing doctors to emigrate and investors to look elsewhere, while creating the biggest opportunity for corruption yet in a country with no real clue how to combat this.

Ramaphosa spoke of how it is “an abomination” that quality healthcare is only available to an elite minority, arguing that “this is why NHI must be implemented”. That is some deflection. Surely the real abomination is that even though his government spends R270bn on healthcare every year, it is unable to provide its citizens with quality healthcare? And, following that logic, would it not then be iniquitious for the private sector health infrastructure to be sacrificed for the failures of Ramaphosa’s party in the 32-years since democracy.

_{Top image: Gallo Images/Ziyaad Douglas; Rawpixel/Currency collage.}