President of SAMA
Chairperson of SAMA
General Secretary of SAMA

I would like to open my address, by quoting one of the historical documents of the movement, the ANC, the National Health Plan of 1994.

"Because of the burden associated with paying for health services at the time of illness, in the long term we are committed to the provision of free health care at the point of service for all citizens of South Africa" - A National Health Plan for South Africa (ANC, 1994).

We are now 15 years into our democracy and we have yet to remove one the most important barrier for access to health by the poor - money. The 1994 National Health Plan of the ANC called for ensuring that all South Africans, rich or poor, have must free health care at the point of service.

Apartheid had a fundamental impact on people's health and the organisation of the health system in South Africa. That legacy, despite many achievements in our health care system, continues to this day. The critical health problems reflect the prevailing socio-economic conditions in the country. For most of the population, life expectancy has declined to 47 years.

The mortality and morbidity rates are unacceptably high, preventable communicable diseases are common, and diseases associated with extreme poverty still occur. At the same time, a wealthy minority suffer from lifestyle-related diseases more typical of developed countries. The HIV/AIDS epidemic has become the country's most formidable health challenge, with rates of infection among the highest in the world.

Before 1994, the public health sector focused mainly on the provision of curative, tertiary level services for whites in urban centres so that health services in other areas, particularly rural primary health services, were critically under-resourced.

Post-April 1994, government embarked on a major transformation project of the health system as a whole, and there have been both achievements and challenges.

The major achievement since 1994 included but not limited to the following:

• Enshrining health as a human right. This guaranteed access to health care to every South Africa and empowers to the state to ensure progressive realization of this right.
• Abolition of the apartheid fragmented health system structured along racial lines - For example there were departments of health for white, for Africans, for coloureds and Indians.

The introduction of free health care for pregnant mothers and children less than six years of age was successful in decreasing financial barriers to health care access. Studies showed that health service utilisation at public sector facilities increased after the introduction of the policy, particularly for antenatal care.

There has been also significant expansion of primary health facilities' - 700 new clinics to the existing 3,600 clinics.

We must also emphasize that health policies are only one of a range of government policies that influence the health and social being of our people. The delivery of clean water, improving access to social grants, housing and electricity, all contributed to the improvement of health care.

But our dream of free health care, at the point of service for all has yet to be realized. Many challenges remains and to a great extent have expanded the reproduction of apartheid health legacies, if not worse. They include but are not limited to the following:

• Key health indicators continue to disappoint and some are worsening - life expectancy and child mortality rates. Our life expectancy rate has actually declined to 47 years, while in 1994 it was 57 years. There are more poor children dying before they reach the age of five - more than 70,000 died in 2007. This is unacceptably high. HIV/AIDs prevalence is very high by international comparison.
• Slow movement toward primary and frustrated efforts towards free health care to all. Many of the provisions of the National Health Act, including the District Health Authority have yet to be full complimented.
• Health inequalities mirror social and economic inequality with those who receive better resourced health care facilities are mainly urban, middle-class and white and the rural, the poor and black experience poorly received health facilities.
• Human resource challenges: We do not have enough doctors and other health professionals to fully support our health system. Even existing human resources are unevenly distributions, concentrated in the private sector.
• Popular mobilization around health our communities, particularly black working class communities is totally missing, except in few and issue based circumstances, such as HIV/AIDs.

At the heart of all these is the two-tier, contradictory, wasteful health care system:

• On one hand it is a public health care which treats health as a social need, yet starved of adequate funding and resources. Less than 40% of total health care resources are in this sector, yet it serves 85% of the population, the majority of whom are black and poor.
• On the other is an expanding private sector, which treats private health care health as a commodity/business, accounting more than 60% of the total health care resources, including majority of health professionals (other than nurses), yet it serves a minority of the population, majority of whom are white, and wealthy.

The private sector creates a market-driven private health care system based on avoiding the sick: medical schemes and private providers compete not so much by increasing quality and lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to the under-funded, under-resourced public health system.

It generates huge admin costs that, along with profits, divert resources from clinical care to the demands of business. In addition, consulting and marketing firms consume increasing fraction of health care money.

Our government policies also contributed to this trend. We refer to, for example:

• Macro-economic policy that weakened the building of a well-resourced, well-remunerated the public health care system and movement towards free health care for all (for instance):
• Budget cuts, including closure of health facilities like hospitals, nursing colleges, and loss of more than 40,000 health care jobs since 1997.
• Various forms of privatisation - outsourcing, PPPs, including privatisation of public hospital wards. All these contribute to the expansion of the private sector, employing an increasing proportion of doctors and other health care providers, most of whom were public sector workers.
• Piece-meal reforms and policies, that sought to regulate the private health sector - rather than transform the sector - leading to ever concentration of resources in a subsidized, for-profit private sector and ever rising costs of care etc. All these to the detriment of the public health sector.

These policies have further entrenched the dualistic, two-tier health care system, rather than ending it. Once again it is important to remember what we said in 1994 about the future of our health system. The ANC Health Plan recognized that "because of the burden associated with paying for health services at the time of illness, in the long term we [ANC government] are committed to the provision of free health care at the point of service for all citizens of South Africa.

Regulatory reforms of the past had emphasized private sector solutions to the question of universal coverage (Lower-income schemes, social health insurance, etc). They actually endorsed central role of for-profit driven private medical scheme industry in health care and nourished for-profit (shareholder) private ownership of health care. But promises of greater inefficiency and cost control remain unfulfilled. Meanwhile, membership of medical aids remains stagnant, down from 20% in 1994 to 15% in 2007.

So what is the way forward?

In 2001, COSATU National Congress adopted a comprehensive resolution on the National Health Insurance, which called for a fundamental change in the current health care system through direct state intervention in the private health industry and strengthening of the public health sector.

The ANC Polokwane further resolved for urgent implementation of a comprehensive national health insurance - NHI - in the next five years.

To achieve a universal, comprehensive, free national health care system, founded on the primary healthcare approach, requires a well-funded and well resourced funded public health system.

There is a need to radically shift the way society funds its healthcare - by incorporating all health care resources in the public sector. This is possible by building on strengths of our public health system.

With 8, 5% of GDP spent on health in 2006 (about R135-billion) SA has enough resources to provide health care to everyone, what is required is the redistribution of these resources, from the minority of the population to the majority.

NHI only provides the funding framework for building a unified health care system, within which we can address our health care challenges. Funding is not only what we need to address these challenges, but funding is the strong leverage through which we can address these challenges.

There are various definitions of what National Health Insurance internationally. This is understandable, as this is a seriously contested concept internationally and even here at home. We clearly define National Health Insurance as a state-mandated; state-administered system; in which a single authority organizes health finance aimed at ensuring that all persons, irrespective of his or her financial status have free access to health care at the point of service.

Only within the framework of the NHI will our government and people will have enough capacity to:

• Build an optimal, unified free and comprehensive health care system;
• Build on the current government efforts to end racial and geographic inequalities in the current two-tier, wasteful and contradictory health care system;
• through Effective planning, rational investments and equal distribution of health resources.

Finally let me emphasize, that we expect our government to begin to implement the NHI system as the only affordable option for a comprehensive universal coverage.

I thank you for listening, and I wish you well in your deliberations.

This is the text of the address by the General Secretary of COSATU, Zwelinzima Vavi, to the South African Medical Association, SAMA Conference, August 31 2008