NHI: The promise not worth the peril
25 February 2020
I have attended more than 10 public hearings on National health Insurance (NHI) over the last few months. It has become abundantly clear to me and most others who understand the policy and its context that many people still don’t grasp what it will entail and offer. Some just don’t want to see it for the catastrophe it will ineluctably be, whilst others welcome whatever outcome, good or bad, it delivers. And yet, it isn’t difficult at all to see where it will lead.
I was asked at a roundtable discussion with health minister Dr Zweli Mkhize in December whether I support the idea behind NHI. My answer was that I support improved health services for everyone in the country, but that NHI is not a means to that end. I would think all reasonable and compassionate people do.
The hearings and regular media reports have produced many heart-rending and sordid tales of people being ill-treated at hospitals, a dearth of equipment and personnel, bad staff attitudes, squalid hospitals, preventable deaths and many more ills afflicting the public sector. It is hard not to sympathise with those on the receiving end of such service (and I personally know quite a few). But to support NHI as a way of remedying these problems, is hopelessly naïve.
The bad news for those who (reflexively) support it is that it that there is no evidence to support that it will be a success and live up to government’s intention of universal healthcare. And they will not be getting all the wonderful goodies that is so loftily and vaguely promised. I have ruminated on its various guises and formats for years and still cannot find much good in it. The current dire situation of the public health sector didn’t just happen – it was caused. Ditto the mess at state-owned enterprises.
Auditor General Kimi Makwetu wrote the following in his 2018-’19 audit report on the financial health of provincial governments: “The financial health of provincial departments of health and education needs urgent intervention to prevent the collapse of these key service delivery departments. In comparison with the other departments, these sectors (particularly the health sector) are in a bad state.” According to a report by Dr Anthea Jeffery from the Institute of Race Relations (IRR) 85% of hospitals and clinics in the country cannot comply with basic norms and standards. Sunday newspaper Rapport late last year reported how R150 million allotted for linen in the NHI budget in 2018-’19 remained completely unspent. Some 4000 people died in 2018 in Gauteng’s public hospitals due to preventable causes.
There is no proof that a bigger system will be any different or that more money will be a fix-all.
In terms of financing, the whole thing is still uncosted and there is no accompanying money Bill to the much-vaunted NHI Bill. And President Cyril Ramaphosa’s insistence in a recent newsletter that it will enjoy a phased implementation is hardly reassuring. No timelines or details are given. We as taxpayers and staunch opponents of this farce should probably consider ourselves lucky that this government takes forever to get anything done, but it also goes to show that Ramaphosa and his government have no operational plan to implement it – except that it needs to be fully operational by 2026.
The NHI and every other policy to be financed will depend on government’s ability to finance it – even if it is a universal human right. Government is, however, an unproductive entity reliant on the taxes it receives from individuals and corporations. It is only logical that you’d want to make it as easy as possible for them to work, do business and earn more, in order to pay more tax and to save and spend more. But no, in the ANC’s fantasy cornucopia of unlimited money and growth with no trade-offs you could have your socialist cake and eat its capitalist fruits.
Unfortunately for them, reality has poured cold water on this quixotic delusion. Our growth for 2019 is likely to be 0.4% and many economists already predict no more than 1% for this year (which means it will eventually be much lower than this). The unemployment rate remains around 30%, and almost 40% according to the broad definition. If the existing money had only been prudently and judiciously spent and government’s ethics had been copacetic, some empathy would in order. But the fact that only 8% of the country’s municipalities receive a clean audit and SOEs such as SAA and Eskom are in a shambolic state shows that this government cannot be trusted to run a complex and gargantuan health system the likes of which this country has never seen.
A common complaint heard at the hearings is that people are unemployed, or too poor to afford medical aid coverage. This is unfortunate, but this does not bode well for financing the NHI and it goes to the heart of the challenges in the health (and every other) sector. For something like the NHI to even approximate an auspicious start, more people must work and pay tax. If the 600 000 people who pay 60% of the income tax decide to leave the country due to the restrictions of the NHI or whatever reason (as they already are), everything else will necessarily suffer.
Through its corruption and mismanagement of the economy, the ruling party has nixed any realistic prospect of implementing the NHI. Not even hijacking the private sector’s funds will help. As Ayn Rand once said: “Money is made – before it can be looted or mooched – by the efforts of every honest man, each to the extent of his ability. An honest man is one who knows that he can’t consume more than he has produced.”
Ramaphosa wrote in his newsletter that it is “one of the greatest travesties of our time” that income level determines access to quality healthcare. The real travesty is that the ANC is trying to cover up its failures with the promise of something that cannot be realised, and imperilling our future in the process.
Dr Brink is a strategist and political analyst.