The recent State of the Nation address gave President Cyril Ramaphosa the opportunity to confirm the vision of the rollout of National Health Insurance (NHI).

Equity, access, rights and participation are core elements of social justice that are essential to health promotion. The NHI presents a prime opportunity to improve social justice across South Africa, but in its current draft form, the noble vision appears to fall short in a few crucial areas, particularly relating to the extent of universal access and the rights of healthcare workers.

As with many variants of social inequality in South Africa, asymmetries in the access and quality of public health have their roots in apartheid-era segregation. Based on 2017 data from Statistics South Africa, only about 17% of the country has medical aid, with access dramatically skewed along racial lines. Although 72.4% of white people are members of medical aid schemes, the figures drop to only 20% of coloured people and 10% of black people. The burden of out-of-pocket health costs weighs heavily on the majority of South Africans.

The National Health Insurance Bill represents the South African government’s response to address this social injustice by providing affordable healthcare to all South Africans. This is part of the broader journey to universal health coverage.

Whom should we hold accountable for an unhealthy society? It is hardly a secret that healthcare in South Africa is inequitably distributed and that provision of health is wrapped up in our politics at every turn. Conversely, a population’s health has significant effects for political participation, economic prosperity and human security. As such, it is imperative that health is addressed from its political and social roots.

The South African healthcare system suffers from a multitude of challenges, including delays in care delivery, the high incidence of preventable errors, insufficient human resources, prolonged waiting times and severe overcrowding. A major challenge that the NHI also seeks to address is the unequal distribution of medical personnel between the public and private sectors, deepening the inequality along structural lines and highlighting the absence of a unitary health system. Healthcare services would benefit from greater pooling and mobilisation of the country’s resources — private and public — for everyone, regardless of socioeconomic class.

However, given the evidence of perpetual failure in the running of state-owned enterprises such as Eskom and SAA, cynicism abounds about the state’s capacity to embark on another massive state-led endeavour, such as the NHI. South Africans have lost trust in public institutions. According to findings from the Afrobarometer, public confidence in the government to provide basic services is limited. In 2018, 33% of South Africans said that the government is handling the task of improving basic services “very badly”, and nearly 22% felt that it does so “fairly badly”. These findings suggest that much will need to be done in terms of governance efficiency to realise basic socioeconomic justice targets, including health.

If managed poorly, many medical-aid scheme members with limited benefits may be pushed into using an overcrowded and strained NHI that could fall short of current access and quality standards. And the challenges do not exist only on the demand side. If the new system fails to compensate nurses and health practitioners’ adequately, quality may also be compromised on the supply side. Although quality healthcare will ultimately be measured in terms of the wellbeing of the ultimate recipients, a new system needs to cultivate the infrastructure to do so, which starts with motivated personnel.

The results of early NHI pilot projects have not been promising. Many doctors working in the NHI’s biggest pilot site, Tshwane, point to persistent drug and staff shortages, long queues and government failings in attracting the necessary general practitioners from the private sector. The latter suggests that it is likely that some doctors and hospitals in the private sphere may decide to opt out of the accreditation process to maintain their levels of quality and income. This would compromise efforts to make quality healthcare more accessible; instead, it would lead to greater inequality across South Africa and defeat the purposes of the NHI.

The case for universal access

Its ultimate test would be whether the health system could provide universal access, and particularly to the most vulnerable, which includes women, children, the elderly, the LGBTQIA+ community and asylum seekers. In its present form, the Bill allows asylum seekers and undocumented migrants access only to “emergency medical services; and services for notifiable conditions of public health concern”. This would mean the exclusion of many people who have already suffered immensely due to violence, genocide, war crimes and other human rights violations. Healthcare is not universal if it does not extend to the rights of illegal migrants, and this is particularly pertinent in South Africa, which is guilty of recurrent outbreaks of violent xenophobia.

The World Health Organisation (WHO) defines universal health coverage as “a system whereby all individuals and communities can access the quality health services they need, without suffering financial hardship”. Previous frameworks, such as the Refugees Act of South Africa and a 2007 department of health circular, stipulate that refugees and asylum seekers, whether documented or undocumented, are free to access the same health services and payments as South African citizens.

Over the past decades, many health laws and policies have been contradictory, leaving medical staff confused about how to handle migrant healthcare. However, the national introduction of different rights within the NHI would be at odds with the overarching message of the WHO and the South African Constitution, which ensures the provision of healthcare for all people within South Africa. Accessible healthcare must be ensured independent of migrant status within the NHI to achieve inclusive social justice and to consolidate integrity into South Africa’s pan-Africanist rhetoric.

If implemented successfully, the NHI could be a massive win for socioeconomic justice by equitably distributing quality healthcare to a much broader base of society and decreasing out-of-pocket costs. It is unacceptable from a moral and political perspective to continue a path of exclusionary healthcare, and the NHI should be seen as a positive investment in the health of the country.

A poignant difference between South Africa’s attempt at national insurance and predecessors elsewhere such as the National Health System in the United Kingdom, is that the UK not only has far superior infrastructure and resources but has the means to exploit a taxable citizenry. South Africa is in a completely different economic situation. There is a distinct lack of successful examples from similar low- and middle-income countries to set the bar. We have no blueprint for how to create an African NHI that addresses the injustices of the past. But this also gives us an incredible opportunity to lead.

Kayla Arnold is an intern at the Institute for Justice and Reconciliation in Cape Town. She holds an Honours degree in International Studies from the University of Stellenbosch. Her work focuses on sociopolitical development, human rights and global health. 

Article first published on Mail & Guardian