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Another opportunity to address deep-seated inequality

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President Cyril Ramaphosa signs the National Health Insurance Bill into law in Pretoria. Ramaphosa, correctly, has identified the core problem we need to overcome: health inequality. He emphasises the struggle for a National Health Insurance as emblematic of a broader fight against systemic inequalities rooted in race, class and gender, the writer says. – Picture:Leon Sadiki / Bloomberg

By Tebogo Phadu

After many years of public policy making and debate, South Africa’s National Health Insurance (NHI) has finally become law.

The signing of this law by President Cyril Ramaphosa on May 15, marks a historic victory for equitable healthcare and for progressive and socialist forces in South Africa. It heralds a new era in which healthcare is treated as a right for all citizens, not just the privileged few.

As we embark on this transformative journey, it is essential to remain steadfast in our commitment to equity, universal coverage and social solidarity. The NHI is not just a policy; it is a promise to the people of South Africa that their health and well-being will always be a priority.

Ramaphosa correctly identified the core problem we need to overcome: health inequality. He emphasised that the struggle for a National Health Insurance was emblematic of a broader fight against systemic inequalities rooted in race, class and gender.

From progressive and socialist perspectives, the NHI represents a critical step toward addressing the deep-seated inequities by ensuring that all South Africans, regardless of their economic status, have access to good healthcare.

Healthcare is a fundamental constitutional right, not a commodity or a privilege. The right was egregiously violated under successive colonial and apartheid regimes that denied healthcare to most South Africans.

For many generations, the broader democratic movement, led by the ANC and its allies, has been advancing the cause of healthcare for all South Africans. By enacting the NHI law, the government builds on the progress made over the past 30 years, drawing lessons from this experience to establish a publicly administered fund (NHI Fund) that guarantees free access to health services for all citizens, whether the services are in the public or private sector.

The unequal and two-tier health system in South Africa is plagued by significant inequalities. The profit-driven private health sector, serving only 16 percent of the population, consumes more than half the country’s health expenditure.

By international standards, we are the only country (besides the US) where health care financing is concentrated in voluntary medical schemes. This leaves the public sector, which serves 84 percent of the population, chronically underfunded and overburdened.

Consequently, health outcomes are starkly divided along economic, racial and gender lines – those with means live longer, healthier lives, while the predominantly black, female and poor majority suffer from higher disease burdens and reduced life expectancy.

The inequalities are rooted in the broader socio-economic landscape of South Africa, with deep roots in our colonial and apartheid past, characterised by extreme levels of income and wealth inequality. The capitalist-dominated economic structure exacerbates the inequalities, with healthcare being one of the most visible manifestations.

The NHI seeks to address health inequality by redistributing available health resources more equitably and ensuring that health care is based on need, not the ability to pay.

Over the past 20 years, the ANC, the SACP and Cosatu, along with a broad range of progressive civil society organisations, have championed the idea and commitment to the NHI. We rallied the nation around four core principles that guided our approach to the NHI.

First, the principle of healthcare as a right. Access to healthcare should not be contingent on financial capability. By treating healthcare as a constitutional right, the NHI ensures that everyone can receive necessary services without the barrier of cost, prioritising healthcare needs over profit-taking.

Second, the principle of universality. Healthcare services under the NHI Act will be comprehensive and of good quality, with a strong emphasis on primary healthcare. The universality is essential for addressing the health needs of the entire population, particularly the poor majority.

Third, the principle of social solidarity. Achieving universal coverage in healthcare requires a political commitment to an equitable health financing system, necessitating a shift from private financing (medical schemes) to more public financing. Funding for the NHI will be based on social solidarity, with the wealthy contributing more through progressive taxation. This redistribution of health resources is crucial for achieving equity in health care.

Fourth, the principle of public administration. Since universal health coverage can be achieved only through public financing, the NHI must be publicly funded and administered. By passing the NHI Act, which requires the establishment of the NHI Fund, the ANC government has demonstrated a bold political commitment to overcoming the two-tier health system and creating a unified health system. The NHI Fund will provide the public health sector with adequate resources to deliver good healthcare.

Precisely because we are addressing inequalities in healthcare, it is unsurprising that, after many years of public policy debate, consultation, and the passing of the NHI legislation, the NHI continues to face persistent challenges from interest groups benefiting from the fragmented and expensive privately financed system. The forces sought to silence the voices supporting the NHI through a deluge of counterarguments presented as scientific and reasonable.

The opposition is reminiscent of the eve of the first democratic elections in April 1994. Mmusi Maimane declared that the NHI was a “death sentence to healthcare”, while the DA threatened that it would lead to the “collapse” of the health system. A right-wing trade union claimed that 94 percent of health professionals would leave the country, without acknowledging that the countries they want to migrate to have their own versions of the NHI.

This kind of opposition is not unique to South Africa; it was seen during the early years of the National Health Service in the UK and the National Health Programme in Canada. While the programmes seek to draw support from all sections of society, they tend to be championed by forces advocating for a socially just and more equal society.

The fear-mongering tactics and legal threats should not distract us from focusing on what is important now: moving from policy debate to the reality of implementation. As long as there is an ANC government, the law cannot be delayed.

Over the past 20 years, opponents of the NHI, primarily from sections of the private health industry, have campaigned to undermine or delay its implementation. The entities, such as medical scheme administrator companies, benefit from the unequal system and have vested interests in maintaining the status quo. However, they have failed to provide credible alternatives that address the core issues of health inequity.

The implementation of the NHI in South Africa is not just a health reform; it is a social justice imperative. By ensuring universal access to healthcare, the NHI will help dismantle the deeply entrenched inequalities that have long plagued the country. The vision of healthcare emphasises the redistribution of resources, the protection of public goods and the prioritisation of people over profit.

The successful implementation of the NHI will be a testament to the country’s commitment to equity and justice, contributing to the global 2030 agenda for sustainable development and setting a powerful example for other nations grappling with similar challenges.

It is a call to action for all South Africans to support this transformative initiative and work towards a future where healthcare is a right enjoyed by all, not a privilege reserved for the few.

Tebogo Phadu is a member of the SACP central committee.