Universal Health Care
Universal Health Care
Universal Health Care
Edited by
Greg Ruiters and Robert van Niekerk
Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Introduction
Inequality and health systems in context . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Greg Ruiters and Robert van Niekerk
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Inequality and health systems in context 1
INTRODUCTION
1
2 Universal health care in southern Africa
Acknowledge that the South African health system has challenges that
can only be addressed through a comprehensive transformation of the
system. The implementation of the national health insurance plan means
transformation of the funding model for health as well as reorganisation
of health care delivery. Universal access to health services can only be
achieved through a simultaneous and two-pronged approach. First,
significantly strengthen the public sector so that it becomes the provider
of first choice. Second, design mechanisms for ensuring that scarce and
critical health service resources in both public and private sector are shared
and optimally used by all to maximise social value.
Against this background, this volume examines private health care and health
financing in South Africa and Zimbabwe. These two countries have the largest
private medical sectors in sub-Saharan Africa. In Africa as a whole, private medical
aid schemes cover only 1 per cent of the population. In 2006, the Board of
Healthcare Funders (BHF) reported that there were 108 private medical aid
schemes in South Africa, 20 in Zimbabwe and nine in Namibia.
The role of the private sector in South African health care is well known.
However, Zimbabwe is also characterised by a system of highly fragmented medical
aid societies, which (unlike their South African counterparts) have themselves
become direct providers of health care as well as owners of hospitals, pharmacies,
training systems and emergency transport services. In this country, mandatory
national health insurance has been discussed for three decades without any
conclusion being reached or any new system implemented. This option, which is
now being implemented in South Africa, needs to be revisited as the economy
stabilises and confidence in governance improves. In both countries, sound health
care is becoming more and more expensive, moving increasingly beyond the reach
of ordinary citizens (see Chapter 9). Those still able to pay for membership (about
15 per cent of South Africans and 10 per cent of Zimbabweans) belong to one of
the many fragmented private medical aid schemes.
The NHI system proposed for South Africa aims to provide all South Africans,
regardless of socioeconomic status, with access to affordable, efficient and good
quality health care (DoH 2011: 4). Moreover, Motsoaledi has stated that health
care reform should realise the principle that health is a public good and not a
commodity (Motsoaledi 2011). In this context, major features of the proposed
scheme are universal access to a basic package of services for both the rich and
poor, increased funding for the public health sector and pooled resources for the
health sector as a whole, all aimed at creating a common institutional platform
for improving health outcomes. According to the Green Paper, NHI will improve
the nation’s health. Healthy people are more productive and live longer, which
will help the economy in a number of ways. Less money spent on health care
means greater demand for other goods and services.
Perversely, the growth of private health care during the 1980s was driven by
the cash-strapped apartheid state on the one hand, and corporate capital,
particularly the Rembrandt Group (which has major tobacco interests) and the
mining houses on the other hand. The new for-profit general hospitals that sprang
up throughout the country drew doctors and nurses away from the public sector.
In the early 1980s, 40 per cent of all doctors worked in the private sector; a
4 Universal health care in southern Africa
decade later, 62 per cent of general doctors and 66 per cent of specialists had
shifted to the private sector. In 1985, ‘over 85 per cent of the white population
was privately insured . . . but only eight percent of blacks held private insurance;
their coverage also tended to be less comprehensive’ (Naylor 1988).
NHI promises to be the ANC’s most important universalist policy yet, signaling
a shift towards a politics of solidarity that does not separate the poor from the
rich. If the overall goal of post-apartheid South African public policy is social
integration, dignity and reduced social apartheid, we need to ensure that the
interests of the middle class (black and white) are served by inclusive public delivery
systems. The proposed NHI scheme constitutes a shift away from the targeted
poverty alleviation approach, which has been the stock in trade of the past three
decades of neoliberal policy design (including the Millennium Development Goals),
and treats the poor as a residual problem, towards a more inclusive approach.
The current two-tiered health citizenship reflects South Africa’s ongoing social
fragmentation, lack of national social cohesion and residual apartheid mentality.
It also reflects a continuing bias towards privatisation as well as continued support
for the idea that the state is incapable of sound service delivery. The implicit
message is that the poor majority should continue to seek (inferior) health care
from the state, while the wealthy minority should avoid the state and purchase
(superior) private health services.
Contrary to this segregated conception, a well-functioning and rational health
system can be defined as a cohesive set of policies, processes, actors and co-
operating institutions delivering high-quality health services to all people, when
and where they need them. Policy for national health instruments such as NHI
need to stimulate the power of civic claiming, provide effective accountability
mechanisms and prepare for resistance from hostile interests groups, including
street-level bureaucrats who might seek to thwart the policy’s intentions.
We argue that the success of an NHI scheme can be eroded by an unregulated
and aggressive private sector that sees patients as commodities and competes
with the public sector. There is more to a health system than technical, material
and human resource issues. Entrenched but narrow economic groupings such as
insurance companies, private hospitals and pharmaceutical corporations skew
the system away from prevention, introduce structural irrationalities and increase
social costs so that wider national imperatives are compromised (Leys 2001).
Exclusionary forms of privatised service delivery may be vociferously defended
by mobilised middle-class elements (in the South African media, for example)
and the wealthy may even – in the name of constitutional rights to ‘free’ choice
and anti-statist market fundamentalism – reject calls to impose larger or perhaps
more public rationalities (see Chapter 1).
The dominant anti-statist neoliberal mindset with its bias towards privatised
services tends to measure success and efficiency in narrow terms, which understate
6 Universal health care in southern Africa
In short, in the ‘new’ South Africa little has changed in the social geography of
race and class. The middle class has walled itself off from the poor who experience
unemployment, overcrowding, bad roads, pollution from indoor fires and long
travel times – a system of compounded dis-welfares. These remain specific features
of the punishing and shortened lives experienced by blacks in townships and
rural areas (SACN 2003). It is impossible to find a private hospital or decent
amenities in most townships, which were designed as a solution to the ‘native
question’ (Mamdani 1996) and as dormitories and places of confinement
(Robinson 1995). Therefore, social and health citizenship cannot be discussed
without referring to the ongoing re-segregation between black townships and
informal settlements subject to faltering public services on the one hand, and the
largely white suburbs marked by the growing privatisation of services and space
on the other hand.
As suggested in this volume, to break down this culture of exclusion and
replace it with one of a sharing of space will require a number of interventions –
including the building of an integrated health system in the place of the existing
two-tier system. The NHI, as Mooney notes, ‘must be part of the South African
social fabric’ (2011). New ways of overcoming apartheid spatial legacies alongside
major improvements in housing, water supply and working conditions, and access
to a more rational and effective health care system focused on reinforcing the
confidence and capacity of the poor to make claims, need to be explored and
advanced.
the private sector (as defined above) owns about 30 per cent. There are 30 medical
aid societies in the country, covering about 10 per cent of the population of 13
million who can access private for-profit facilities (AHFoZ 2009). Ten of these
schemes are restricted to employees of particular firms, while the rest are open to
anyone. Unlike their South African counterparts, though, Zimbabwe’s medical
aid schemes have been allowed to acquire hospitals, pharmacies and laboratories,
which permits them to directly control these facilities and services as part of their
managed health care plans. Levels of infant mortality (58 per 1 000 live births)
and life expectancy of close to 50 years are similar to those in South Africa.
Health system reforms are often compared across countries, but each country
has its own sets of institutions, historically conditioned forms of citizenship
segmentation and denigration, and specific ways of constructing social problems,
public issues and solutions. In South Africa and Zimbabwe, both former colonies,
spatial segregation shielded white settler communities from experiencing the
poverty of the black majority, or sharing a common fate. It profoundly distorted
ideas about whose interests counted as public interests, since only white privileges
mattered. The ongoing inequalities in the distribution of infrastructure and the
existence of racially isolated, vastly unequal residential areas have sustained such
social and ethical distancing and made it very difficult to set a common public
policy agenda. The politics of universalism means that the middle class needs to
be brought back into public services.
South Africa remains an extremely unequal society, marked by huge disparities
in wealth between a largely white privileged minority and a largely black poor
majority still forced by financial circumstances to live in risky and less healthy
living spaces and to undertake the most dangerous and menial jobs.
Life expectancy at birth is 49 years, up from 42.45 in 2007, but down from 51.1
in 2000, and is the fifth worst in the world. The only countries in the region with
worse figures are Swaziland (48.66) and Angola (38.76).2 According to one estimate,
the life expectancy of white and black South Africans differs by more than
20 years (SAIRR 2009). The life expectancy of white women is 50 per cent longer
Inequality and health systems in context 9
than for black women (Coovadia et al. 2009).The infant mortality rate (deaths in
the first year per 1 000 live births) has improved from 58.8 in 2000 to 43.2 in
2011, but remains far worse than the figures for Zimbabwe (29.5) and Botswana
(11.4), and places South Africa among the worst 25 per cent of countries in the
world.3 Infant mortality rates differ markedly across race groups, from 7 per 1 000
live births among whites to 67 per 1 000 live births among blacks – a difference
of no less than 900 per cent (Coovadia et al. 2009). Mortality of children under
five per 1 000 live births is 61.9, down from 81 in 2003, but virtually the same as
in 1990.4
The efficacy of the post-apartheid state has been reduced by inherited socio-
economic problems, the limits of the negotiated political settlement involving a
quasi-federal governmental structure and self-imposed problems such as the current
elite use of the state and black economic empowerment as vehicles for rapid
capital accumulation. The medical-business complex (comprising pharmaceuticals,
private hospital groups and medical aid schemes) is also a prominent feature of
South Africa’s health landscape. By the mid-2000s, Coovadia et al. (2009) argue,
‘these capitalist institutions ha[d] influenced the political economy of South Africa
and its health system to a greater extent than in most other post-colonial African
and Asian countries’. Moreover, they are defended vociferously by white privileged
groups and members of the new black middle classes, such as Mamphela Ramphele
(and almost all the eminent ANC political families with investments in private
health). Ramphele, ex-director of the World Bank and vice-chancellor of the
University of Cape Town, has warned against ‘destroying the private [health]
sector’, suggesting instead the need to ‘leverage what the sector has to offer’.5
The private health care system itself has begun to play a major role in
reproducing class and racial inequality. Together with private education, private
security and so on, it has played a major role in perpetuating social apartheid.
South African society remains extremely unequal, yet it has one of the world’s
most commercialised health systems (McIntyre et al. 2004). Forty-four per cent
of money spent on health care is spent on medical aid schemes, which provide
private health care for some 16 per cent of the population. A key challenge facing
the private health sector is how to deal with the rapid increase in contributions
to, and spending by, medical schemes.
In 2010 expenditure on the public health sector comprised about 4 per cent
of gross domestic product (GDP), and 14 per cent of the national budget. South
Africa’s public sector in general is becoming increasingly dysfunctional, with
immunity for corrupt officials and an almost demoralised citizenry that has given
10 Universal health care in southern Africa
up on the state and resorts to violent protests (Public Service Commission 2010;
Sole 2005). Immediate reasons for poor health outcomes include poor state
planning; a quasi-federal system with a confused division of responsibilities among
levels (or spheres) of government; generally weak implementation capacity in the
public sector, especially in provinces incorporating former ‘homelands’; an
inability to prioritise and sustain basic services such as a universal supply of clean
water and sanitation; inadequate evaluation of state programmes; an urban and
curative bias in state health spending (80 per cent of government spending is on
hospitals); and a flight of medical skills. The public health sector employs more
than 250 000 people, but there are severe shortages of specialised personnel as
well as nurses.
The dynamics of a parallel private and public health sector have been
intensively debated in South Africa and elsewhere. Thus, the Centre for
Development and Enterprise, a vocal policy think tank close to big business, has
declared:
The demand by the powerful few for curative health care diverts resources away
from primary health care and national welfare. Moreover, the private sector has
a mixed record in respect of health care, with poor performance including low-
quality care, overprescribing, limited reach beyond higher income groups and
barriers to access due to user charges and the fragmentation of risk pools. As
McIntyre et al. have argued, ‘the fragmentation of the health system between the
rich, insured and still largely white users of the private sector and the poor,
uninsured and still largely black users of the public sector has deepened over
time’ (2004: 444). More importantly, the private health sector limits the ability
Inequality and health systems in context 11
of the public sector to achieve the income and risk cross-subsidies required to
achieve universal health coverage, which the World Health Organisation (WHO)
has called on all member states to pursue. As a new frontier of class apartheid,
the private health sector continues to be reinforced by a landscape of increasing
social polarisation where the select few literally wall themselves off from the poor.
The private sector has appropriated skills and concessions from the public
sector, and the fundamental principle of social solidarity and universal coverage
via cross-subsidisation between the rich and poor and healthy and ill people is
not being honoured. As Maureen Mackintosh has noted, bad health care systems
‘contribute profoundly to people’s experience of what it means to be poor. To
have fear cumulated when at one’s most vulnerable – to be denied care – is at the
core of social exclusion’ (2003: 185). State support for the private health sector
not only legitimises inequality, but also reduces social commitment to cross-
subsidisation.
A recent WHO report has tried to explain why it has been difficult for
countries such as South Africa to improve their health care. It cited three main
reasons: ‘hospital-centrism’, or the idea that many health issues can or should be
resolved in a hospital; ‘deep fragmentation’, which is particularly problematic in
South Africa, given its history of segregated health systems; and commercialism,
which becomes problematic when it is dominant and ‘uncontrolled’ (WHO 2008).
All three of these maladies exist in South Africa and are overlaid by politically
explosive race-class polarities.
The existence of an extensive private health sector in any country distorts
that country’s public health system. For example, in the United States the profit
motive is the driver of an expensive, commodified health system that focuses on
selling medical treatment rather than health care. As Motsoaledi has stated, private
medical aid schemes provide a ‘source of effective demand for expensive and
arbitrary private treatment’.6 Moreover, in the 1990s, ‘open’ schemes were
permitted to exclude high-risk individuals from membership and engage in risk-
rating. As a result they ‘skimmed off the cream’, leaving the public health sector
to care for South Africans with the greatest health needs, namely the mostly poor
citizens euphemistically and degradingly labelled as ‘high risk’. When members
of medical aid schemes deplete their annual benefits, they often revert to the
public sector for specialised and hospital-based care. The impasse facing the South
African health system is the growing disparity in the public-private mix and the
magnitude of resources (financial and human) located in each sector relative to
the proportion of the population served by each.
12 Universal health care in southern Africa
This volume asks and seeks to answer these and numerous other questions,
including the following: What historical precedents exist in South Africa for a
national health service; can the NHI succeed and be made to function effectively,
given the poor state of the public health sector and the low morale of its workforce;
and if so, what other changes are needed?
How will the powerful private sector respond to its own internal problems
and to NHI? Will NHI cover all high-end services as well, or leave some to the
14 Universal health care in southern Africa
private sector? Could it, perversely, boost the private health sector by purchasing
services from it as well? And, how much political insurance does the black
ownership of private hospitals (under black economic empowerment schemes)
buy the largely white-owned private medical sector?
What regional consequences might there be? How have South African
companies responded to the NHI, and might they not attempt to escape regulation
by moving their operations to neighbouring countries? What are the entry points
for new capital?
The book is divided into four parts. Part 1 provides an overview of the battle
of ideas on the notion of universal health care. Chapter 1 examines competing
views of the good society and the related policy positions adopted by various
political parties and social movements in the current South African debate on
health care and the NHI. Chapter 2 examines earlier debates about national
health insurance, notably the Gluckman Commission of the early 1940s, and
claims made by the ANC under Dr A.B. Xuma. Chapter 3 examines health
policy reform in the last days of apartheid and the dilemmas facing the ANC on
health issues as it prepared to assume power.
Part 2 examines health care in southern Africa, notably recent trends towards
its commercialisation. Chapter 4 focuses more broadly on public and private
health care in the region. Chapter 5 explores the development of medical aid
societies in Zimbabwe up to 2007. Chapter 6 examines their development since
then, as well as issues of equity raised by their prominent role in providing medical
cover.
Part 3 deals with privatised health care in South Africa. Chapter 7 considers
the rise and consolidation of private health care from the early 1990s up to 2007.
Chapter 8 focuses on their subsequent development, the political economy of
the South African health industry and the current crisis in the private health
sector.
Part 4 examines the way forward. Chapter 9 analyses the debate on the
proposed NHI in South Africa and Chapter 10 reviews this debate in the light of
international experiences and best practice. Chapter 11 reflects on prospects for
achieving the goal of universal health coverage in the southern African region.
Inequality and health systems in context 15
Notes
1. http://www.news24.com/Opinions/QAndA/Cronin-vs-Leon-Service-delivery-protests-
20090806.
2. http://www.indexmundi.com/south_africa/life_expectancy_at_birth.html.
3. http://www.indexmundi.com/south_africa/infant_mortality_rate.html.
4. http://www.indexmundi.com/south_africa/infant-and-child-mortality.html.
5. Sunday Times, 20 April 2008.
6. Cited in The Daily Dispatch, 30 June 2011.
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