In the summer of 1944 during the Second World War the Allies launched an airborne operation, named Market Garden, aimed at securing a crossing over the Rhine River and thus an advance into the heart of Northern Germany. The aim of the operation was to seize key bridges with airborne troops allowing ground troops to advance over 100 kilometres to the Dutch town of Arnhem and by so doing outflank the German frontier defences. The plan which was backed by the British General Montgomery and Prime Minister Churchill despite concerns expressed by others in the Allied High Command lead by General Eisenhower. The operation despite the heroic efforts of allied troops failed due to the inability of the British airborne soldiers to take and hold the bridge at Arnhem long enough for the ground troops to reach them before they were overwhelmed. In addition to the underestimation of German armoured strength near to the town, the plan was hampered by the logistics of moving the large numbers of ground troops quickly along a narrow road surrounded by marshes that limited off-road movement. The collateral damage that resulted in the town of Arnhem to buildings and the civil population as a result of the conflict was very severe. The conclusion of military historians is that the operation, while bold and innovative, was “just a bridge too far.”
Recently various reports and opinion pieces have indicated both the intention of government to push forward with the implementation of National Health Insurance and support for this from various groupings including those termed “progressive health professionals”. The National Minister of Health speaking recently to a parliamentary health committee assured the committee that National Health Insurance would require no additional funding based on the premise that the current estimated 8.5% of GDP spent on healthcare both in the public and private healthcare taken together would suffice. This appears to be based on the premise that all South Africans currently serviced by the private health sector would voluntarily or through force of legislation relinquish healthcare from this source and that this funding would then provide quality healthcare that meets the expectations of all South Africans. It also assumes that this quantum of funding alone would address the healthcare needs of South Africans as determined by the “Benefits Advisory Committee” as described in the NHI Bill before parliament. Finally, it is assumed that when NHI is implemented that the current ills that exist within the public health sector, that are without fear of contradiction manifold, will simply evaporate like the dew before the rising sun!
While I am not an uncritical advocate for the South African private sector and agree with much of the criticism of the sector, as outlined in the Health Market Inquiry, I find it regrettable that the response to criticism of the current NHI Bill is categorised as a “lack of concern for the poor” and in certain circles as even “unpatriotic and reactionary”, the latter the antithesis of progressive. Accusations that those who wish to debate and question what is contained in the bill do not care for the poor, while populist in nature, are in my view not constructive.
It is insightful that the National Treasury has to date neither allocated significant funding in multi-year budgets nor published a detailed analysis of the funding required on a multiyear basis to ensure the viability of what is set out in the proposed legislation. To date only relatively insignificant seed funding for NHI “pilots” and more recently modest funding for posts centrally located within the National Department of Health has ben provided. Nevertheless, it is expected that a reassuring statement from the National Minister of Health should suffice and this despite a senior executive in his department, recently conceding that additional funding would indeed be required.
The National Finance Minister, responding to a parliamentary question, indicated that little work had been done on the financing and that implementation was “still some way off”. He indicated that the NHI costing model would be determined by the practical progress with NHI, spending patterns and the timing of the legislative progress. A telling comment from the Finance Minister was that, “the cost model will not automatically translate into budget allocations as these would have to be made as part of the budget process which would take into account the macro-economic environment and fiscal space.” The reality is that South African public sector health departments are currently experiencing reductions in real terms of their budget allocations and this is occurring in an environment when many health departments face service delivery challenges and year-on-year accrual of unpaid amounts due to service providers. It is difficult to accept the reassurance that the redirection of funding from the private sector alone will enable the health sector overall to meet its obligations.
As I have indicated in a previous post, my experience of parliamentary debate on health matters is that it has not been impressive in terms of the rationality but rather strong on rhetoric and emotion. In this vein, I was drawn to a recent article in the Daily Maverick by the National NHI Coordinator of the Progressive Professionals Forum (PPF). The PPF is described on their website as “a non-racial, non-sexist and non-xenophobic organisation of progressive professionals, academics, intellectuals and patriotic entrepreneurs subscribing the values of the Freedom Charter and the Constitution of South Africa and who are the think tank and resource base of South Africa in the realization of the country’s developmental goals through policy, research and advocacy.” This would seem to be the type of organisation that should be prepared to objectively address the realities of what is set out in the NHI Bill currently before parliament.
The author draws attention to Section 27(2) of the Constitution that states that “the state must take reasonable legislative and other measures within its available resources to achieve the progressive realisation of access to healthcare services”. He elaborates further that the goal of NHI is to ensure equity and access to quality healthcare services based on need and not on affordability and universal health coverage for all South Africans based on the principle of solidarity. Noble goals that few will contest which I have supported for the duration of my professional life and to which I have contributed during my career in the public health sector that extends over 40 years. The bill is described as a critical and indispensable vehicle that can transform healthcare toward a unified private and public healthcare system and it is acknowledged that is “the most complex system to be implemented since the dawn of democracy.” The PPF then endorses various components of the draft legislation repeating in essence what is set out in the bill stating that the NHI funding will ensure quality healthcare access for all South Africans and repeating the well known fact that there is an unequal distribution of resources between the public and private sectors. The need to implement NHI without any further delays is justified by what is termed “the current state of the national health system” and what was outlined in the Health Market Inquiry report. I think that it is undoubtedly true that the current state of the national health system requires urgent attention which it has required that since 1994. My disappointment with this article and others penned in support of National Health Insurance is what I regard as the uncritical nature of that support.
While the private sector is seen as profligate by many critics, myself included, it alone cannot be held accountable for the poor state of the public health sector in South Africa. Sadly those in charge of and who manage the public health sector, myself included in the past, must accept responsibility for the current state of affairs. In more than two decades there has been failure to right many of the ills afflicting the public health sector that currently services the majority of South Africans. The reasons for this are many and reflect what is wrong with many sectors in this country apart from health as starkly illustrated by what is happening for example at Escom and in municipalities across the country. The excellent book, Days of Zondo, authored by Ferial Haffejee and Ivor Chipkin, that should be required reading for all South Africans but particularly those who uncritically support what is proposed in the NHI bill, highlights the significant risk of the centralisation of all the resources for healthcare in a single public entity under the jurisdiction of a politician, the National Minister of Health. I have previously argued that if resources are to be centralised in this manner the jurisdiction should reside with the National Treasury. Days of Zondo emphasises the key role played by the National Treasury in resisting the fraud and corruption of State Capture.
While the noble intentions set out in the NHI bill are laudable and echoed in the article referred to above, I fear in the context of South Africa today, as with the Market Garden operation of World War 2, what is proposed in the NHI Bill is simply a bridge too far. Similar to the planners of Market Garden in 1944, those supporting the proposed legislation have failed to adequately address the complexity of what is envisaged and similar to Market Garden ignore the complexity of the logistics required. Garnered by groupthink, as exemplified by the article referred to above, policy makers along party political lines appear to be launching a process that has the risk of significant collateral damage for ordinary South Africans if the already challenged public health sector finds that NHI is not the salvation that its seeks. I fear that I am in a minority and like the critics of Market Garden all those years ago will be ignored but it does not deter me for warning that NHI as currently envisaged may be just that bridge too far! I sincerely hope that history proves me wrong.
