The more things change the more they stay the same
Ah, is it just me or does anybody see
The new improved tomorrow isn’t what it used to be
Yesterday keeps comin’ ’round, it’s just reality …
The words of a song by Bon Jovi echo in my mind as I reflect on the state of South African healthcare. The song itself echoes the words of the French writer Jean-Baptiste Alphonse Karr from the 1800’s who wrote that “plus ça change, plus c’est la même chose” – the more things change, the more they stay the same – indicating that turbulent changes do not affect reality on a deeper level other than to cement the status quo.
The hopes of change that enthused health activists in the turbulent times before and immediately after 1994 with ambitious plans that envisaged a reformed and transformed healthcare system focused on the needs of the majority have faded as time has passed. Despite progressive legislation and a plethora of policies and plans driven often by well meaning people, it could be said that the more things have changed, the more they have stayed the same and the status quo has become even more entrenched!
Certainly healthcare facilities are no longer segregated by race but 28 years later healthcare facilities remain segregated rather by socioeconomic status with the majority dependent on the public health sector and those with means having access to the private health sector. There are stark differences between the public and private health sectors and even further differences between the quality of care in the more affluent urban provinces compared to that in the poorer more rural provinces in the public health sector. This is born out by the differences in ratio of medical personnel to population between more urban and more rural provinces which persist despite efforts to achieve a more equitable distribution of health personnel through a system of community service. In addition, management challenges in the public service in many provinces have resulted in key staff shortages, stock outs of medicines and medical supplies, crumbling infrastructure, failing equipment which condemn the poor to an inferior health service.
In the 1970’s, I worked for a time at the Holy Cross Hospital, a rural former Anglican mission hospital near Flagstaff in the then Transkei homeland, which although at the time largely funded by the National Department of Health, was adequately staffed largely by people, many South African, recruited as a result of a network of mission hospitals and church organizations committed to providing healthcare to poor rural populations. While this philanthropy could be challenged as paternalistic, (used in a gender neutral context) at that time with effective management medicines and medical supplies were adequate, the hospital was appropriately equipped and provided good quality district based healthcare to the surrounding population. Adhering to the principles of community orientated primary health care as espoused by people such as Sidney Kark and David Morley (the latter who spent some time at the hospital during my time at the hospital) the hospital at that time provided outreach through clinics that increased access for both preventive and curative services to many near where they lived scattered on the hills of Eastern Pondoland. Yet despite significant refurbishment valued at over R100 million at the hospital completed in 2012, conditions at the hospital at one time staffed only by foreign doctors, has remained before and since in the spotlight due to various issues related to shortages of water, lack of medicines, poor staff attitudes and failed inspections by the Office of Health Standards Compliance (OHSC). A far cry for the days when I worked there almost 50 years ago when the hospital was still run along the lines of a mission hospital in a then apartheid era “bantustan homeland” dependent to a degree with support from charitable donations and medical staff recruited through faith based organizations across the world. Why is it that 28 years post 1994, that the situation at a hospital such as this is worse than it was in the mid 1970’s?
National Health Insurance (NHI) is seen as the solution to the challenges faced by healthcare in South Africa. It is purported to address the glaring differences currently between the standard of care in the public versus the private health sector by creating a common pool of funding for healthcare in South Africa. As an aside, I am fascinated by the views expressed by several South African “experts” in healthcare who see the experience of so-called “cooperation” between the sectors during the COVOD-19 pandemic as evidence that NHI, as set out in the draft NHI Bill now before parliament, is the solution to the challenges facing healthcare in this country. I find it difficult to identify exactly what occurred during the last two years that would support that argument as in my view while on a superficial level there was cooperation, in real terms, the two sectors remain as apart as they were prior to the advent of the pandemic.
The entrenched differences between the public and private sectors both in the manner in which healthcare is managed and delivered have remained fundamentally unchanged since 1994. In fact, the words of Jean-Baptiste Alphonse Karr ring true that the turbulent changes that occurred in the 1990’s did not affect reality on a deeper level other than to cement the status quo. The question is whether NHI will change that deeper reality? If implemented under ideal circumstances what is proposed would certainly change the manner in which healthcare is funded and delivered in this country. Without doubt every South African both rich and poor would welcome a health service that offers quality and where the lack of resources is irrelevant to the decision of where an individual is treated. However, there are several preconditions, some of which I have outlined below, that would be necessary to provide confidence that this would indeed occur with what is proposed as National Health Insurance and that would meet muster to provide the sought after Universal Health Coverage.
Firstly, the level of fraud and corruption that is rife in South Africa and continues despite commissions and investigations must be addressed. It cannot be in this environment that the sum total of all health funding is concentrated in a single fund governed by a single public entity, the governance of which is at the discretion of a political appointee, i.e. the National Minister of Health. The experience in South Africa over the last two decades should have taught us the potential consequences of such a path. A mechanism with appropriate checks and balances resistant to the vagaries of fraud and corruption must be found to govern the funding of healthcare for the South African population, which I do not believe is adequately addressed in the draft legislation.
Secondly, the management capacity and governance culture of healthcare must be significantly bolstered to achieve an organisational culture that is vested in integrity, skill, capacity and accountability. Those who demonstrate a lack of theses requisite qualities must be removed from positions of authority. There must be an intolerance of dishonesty and incompetence with a direct and swift consequence when evidence of such actions are identified.
Thirdly, politicians, as with management, must evidence integrity, skill, capacity and accountability but cannot be directly involved in the management of healthcare services and must restrict their activities as political appointees to that of policy determination and the monitoring of the implementation within policy frameworks. Those who fail to adhere to these principles must be removed from political positions of authority and held accountable for their actions.
Fourthly, that the fiscal realities facing South Africa are taken into account. While the plea for additional funding for healthcare will always find justification, the reality of what is affordable and possible given the state of the national fiscus cannot be avoided or blamed on neoliberal policies as some are won’t to do. Similarly that even a simple combination of what is currently spent in the public and private sectors into the envisaged NHI Fund will fully address the overall funding requirements of what is envisaged for NHI is unrealistic.
Finally, given that almost thirty years of apparent transformation has achieved little in altering the underlying fundamentals, it is necessary that the debate on the future should be based on realistic assessments of what is possible within the South African context. Grand schemes are doomed to failure as are theoretical arguments which fail to connect with the possible and the probable. To advance fixedly into an ideologically driven future, irrespective of the consequences, has the potential to do more harm than good. That things need to change and that they should not stay the same is an incontrovertible truth, but let us proceed with caution so that in another thirty years someone else does not again quote the words of Jean-Baptiste Alphonse Karr when discussing healthcare in South Africa.
