How we can create free health care for all

We are now 15 years into our democracy and we have yet to remove one of the most important barriers to access to health by the poor – money. The 1994 National Health Plan of the ANC called for ensuring that all South Africans, rich or poor, had free health care at the point of service. Apartheid had a fundamental impact on people’s health and the organisation of the health system in South Africa. That legacy, despite many achievements in our health care system, continues to this day. The critical health problems reflect the prevailing socio-economic conditions in the country. For most of the population, life expectancy has declined to 47 years. Mortality and morbidity rates are unacceptably high, preventable communicable diseases are common, and diseases associated with extreme poverty still occur. At the same time, a wealthy minority suffers from lifestyle-related diseases more typical of developed countries. The HIV/Aids epidemic has become the country’s most formidable health challenge, with rates of infection among the highest in the world. Before 1994, the public health sector focused mainly on the provision of curative, tertiary-level services for whites in urban centres so that health services in other areas, particularly rural primary health services, were critically underresourced. Post-April 1994, the government embarked on a major transformation project of the health system as a whole, and there have been both achievements and challenges. The major achievements since 1994 have included but are not limited to the following: Enshrining health as a human right. This guarantees access to health care to every South Africa and empowers the state to ensure progressive realisation of this right. Abolition of the apartheid fragmented health system structured along racial lines. The introduction of free health care for pregnant woman and children less than six years of age was successful in decreasing financial barriers to health care access. Studies showed that health service utilisation at public sector facilities increased after the introduction of the policy, particularly for antenatal care. There has also been significant expansion of primary health facilities – 700 new clinics to the existing 3 600 clinics. But our dream of free health care at the point of service for all has yet to be realised. Many challenges remain and to a great extent have expanded the reproduction of apartheid health legacies. They include but are not limited to the following: Key health indicators continue to disappoint and some are worsening – life expectancy and child mortality rates. Our life expectancy rate has actually declined to 47 years, while in 1994 it was 57 years. There are more poor children dying before they reach the age of five – more than 70 000 died in 2007. This is unacceptably high. HIV/Aids prevalence is very high by international comparison. Slow movement toward primary and frustrated efforts towards free health care to all. Health inequalities mirror social and economic inequality, with those who receive better-resourced health-care facilities mainly urban, middle-class and white, while the rural, the poor and black receive poorly resourced health facilities. Human resource challenges: we do not have enough doctors and other health professionals to fully support our health system. Even existing human resources are unevenly distributed, concentrated in the private sector. Popular mobilisation around health in our communities, particularly in black working-class communities, is totally missing, except in few and issue-based circumstances, such as HIV/Aids. At the heart of all these is the two-tier, contradictory, wasteful health care system: On one hand is a public health service that treats health as a social need, yet is starved of adequate funding and resources. Less than 40% of total health care resources are in this sector, yet it serves 85% of the population, the majority of whom are black and poor. On the other is an expanding private sector, which treats private health care as a commodity/business, accounting for more than 60% of the total health care resources, including a majority of health professionals (other than nurses), yet it serves a minority of the population, the majority of whom are white, and wealthy. The private sector creates a market-driven private health care system based on avoiding the sick: medical schemes and private providers compete not so much by increasing quality and lowering costs, as by avoiding unprofitable patients and shifting costs back to patients or to the under-funded, under-resourced public health system. It generates huge admin costs that, along with profits, divert resources from clinical care to the demands of business. In addition, consulting and marketing firms consume an increasing fraction of health care money. Our government policies also contributed to this trend. We refer to, for example: Macro-economic policy that weakened the building of a well-resourced, well-remunerated public health care system and movement towards free health care for all. Budget cuts, including closure of health facilities like hospitals, nursing colleges, and loss of more than 40 000 health care jobs since 1997. Various forms of privatisation – outsourcing, PPPs, including privatisation of public hospital wards. Piecemeal reforms and policies that sought to regulate the private health sector, rather than transform it – leading to ever-greater concentration of resources in a subsidised, for-profit private sector and ever-rising costs of care etc. All these are to the detriment of the public health sector. These policies have further entrenched the dualistic, two-tier health-care system, rather than ending it. It is important to remember what we said in 1994 about the future of our health system. The ANC Health Plan recognised that “because of the burden associated with paying for health services at the time of illness, in the long term we [the ANC government] are committed to the provision of free health care at the point of service for all citizens of South Africa”. Regulatory reforms of the past had emphasised private sector solutions to the question of universal coverage (lower-income schemes, social health insurance etc). But promises of greater efficiency and cost control remain unfulfilled. Meanwhile, membership of medical aids remains stagnant, down from 20% in 1994 to 15% in 2007. So what is the way forward? In 2001, Cosatu National Congress adopted a comprehensive resolution on National Health Insurance, which called for a fundamental change in the current health care system through direct state intervention in the private health industry and strengthening of the public health sector. The ANC at Polokwane further resolved for urgent implementation of a comprehensive national health insurance – NHI – in the next five years. To achieve a universal, comprehensive, free national health care system, founded on the primary health care approach, requires a well-funded and well-resourced public health system. There is a need to radically shift the way society funds its health care – by incorporating all health care resources in the public sector. This is possible by building on strengths of our public health system. With 8.5% of GDP spent on health in 2006 (about R135 billion) South Africa has enough resources to provide health care to everyone – what is required is the redistribution of these resources, from the minority of the population to the majority. The NHI only provides the funding framework for building a unified health care system, within which we can address our health care challenges. Funding is not all that we need to address these challenges, but funding is the strong leverage through which we can address these challenges. There are various definitions of what national health insurance (involves) internationally. This is understandable, as this is a seriously contested concept internationally and even here at home. We clearly define national health insurance as a state-mandated, state-administered system, in which a single authority organises health finance aimed at ensuring that all persons, irrespective of financial status, have free access to health care at the point of service. Only within the framework of the NHI will our government and people have enough capacity to: Build an optimal, unified, free and comprehensive health care system. Build on the current government efforts to end racial and geographic inequalities in the current two-tier, wasteful and contradictory health care system, through: Effective planning, rational investments and equal distribution of health resources. Finally, let me emphasise that we expect our government to begin to implement the NHI system as the only affordable option for comprehensive universal coverage. This is an extract from Zwelin-zima Vavi’s address to the SA Medical Association.