The recent publication of the National Health Insurance Bill, the Medical Schemes Amendment Bill, and the Provisional Report of the Health Market Inquiry, has reignited the debate about the structural deficiencies in the national health system, and thrown a new spotlight on the relationship between the public and the private health sectors. It is now common knowledge that our public health system is severely overburdened and under-resourced, resulting in many of those who depend on it unable to access the care they need, when they need it.
On the other hand, the private sector has been unable to grow its reach, as the cost of medical aid has become prohibitive, with those in the system experiencing higher costs for less cover. It is unfortunate that, in these debates, the public and private sectors are often placed next to each other, as if the one is an enemy to the other. These two sectors actually exist in a way that is interdependent, with an even greater potential for complementarity if the key role-players can rise above their self-interests.
The public sector houses much of the country’s medical research and clinical expertise, and produces most of the healthcare professionals, many of whom eventually move in between the private and public sectors. The public sector has also preserved many elements of global best practice in health systems, such as referral pathways, rational use of the healthcare workforce, and essential medicines list, which the private sector is reintroducing with varying degrees of success. SA’s private health sector plays a significant role in the health system, as around half of health expenditure occurs in the private sector, making it also a major direct contributor to the economy. It is certainly better resourced than the public sector, and generally has better access to the latest medical technologies.
The private sector has invested in infrastructure capacity that the public sector benefits from. A recent example of this is the involvement of the private sector in resolving the crisis surrounding Gauteng’s long-term mental health patients, where at least 140 patients are known to have demised as a result of substandard care. There are many other ways in which the public and private health sectors feed off each other, with both having strengths that should be exploited.
Yet, the one stark reality about these two sectors is that they are divided along socioeconomic status, with the public sector servicing 84% of the population, which is mostly impoverished, while the private sector caters largely for the relatively well-off, 16% of the population that is on medical aid. This divide is not unique to healthcare.
Similar trends will be found when looking at income levels, employment levels, food security, access to tertiary education, land ownership, municipal services and the like. Of course these all point to the huge inequalities in South Africa, where by some estimates, 90% of the country’s wealth is in the hands of 10% of the population. Consequently, SA carries the status of being the most unequal country in the world. The ongoing health policy debates should be seen in light of the transformation imperative to correct these persistent patterns of inequality in the country.
While the technical merits of the various proposals should be debated, the fundamental objective of attaining to a just, and equitable society is now urgent and can no longer be sacrificed at the altar of protecting those of us who are privileged. The levels of inequality seen in South Africa are not sustainable, and pose the risk of both social and political unrest. Those who have, both black and white, can no longer remain comfortable while the majority of the country languishes in squalor and poverty.
We must now take inspiration from the selfless leadership of Madiba and Mama Albertina, who could have led relatively easier middle class lives, but opted to be at the frontline of the liberation movement with all its associated risks. In healthcare, we are inspired by the vision of the late Dr Nthato Motlana, the Mandela family doctor, who along many others advocated for improved access to affordable and quality care for the masses of our country who were displaced into the townships.
The heroes of the struggle achieved a lot despite being confronted with an illegitimate regime that was fighting them with all its military prowess. 24 years into democracy, they would be expecting us to accelerate our efforts toward a just, non-racial, united, democratic society. The public and private sectors have numerous immediate areas where they can collaborate in a way that can benefit the broader society much quicker than the envisioned roll-out plan of the national health insurance fund.
This is not time for the two health sectors to be antagonizing each other but rather to be on the side of our beloved country and her dear citizens, to ensure we can pass onto the next generation a better society than what we inherited. We must not fail.