Lofty principles exist
The Wiser Symposium: A debate on the ANC’s ‘second transition’ policy documents was hosted by the Wits Institute for Social and Economic Research with the M&G and the Wits faculty of humanities
Health is a critical element of social and economic transformation, but the post-1994 health system has failed to deliver improved health to the citizens of South Africa and our health status indicators remain significantly worse than other countries with similar levels of development.
The last ANC policy conference in 2007 finally recognised the developing crisis and identified health (and education) as key priorities for the ANC. The ANC health policy discussion document, released in March, summarises the progress that has been made since Polokwane and aims to identify the strategic health issues for the next policy conference in June.
Most of the discussion document is concerned with the development of a National Health Insurance system. As such, it needs to be read in parallel with the green paper released by the national health department in August last year. Other policy issues discussed more briefly in the document include transferring responsibility for central hospitals from provinces to the national department, clarifying ANC policy on HIV notification and the integration of South African military health services into the national health system.
In this article, I focus more on the policy process issues highlighted by the document than on policy content. There are only 12 pages devoted to health policy in the ANC education and health discussion document, so it cannot be expected to discuss policy issues in any detail. Indeed, documents from other political parties are similarly vague and aspirational. However, effective implementation requires something much more detailed.
There is a widely held notion in South Africa that we have good policies but suffer from poor implementation. Most analysts would dispute this, arguing that good policies are those that plan for implementation challenges. I agree that we have good policy principles, but I am less convinced that we have good policy.
The problem is how to move from a vague statement of principles to an acceptable policy proposal. Where does the technocratic capacity for such health policy development reside? Clearly, not in the ANC. But the problem is that it is not available in the health department either.
Re-engineering
As one example, all the current policy proposals of the department – re-engineering primary health care, the new human resources plan, the establishment of the office of health standards compliance and the insurance scheme – have been developed largely by external consultants and funded by external donors. The internal policy machinery of the department is weak and little has been done to develop the necessary in-house capacity over the past 18 years.
The National Health Insurance green paper is a case in point. Although it has already taken four years to get to this stage, the document is completely inadequate as a detailed policy proposal, particularly given the scale and cost of the plans. I may agree with the principles that inequity between the public and private healthcare sectors needs to be reduced, and even that compulsory health insurance is part of the solution for financing healthcare in South Africa, but the green paper fails to make the case that the proposed changes will improve health outcomes and indicators. There are too many details missing: What will it cost? How will it be financed? What exactly will be covered? How does the NHI Fund relate to the existing public and private health systems? Where will the personnel come from?
Another process issue highlighted by the documents is the apparent lack of learning from previous policy initiatives of the health department. There is little mention in either the ANC document or the green paper of the concerted efforts undertaken over the past 18 years to improve the public and private healthcare systems. It is as if we are back in 1994 and this time everything is suddenly going to work out better. Somehow, the NHI has become the magic bullet that is going to solve all the problems of the South African health system.
So, even though we have not clearly defined what it is, the insurance scheme will not only eliminate the dual public-private health system, it will also correct the failings of public health services, strengthen primary healthcare, finally create a functional district health system and solve the human resources crisis.
One potential risk of this approach is that, while we wait for the insurance to be implemented over the next 14 years, we fail to address other fundamental problems of the public health system. The ANC health policy document does not mention other issues requiring urgent attention, such as the need to strengthen priority health programmes, address the attitudes and values of health professionals as well as their numbers, develop necessary technical and healthcare management skills and create effective systems of accountability at all levels.
In conclusion, the intentions in the ANC health policy discussions are promising, but we cannot be certain that they will eventually translate into better health for South Africans. It is no longer sufficient to have vague policy aspirations; we need clear technical plans for implementing effective change. As the political party in power, the ANC needs to take more responsibility for ensuring such policy development.