/ 12 April 2020

Spain did it, so why can’t South Africa nationalise healthcare to save lives?

Doctors and nurses were held at gunpoint to stop giving patients treatment.
Health worker infections have risen to 170 at state and private hospitals and two healthcare staff succumb to the disease in a space of seven days. (Paul Botes/M&G)

We have never met before. But if you have lived in South Africa, you helped save my life.

The time I had a cycling accident, the time I nearly died from pneumonia and every time I’ve needed life-saving medication or blood transfusions — you helped me every step of the way by paying taxes to fund our public health system. 

By doing this, you have bound me to you. We might not speak the same language, come from the same culture or share the same political views. But we are closer than family, because I owe you a life debt. I will spend the rest of my days trying to repay this, and I will be more fiercely loyal to you than any other person on Earth.

But if you’re reading this, the chances are that you don’t use the public health system very often. You probably have a medical aid or maybe a hospital plan. You probably haven’t had to stand for hours in line at a clinic that has no doctors and no medication. You haven’t had to bring food and blankets to your sick family members as they lie dying in hospital. You haven’t been to ER on pay day or Friday night, when the smell of terror and death is everywhere, when there are never enough beds or doctors, when medical staff have to make a choice of who lives and dies many times in a single evening.

But you probably have family, friends or colleagues who have gone through this. You know what damage and pain an underfunded public health system causes. We all do.

The system is underfunded because the private sector captures the majority of health spending. In 2016, our state spent R191-billion on public health. But the private sector netted R198-billion through medical aid fees, out of pocket payments and the Government Employees Medical Scheme. Medical tax credits — a generous subsidy to those who can afford medical aids — generated a further loss of R20-billion in tax income for the state. The result is that the private sector captures 80% of our doctors, even though only 16% of our people have medical aid.

The truth is this: we don’t yet have enough information to accurately predict the effect of Covid-19 on the health of our people. But even before the pandemic, our public health system could not cope. 

After decades of underfunding, our public health system is understaffed, under-equipped and demoralised. As a result, many of our people die needlessly. South Africa’s maternal mortality rate is seven times higher than other middle-income countries such as Turkey. This will not get better during the pandemic, and will probably get worse.

To protect our people, we need to bring the resources of the private sector back into the public sector. This is what Spain did in response to coronavirus — they nationalised private hospitals overnight, reversing post-2008 privatisation reforms. As thousands died in Spain, the government was forced to recognise that doctors and nurses were right to oppose privatisation as unsustainable and ineffective.

But unlike Spain, we actually have a plan in place. This plan is called the National Health Insurance. Under the NHI, you will no longer pay your own medical aid for you alone. Instead, you will put this money into a national fund for all our people. This fund will be used to bring doctors, dentists, optometrists and specialists back into our public health system. You can continue to use your GP, but you will not pay any fees to do so. The only change is that you will see your GP at a clinic, instead of at a private surgery, and that you will sit side by side with a cross-section of all our people — rich and poor, black and white. In this way, the rich and healthy will cross-subsidise those who are poor and sick.

A national health service has been on the cards ever since 1944. But for one reason or another, it has never been implemented. First it was rejected because white people didn’t like the thought of using the same health services as black people. Then in the post-1994 era, provincial governments opposed the NHI because it takes money away from them — removing a key source of patronage and corruption. And private hospital chains have opposed the NHI because it threatens their billion-rand profit margins

Some middle-class people have claimed that the NHI cannot be implemented because the government lacks the capacity to do so. But this is a chicken-and-egg scenario. When public health is chronically underfunded and the middle-class receive generous subsidies to use the private sector, then there is little incentive to ensure that the public sector does a good job. If we want it to work, those of us with power will have to use public health and put in the time and effort to make it a success.

After all, if Spain can do it, then maybe we can too. And we can finally join the list of many other countries with a universal national health service, including Botswana, Ghana, Tunisia, Trinidad, Cuba, Canada, Singapore, Bhutan, Germany and the United Kingdom.

We’ve done this before. Last time we faced a pandemic, it was our public sector that stepped up to the challenge, not our private sector. In response to HIV, the public sector implemented the largest antiretroviral programme in the world, saving an estimated 1.72-million lives and increasing life expectancy by 10 years within a decade. 

Here’s a proposition: let’s try nationalising our health system during this pandemic. Just for a little while. If it doesn’t work, we can always go back to our old, unhappy health system. But if it works, we will come out of this stronger, more together, more vas. Each of us will learn that what unites us is not our language, our culture or our race. What unites us is our solidarity during the darkest, most difficult hours of our lives.

Nimi Hoffmann is a lecturer at the Centre for International Education, University of Sussex, and a research fellow at the Centre for International Teacher Education, Cape Peninsula University of Technology. She works on social policy and intellectual history