MALAIKA MAHLATSI: Criticism of the NHI by the middle class is not inherently reactionary

I support universal health coverage – unwaveringly.

And so, when it was announced that President Cyril Ramaphosa would be signing the National Health Insurance (NHI) Bill into law on the 15^th of May 2024, I was very excited about what this could mean for the struggle for universal access to quality healthcare for all South Africans – a right enshrined in the country’s Constitution.

The NHI, like other universal healthcare programmes the world over, aims to equalise access to quality healthcare that is not dependent on income and other differentiating factors. Many countries worldwide have universal health coverage that covers the full continuum of essential health services - from health promotion to prevention, treatment, rehabilitation and palliative care.

For many of these countries, providing primary healthcare was the starting point. The National Health Insurance White Paper describes it as “a substantial policy shift that will necessitate massive re-organisation of the current healthcare system”.

And it is, indeed.

There will be one pool of healthcare funding for public and private healthcare providers. This will mean that when people visit healthcare facilities in the country, public or private, they will not be charged as the NHI fund will cover the costs of these medical expenses – exactly as medical aids cover costs for their members.

The NHI will disrupt the two-tier healthcare system that the country currently has – a system that reproduces inequalities due to uneven standards of infrastructure development and resources between healthcare facility types (public and private) as well as geographies (urban, peri-urban, rural and semi-rural).

These inequalities, occurring in a country with a history of separate and uneven development, have been difficult to bridge, resulting in South Africa having one of the most expensive healthcare systems in the world.

A 2011 study titled Primary Healthcare in SA Since 1994 and Implications for the New Vision for PHC Re-engineering by Tracey Naledi, Peter Barron and Helen Schneider gives a comprehensive assessment of the state of primary healthcare in South Africa, arguing that the country’s healthcare system is under-achieving concerning its gross national income primarily as a result of the government’s initial response to HIV/AIDS, and a weakly developed primary healthcare system.

It further makes the argument that long-standing social determinants of ill health resulting from the legacy of apartheid – many of which fall outside the control of the health sector – have further hampered the country’s progress towards good health outcomes.

The study illustrates what those of us who support the NHI know to be true – that structural inequalities in South Africa are being reproduced in all areas of life, including in healthcare. This facilitates generational poverty, which is both the consequence and one of the causes of poor health outcomes.

The announcement of the signing of the NHI Bill into law was met with concern and outright criticism within some sections of society, the loudest of these voices is coming from middle-class South Africans and medical schemes.

Medical schemes, despite their well-articulated statements about their concerns about inadequate resources for the effective implementation of the NHI, are, quite frankly, concerned about their bottom line.

This much was made clear by MediClinic just two years ago when it argued that the NHI would erode medical cover.

According to the Council for Medical Schemes, the proportion of beneficiaries covered by medical schemes expressed as a proportion of the population in the country has been declining, and currently stands at just under 15% of the population.

This number has been stagnant for decades – a clear indication of the economic difficulties that confront South Africa. But the criticism I am particularly interested in is from the middle class.

There is a temptation to reduce this criticism to nothing more than the desire of the middle class to preserve privilege for itself.

Many argue that the middle class is concerned about sharing resources with the poor. While I believe that there is an element of classism in the matter and that the collective grammar of the middle class has indeed been laced with contempt for those who lack means, I have also noted genuine concerns that must not be dismissed as regressive.

At the core of these concerns is that the government lacks the capacity and morality to implement the NHI effectively. The fear is the real potential that the NHI will be looted. This concern is not baseless.

Recently, the country’s efforts to fight the COVID-19 pandemic were hampered significantly by the extent of the looting that occurred. So glaring was the corruption that Ramaphosa was compelled to establish a collaborative and coordinating centre bringing together nine different state institutions to investigate and prosecute COVID-related corruption.

These institutions include the Financial Intelligence Centre (FIC), the Independent Police Investigative Directorate (IPID), the National Prosecuting Authority (NPA), the Directorate for Priority Crime Investigation (Hawks), Crime Intelligence and the SAPS Detective Service, the South African Revenue Service (SARS), the Special Investigations Unit (SIU), and the State Security Agency (SSA).

More than 50 cases are at various stages of investigation. Numerous people have been successfully prosecuted and several arrests have also been made.

Because of this and other reasons, and because the NHI Fund will be funded from taxes, contributions of high-earning individuals and monthly contributions made by employees, the middle class that we want to dismiss as reactionary has every reason and right to ask uncomfortable questions and to be concerned about the implications of the government running the programme.

We cannot, on one hand, want to see stronger participatory democracy and on the other, shut down dissent from South Africans who want accountability from their government. Those of us who fully support the NHI must also question the government's mechanisms to ensure that the theft of resources from various government-administered COVID-19 funds will not happen with the NHI fund.

We must also question what instruments are in place to stem the corruption that plagues our healthcare system.

We have seen the deteriorating state of our healthcare facilities due to structural inequalities and corruption. We have also not forgotten the brutal assassination of Babita Deokaran, who, in 2021, was gunned down outside her home for reporting corruption at the Gauteng Department of Health where she was employed as the acting chief director of financial accounting.

In our support of the NHI, we must not pretend that our government’s poor implementation track record and the impunity with which most of the looting of the public purse hasn’t happened.

It is possible to support the NHI and still raise these concerns.

And unless we get to a point where our politics are mature enough to allow for this kind of nuance, we will not have meaningful and necessary conversations about the NHI, or anything else.