Thursday, November 19, 2009

National Health Insurance in South Africa put on hold

South African president Jacob Zuma and American president Barack Obama do not seem to have much in common. Obama went to college, and not just any college: Yale University. Whereas Zuma only attended school until Standard 3 (or Grade 5). Zuma has been tried in court on charges of rape and corruption, and during questioning stated that risk of HIV transmission could be minimized by taking a shower after sex. Whereas Obama used to smoke. Zuma has 4 wives, Obama has Michelle. Despite these and other differences, the two presidents have one thing in common: they are both currently involved in controversial national health care reforms. In the case of Zuma, it is the proposed National Health Insurance (NHI), which has been planned since the African National Congress first took office in 1994.

Social, political and economic inequality, as many studies have indicated, are bad for your health. It would seem to follow that decades of Apartheid would be generally bad for the health of those at the lower end of the ladder in South Africa. And it is. I spent the early part of this week marking medical ethics exams from budding doctors at Groote Schuur Hospital in Cape Town, and some of the case studies they presented were positively hair-raising. So it makes ethical sense, in principle, to increase access to health care for South African citizens.

While everyone seems to agree on the basic principle, the details of the NHI are vexing, and the discussions bring out the old social tensions and wounds. One large question is where the massive amount of money in support of the scheme is to be drawn from. If it is through taxation, this causes concern among those better off in South Africa, who are already been taxed to support the existing public health care system -- though many of them go to private health services when they are sick themselves. There is also a worry that private health institutions would be 'de-skilled' and overwhelmed if subjected to government demands to focus on primary care services. Requiring well-off South Africans to use public health care might also, it is feared, lead to people leaving the country: both patients who fear a drop in their standard of care as well as doctors who do not want to work in sub-standard conditions for less pay. There seems to be a general feeling that if the NHI might lead to the generalization of the health care standards currently provided in the public sector. It depends who you ask, and where you ask, but generally speaking opinions about the health care on offer in public hospitals and clinics are not positive. This is an understatement. The problems the government has had in doing just one thing -- providing antiretroviral therapy for those who need it -- draws serious doubt on its ability to provide a broad spectrum of services at an adequate and affordable standard. For the poorest of the poor, on the other hand, the promise of some (perhaps not great) services may look better than none.

Olive Shisana, head of the Human Sciences Research Council (which is responsible for drafting versions of the NHI) likes to say that opposition to the NHI is based on myths. But this week the Health Minister put the NHI on hold, perhaps for as long as five years. Reason? The public health sector is said to be in shocking shape, so shocking that bringing in the NHI wouldn't help matters. So back to the drawing board.

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