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Flights of healthcare fancy are for another time

- Judith February

The state is too broken to blunder on with universal healthcare.

Everything feels a little gloomy right now. A deep despondence is gripping the country. Perhaps it was intensified by the most recent unemployment figure that now sits at 29% — by the narrow definition of unemployment, which excludes those who have given up looking for a job. The situation is a crisis of major proportions and there are unfortunately no quick fixes or silver bullets.

Perhaps it is the gloom of inevitability and that “Thuma mina!” seems like a lifetime ago? Then there is Eskom and the billions we are told are needed to keep the lights on. Each passing day we are warned of load shedding while there seems to be little intent (to the public at least) that the power utility will be divided into three parts as we were promised. Its situation is entirely unsustainable.

Each day that goes by appears to represent a missed opportunity as Mark Barnes resigns from the Post Office with seemingly similar complaints to Phakamani Hadebe, who himself is now lost to Eskom. In the Johannesburg CBD, raids and riots are the order of the day amid the chaos of illegally occupied buildings and general squalor. It makes a mockery of that famous strapline, “World-Class African City”. World-class cities remove their rubbish and have low crime rates. World-class cities have decent and safe public transport. World-class cities don’t treat foreigners as aliens. One could go on.

And then there is a country generally straining at the seams of ongoing protest action. In Cape Town, spatial inequality, broken promises and degradation of poor communities is catching up with a DA government whose answers seem to be via JP Smith’s “security” portfolio.

In the meantime, there are real concerns in relation to public finances which are in a state of ruin, thanks to those infamous “Nine wasted years”. Whispers of an IMF bailout with all the disastrous conditionalities and consequences are now spoken of aloud.

So much so that Minister in the Presidency, Jackson Mthembu, had to deny rumours of a bailout last week. For his part, Minister of Public Enterprises Pravin Gordhan recently called a radio station, somewhat annoyed, saying we will all see the plan unfolding soon. “We are in control,” he said.

One cannot blame Gordhan for being a bit short. He’s having to put out multiple fires and deal with a public protector who seems intent on exacting revenge on behalf of his political foes. The EFF’s lawfare has been disruptive and destructive in equal measure. And then there is the ANC, whose revolution truly is eating its children.

President Cyril Ramaphosa has been almost sphinx-like on much of this, though we know that much work is happening behind the scenes. As Business Unity South Africa president Sipho Pityana says, no one doubts Ramaphosa’s commitment to reform, but he is hamstrung by what Pityana calls “internal ANC side-shows”. Indeed, the ANC itself seems to be occupying a parallel universe.

But life in South Africa is always more nuanced and more complex than the latest tweets and media reports of doom and gloom. The bottom line is that former deputy minister of finance Mcebisi Jonas is right when he said this week: “It is no mystery, we are in a crisis.”

We are finding out each day just how deep the rot is. But better to know than not to know, of course. Also, better that we have Ramaphosa trying to dig us out of the hole than Zuma or the Radical Economic Transformers (looters) trying to dig us into a deeper hole. So, the Zondo Commission and its “drip-drip” evidence also has the effect of wounding our collective spirit and making us feel even more despondent. But it is probably best to view it as part of a long-haul clean-up. Long haul it will be and it was always going to be thus.

Dealing with the consequences of State Capture means that democratic institutions need to be repurposed for the benefit of all instead of for looting and the vested interests of the few politically connected and corrupt. There is no easy path to such repurposing. Ramaphosa knows this and the sensible parts of the ANC know this. Yet, it can be frustrating to watch paint dry.

The national mood is one of focusing on unemployment, eking out growth. And there seems to be a sense of urgency about the immediate action that needs to be taken.

So when Health Minister Zweli Mkhize unveiled the National Health Insurance Bill last week, it felt a little like the parallel universe the ANC sometimes inhabits was very real. While the rest of us were looking for any sign of economic growth and light at the end of the tunnel (which there is, it just takes some doing to see it at times — South Africa is exacting in that way), Mkhize seemed to be asking us to believe in healthcare Utopia for the poor.

It is a fact that only 16% of South Africans enjoy access to private medical aid and that most citizens are subjected to a broken system. This is untenable and unjust. Healthcare is a constitutional right and mostly, the poorest of the poor suffer at the hands of an uncaring and indifferent state. Ask the Life Esidimeni patients or the Eastern Cape patients who are unable to even reach an ambulance, thanks to degradation and corruption. There is a litany of woes when it comes to citizens’ interface with the state in relation to healthcare.

This is not to say there has been no progress or pockets of decent healthcare practice within the state. To deny that would be cynical and plain wrong. It also does not mean there are not fine doctors and nurses who work within the system, yet all too often they work against the odds in untenable conditions.

Junior doctors have regularly complained about the inability of the department to place them in posts and of having to make clinical decisions that they feel ill-equipped to make. Many work within the state system and do so tirelessly. We should be doing whatever is possible to protect their positions and allow practitioners a say in their future working conditions.

Then along came the politicians and the NHI. They have said that the NHI needs to be implemented in the current economic context no matter what. Make no mistake, it is a Herculean endeavour. Mkhize yesterday told us all not to panic.

Hysteria is unhelpful, yet clear-eyed thinking on this crucial policy shift is necessary.

During the NHI trial period which ran pilot sites, there was a failure in many instances given the lack of commitment, administrative capacity, lack of staff and resources and of course, corruption. Yet, instead of further stress-testing the system, the government has gone straight for implementation by 2026. What we don’t know: where exactly will the billions come from to fund the NHI and what exactly will the NHI cover?

This state has shown itself to be entirely incapable of running anything. Who will run an NHI Fund serving the entire country? A cursory look at our state-owned enterprises and the shambolic public service itself, and one can see where this is headed. The NHI Fund could well become a bloated government enterprise and the tenderpreneurs are probably already licking their lips.

Government has said that money has to be found in an act of “social solidarity” by those who can afford to pay. That sounds noble, but the reality is that the current system is broken. It needs to be fixed first and then the tinkering can happen. Asking citizens to fund a pipe dream, which has the makings of an administrative nightmare incapable of delivery to the poor, seems misguided.

The state has broken trust with its citizens as a result of almost a decade of economic mismanagement and State Capture. We are being asked to give it another chance by helping to bail out SOEs and once again putting faith in SARS to collect taxes ethically. The latter seems easier than the former. And then, of course, we are being asked to again believe that this state, amid a slow-burn reform process, will spend our money wisely. It’s a tall order.

An added burden without the necessary costing and capacity will only lead to frustration, especially for the poor. In addition, this legislation will almost certainly end up in the Constitutional Court, given its potential infringement on the power of provinces.

Maybe that is why there is a general despondency.

Now is the time for laser-like focus on growing the economy, creating jobs, trying to capture the low-hanging fruit in this regard, cutting wasteful expenditure and generally being prudent. Flights of fancy are for another time. Let us start small and fix the healthcare system further — some work has started, as part of the NHI process, but it is not enough.

Once we know what we are dealing with and we have grown the economy sufficiently to ensure we can deal more effectively with the cost, we can start dreaming and doing the nuts and bolts of universal free healthcare.

For now, keeping the ship afloat is ambition itself.

Judith February is based at the Institute for Security Studies and is also a Visiting Fellow at the Wits School of Governance. This article was first published on Daily Maverick.