NHI blues

Reforming public health systems is hard. Perhaps it is little wonder that government’s National Health Insurance (NHI) proposals have generated so much confusion and alarm.

By playing with people’s emotions, however, the big political parties are sabotaging much-needed public deliberation about the future of health care.

The DA sounds very much like a party funded by the private health-care industry. Its reflex has been to “protect” the 15% with private care against the 85% without — and then to wonder why it commands the support of so few potential voters.

Meanwhile, health costs for its base are rising rapidly, alongside shrinking benefits. The DA seems to have forgotten that information asymmetries in the health sector result in waste, spiralling health-care costs and higher premiums.

If debate is to be productive we can all learn from a new international consensus about health care. As the pro-market Economist magazine famously observed in April 2018: “Universal health care, worldwide, is within reach: the case for it is a powerful one — including in poor countries.”

We have always known that poor health care undermines education. Now economists have confirmed that improved health encourages entrepreneurship, higher worker productivity and faster economic growth.

There are plenty of real and contemporary reform cases to tap for lessons. According to The Economist, Thailand’s universal programme, spending $220 per person per year, produces health outcomes on a par with those of the Organisation for Economic Co-operation and Development (OECD) zone. Chile and Costa Rica enjoy life expectancy of about the same as the US on an eighth of the expenditure.

However, it is necessary to concede openly that there will be losers and to affirm that this is not a matter for glee. Public health insurance requires cross-subsidies, and healthy, richer and younger people must be forced to pay through general taxation or mandatory insurance. Rich urban health professionals will have to work more productively for less.

This will not result in any fantasy world of equality of treatment — and not just because politicians and senior public servants will continue to enjoy access to medical schemes that provide the best possible treatment at public expense.

Any revised health-care system, whether supposedly “universal” or not, will continue to favour the middle classes and urban citizens. The key will be to provide an ever-wider range of services to the population as a whole in a relentless and cost-effective programme of change.

Then president Jacob Zuma sensibly pledged in 2009 that NHI would be introduced in “a phased and incremental manner”. NHI, of course, cannot be purely incremental — it requires major structural change. But its initial thrust should be to ensure universal coverage for a relatively narrow range of benefits.

Basic problems of mismanagement and corruption, moreover, will not dissipate as a result of NHI. As many observers have noted, the current proposals are likely to invite more of both.

The government cannot afford to allow the current combination of public confusion and fear to persist, problems made worse by secretive policymaking and the ANC’s ludicrous moral self-righteousness about this issue.

The DA has drawn its own ill-advised battle lines, and the heavy artillery of the insurance and health provider sectors will protect its flanks.

Under a hard-headed and astute health minister, the public deserves both reason and humility from the government. After all, the ANC is the party that brought us a great emotion-fuelled HIV/Aids debacle. Instead, the ANC has doubled down on its approach that NHI is a moral crusade. Since the government has set up an NHI “war room”, it is safe to assume that it thinks it is engaged in a war — and perhaps not just against capitalist health providers.

Since the rise of the EFF, the ANC has started to treat squealing and panic among middle-class whites as an accomplishment in itself, rather than as an unfortunate side-effect of necessary policy change. On such a battlefield, costly and counterproductive outcomes for both sides are likely to be the result.

• Butler teaches public policy at the University of Cape Town.

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