22 JUNE 2009
Johannesburg — THE African National Congress (ANC) decided at its 2004 Stellenbosch conference that SA ought to implement a national health insurance scheme within five years. After nothing happened, it decided this again at its 2007 Polokwane conference. At last, we seem to be having a debate of sorts about what such a scheme might look like. But this is a most peculiar way to debate something as important, and as complex, as national health insurance (NHI). In the wake of Polokwane, the ANC set up a task team, headed by the Human Sciences Research Council’s Olive Shisana (and funded by the Bill and Melinda Gates Foundation), to devise proposals for an NHI. A 200-page draft report from the task team is now, inevitably, doing the rounds. The official version, it seems, is not ready for release yet. But that hasn’t prevented the beginnings of a raging debate around the unofficial, leaked version.
Nor should it. In his state of the nation address a couple of weeks ago, President Jacob Zuma promised that the government would introduce a national health insurance scheme “in a phased and incremental manner”. He made it clear, too, that the process would start with efforts to sort out public healthcare, and that the government would work with the private sector on this: “In order to initiate the NHI, the urgent rehabilitation of public hospitals will be undertaken through public- private partnerships,” Zuma said.

But the document suggests a different and more hasty process. There seems, for example, to be no place for medical aids in the Shisana proposal. It would bring everyone under a single national health authority — and would do so within five years. And though there are many models of national health systems around the world, this seems to opt for one of the more comprehensive and expensive models. The document has not costed its proposals at all. But it envisages that everyone would pay mandatory NHI contributions, except the poor and unemployed, who would be subsidised, presumably by the fiscus. In addition, the government would increase health spending in real terms over the next few years and would end tax breaks for medical aid contributions.

Where this money is to come from is not clear; nor is it clear how workers and employers will respond to the prospect of paying more, potentially for less. No doubt SA’s private healthcare players are desperately trying to puzzle out what the implications might be for them. And if the task team’s radical approach prevails, these could be huge.

But there clearly are different views within the government. It may well be too soon to get frantic about the task team’s proposals. But they are already spooking the market. And the more opacity and uncertainty there is, the less likely it is that there will be healthy debate about national health insurance. SA desperately needs a health system that is more sustainable and delivers better care for all. But there are different ways to get there, and different interests at stake. The sooner we have a proper set of proposals in the public domain, for public debate, the better.