The most far-reaching solution is offered by the African National Congress (ANC) which proposes a National Health Insurance (NHI) system. This is essentially a compulsory single medical aid scheme for all working people that will be used to directly fund free healthcare for all.
The scheme, planned along the lines of the Canadian health system, will be ‘publicly funded and publicly administered’ and aims to improve the quality of healthcare. While the NHI has been talked about for a long time by the ANC, it now promises to implement it within five years.
Patients will be given ‘a choice of service provider’ within a district. This is perhaps tacit acknowledgement that the rigid referral system is unpopular and, given how poorly run and staffed some clinics are, is not always the best way to cure sick people.
While details of the scheme are not yet public, the ANC Manifesto says ‘there will be engagement with the private sector in general, including private doctors working in group practices and hospitals’ to encourage them to take part.
The risks associated with the NHI are huge. The scheme it will be enormously expensive to implement and even Finance Minister Trevor Manuel has expressed doubt about whether it will be possible to phase it in over the next five years because of the state of the global economy.
Currently, government spends about R60-billion a year on health services yet it is unable to keep up with the demand for treatment. Many believe that the only way an NHI will be able to offer free universal service of an acceptable standard is if private medical schemes are done away with. These treat around 15 percent of the population with roughly the same budget as the entire public sector, so if government could harness these resources, it would have double the money available for health.
However, doing away with private healthcare will be politically explosive and government will have to be very sure that it is able to manage an efficient system before depriving monied citizens of their choice.
On the other end of the risk spectrum, however, should the NHI fail to harness private sector resources effectively, it could simply become an additional tax on the working poor. They would be locked into an under-funded and thus sub-standard system and effectively be subsidising the very poor, while those who can afford it would continue to use their private medical schemes.
Aside from the NHI, the ANC also promises to ‘improve quality’ in both public and private health by developing ‘specific targets’ of workers needed at all levels to deliver proper services. Some of the nursing colleges the ANC itself closed post-1994 to save money are going to be re-opened to bolster the recruitment of nurses ‘ with an estimated 40 percent of public sector nurses’ posts vacant (SA Health Review 2008).
Improved working conditions and ‘decent wages’ are promised to health workers, which is important as nurses are particularly badly paid yet form the backbone of the health system.
But again there is the question of affordability. Most provinces overspent in the past financial year in part because they had to fund unplanned wage increases negotiated after the 2007 strike. This led to some provinces cutting down on essential services (with tragic results for the antiretroviral treatment programme in the Free State) and freezing posts.
Treasury will have to substantially increase its health allocation to ensure that the rest of the health service doesn’t suffer if wages are raised.
Finally, the ANC endorses the targets set in the new national strategic plan for HIV/AIDS by committing itself to reducing the rate of new HIV infections by 50% and providing care and support to 80% of those who need it ‘ massive undertakings that are very far from being achieved.
Despite the idiotic recent refusal of Congress of the People (COPE) President Mosiua Lekota to admit that HIV causes AIDS, it appears to be yet another example of Lekota speaking in ignorance about his party’s policies. For COPE’s manifesto promises that the party will ensure ‘the implementation of a comprehensive HIV and AIDS strategy encompassing prevention, treatment, care and support for those affected and infected’.
COPE favours the current primary healthcare model as well as the promotion of ‘healthy lifestyles’.
COPE also speaks of ‘integrating’ public and private sector services and developing a ‘strategic partnership with private health care providers’ to ‘extend affordable health provision for all our people’ ‘ but it is vague on details.
The Democratic Alliance is also keen on ‘bringing the private sector into state hospitals’, and offers some practical solutions. One proposal is that the provision of ‘quality primary healthcare’ offered by clinics will be boosted by the delegation of some services to private doctors and community organisations ‘using competitive tendering’. Interestingly, the DA proposes that traditional healers could also deliver certain PHC services such as vaccinations ‘ provided they get the necessary training.
Another solution proposed by the DA is the use of ‘technology’ to enable public sector patients to collect their prescriptions from ‘any accredited pharmacy’. One of the biggest bottlenecks for patients in clinics and hospitals is the wait for their prescription drugs, mainly because there is a dire shortage of pharmacists.
The DA also maintains that it will require every public hospital ‘to manage itself, not be managed from afar by the provincial administration and it will be funded on the basis of the level and quality of care it provides’.
The DA aims to put the management of ‘the worst hospitals out to tender’ and that all hospitals will be subject to ‘strict standards and rigorous performance requirements, similar to those currently expected of private hospitals’.
However, while the DA sets its hopes on the private sector co-operation to cure our health system ills, recent research by the non-profit organisation Oxfam shows that privatised healthcare can actually result in lower standards and higher costs.
‘The private sector provides no escape route for the problems facing public health systems in poor countries. Instead these problems must be tackled head on because the evidence available shows that making public health services work is the only proven route to achieving universal and equitable health care,’ warns Oxfam in a report called ‘Blind Optimism’.
‘Lebanon has one of the most privatised health systems in the developing world. It spends more than twice as much as Sri Lanka on health care yet its infant and maternal mortality rates are two and a half and three times higher respectively. Costs increase as private providers pursue profitable treatments rather than those dictated by medical need,’ adds Oxfam.
Most of the Inkatha Freedom Party’s (IFP) health proposals relate to HIV/AIDS, which is understandable given the party’s support base in KwaZulu-Natal, the province worst affected by the epidemic.
Pointing to the current government’s ‘ extremely poor leadership’ on HIV/AIDS, the IFP says it will ‘declare HIV and AIDS a national crisis’. It advocates routine testing for HIV, rather than the current voluntary counselling and testing ‘ which is says is a Western import when HIV was seen as a gay disease.
In addition, the IFP says it will stick to patient targets for antiretroviral treatment, ensure messages are ‘coherent and consistent’ and put greater emphasis on abstinence, delayed sexual debut, partner reduction and fidelity in marriage.
Bizarrely, given the worldwide shortage of health workers, the IFP says it wants one nurse for every four patients in general wards.
Bantu Holomisa’s United Democratic Movement (UDM) supports the primary health system, but would ‘streamline referral procedures’ so that patients needing emergency or specialised care get ‘speedy and appropriate treatment’.
Recognising the destructive effect of drug and alcohol abuse, the UDM wants the health department to be part of ‘an integrated response to alcohol and drug abuse’.
Patricia de Lille’s Independent Democrats (ID) supports the introduction of a an NHI, which it says would bring more money and improved quality to the health system.
The ID would also encourage all government officials to take public HIV tests, ensure every government department has an AIDS directorate and youth and child desks and support community healthcare workers to play more of a role in the provision of HIV/AIDS treatment and care.
It also advocates a special ‘basic package of services for poor children’ including food and free healthcare aimed at improving the quality of their lives. It also proposes better assistance fof those with disabilities.
The African Christian Democratic Party (ACDP) offers a short list of solutions, including making HIV/AIDS a notifiable disease and introducing routine HIV testing. It would also ‘prioritise public awareness campaigns to promote abstinence and fidelity’.
While not calling it an NHI, the ACDP also advocates ‘access to medical aid through a national health scheme’ to broaden access to health services.
The Freedom Front Plus wants ‘a national partnership between private and public medical services in which room is allowed for both to operate freely from unnecessary restriction, in the interest of a healthier population’. It also condemns the ‘over-regulation of the medical fund industry’.
Lucas Mangope’s United Christian Democratic Party offers a vague list of general patient rights such as ‘access to healthcare’ but no practical solutions about how these should be achieved.
The health promises of the Pan Africanist Congress of Azania (PAC) hinge mostly on human resources. The PAC believes healthcare should be free for the poor and increase incrementally in line with the person’s ability to pay.
It promises to increase salaries of ‘all nursing and medical staff by at least 18 percent’ and improve their working conditions, and increase the level of health personnel by 30 percent over 10 years.
While expecting parties’ election promises to come truth is naÃ¯ve, it seems certain that South Africa’s health system will face a post-election shake-up in the form of a national health insurance scheme, but the exact nature of this scheme is still the subject of debate and struggle and its form is likely to take some time to emerge.