In commenting on the initiative for national health insurance, Lucy Gilson argues that it is necessary to debate what principles should guide real improvements to the South African health system, and that ‘€œ(o)ur power as citizens must be married with political and managerial power to ensure effective change, to build a health system we can all trust.’€

I believe that Prof Gilson’€™s words are most appropriate.   Mutually agreed upon values and principles, and democratic participation can lead to effective change and trust.   Yet these words are not only relevant to how we address the crisis in the country’€™s health system.   What we are dealing with here is not simply ‘€œa system’€ that doesn’€™t work well and needs to be repaired and/or transformed.  

There is no doubt that by far the majority of people in South Africa do not have adequate social benefits.  In a world characterised by increasing disparities South Africa is one of the countries with the highest levels of inequality.  Yet on a deeper level we are dealing with an attempt, one of many necessary layers, to repair and transform the South African society.   This implies that how we approach health insurance is informed by the way we think about one another, what kind of reality ‘€œfeels right’€, how we interact with one another ‘€“ in short, it is informed by who we are and who we want to be.  

What concerns me deeply is the way processes of transformation are conducted.   Cynical remarks in the media and outright aggressive language by officials represent a perpetuation of power-play and oppression by people who consider themselves as the vanguard of the new order of liberty.   In the same vain, when delivery is pushed ahead at the cost of critical participation and input of all relevant stakeholders, without mutually agreed and sufficiently communicated values and guiding principles, we risk developing a system which may not be sustainable and effectively managed.   As a result we may loose the trust of the very people who are supposed to be the primary beneficiaries.  

Such modus operandi of one-sided decisions accompanied by degrading remarks about whoever is considered as the ‘€œother’€ ‘€“ no matter which side of the fence they are – remind me of a time in our history when the context was different, but the same style of dominance and lack of transparency prevailed.   Is this style of interaction and governing not precisely what no longer serves us?  

Are we really committed to transforming our society?   What kind of society do we really want?   Does our behaviour, our processes reflect this dedication?

The lack of guiding values and principles as well as proper consultation with key stakeholders were key findings from research conducted amongst various sectors of the South African society, including labour, government, civil society, regulators and the media – sectors from which one could have expected significant differences of opinion.   Key stakeholders, in other words those who are supposed to contribute to and comment on government proposals, did not know what should drive decisions.   Even parties who were very close to the reform and actively involved in the design, were not sure what principles and values had been adopted.  

In their opinion, the respondents thought that the ideal values that should drive the reform include a mix of attributes representing solidarity and ubuntu (‘€œwhat’€™s in it for us’€)   mutuality (‘€œwhat’€™s in it for me’€), responsibility and efficiency, as well as transparency.    Equity and fairness were thus advocated from different perspectives by all and everyone wished the reform to be successful.   As a result the necessary willingness to contribute was genuinely present.   The issue was thus not to convince stakeholders of the significance nor the relevance of the reform.   All and sundry were in agreement that it should happen, and that the needs of the poor should be addressed for the benefit of everyone.  

Rather, the issues that seem to pose challenges were related to leadership and accountability (visible leadership at the highest possible level and one single voice and proposal from government), positioning and values (to what extent should principles of solidarity be applied in the design of the new system), the process followed in developing the provisions (extensive and in-depth consultation and a clearly defined process with milestones and deadlines), as well as delivery (especially in administration and management to ensure sustainable benefits).    

The need for consultation was highlighted as a prominent weakness by every sector.   Not a single respondent considered the process of consultation as sufficient.   The respondents indicated that they wish to be consulted through a series of interactive, in-depth and focused discussions.   Listening to presentations and pronouncements for instance, was not viewed as a way of being involved.   However their request for consultation didn’€™t seem to represent a power struggle with government.   It was rather based on a genuine conviction that the needs and views of all parties are important and necessary, as well as a keen desire to make skills and expertise available for the design and implementation of the new system.  

In general, they sensed a ‘€œtop-down’€ approach and there was the impression that government has alliances with some sectors and/or experts.   All the sectors highlighted the need to involve the labour sector in the process.   Thus, even though the different sectors may be supporting different mandates, they recognised that finding a satisfactory solution cannot be achieved without involving those who represent the prime beneficiaries.

However this research was conducted (on behalf of the Department of Social Development) at the end of 2007 just before Polokwane and it related to the reform of retirement provisions.     The same issues seem to be at stake in developing health insurance for the country.    So we have to ask ourselves:   Have things changed after Polokwane and after the elections of 2009?  Are we not currently experiencing ‘€œmore of the same’€?   Will the new regime facilitate the effective delivery of a sustainable system that will result in improved living standards for those who are most vulnerable?  

Social transformation, even when embodied by the delivery of a single system, entails a process, and the way in which the process is conducted has a significant influence on how the delivery of a new system is implemented, managed and perceived.   In other words, what we’€™re working towards, doesn’€™t only lie in the future.   We have to work on creating this new reality throughout the process.   If we want an emotionally mature democracy, we’€™ve got to live it.   Now.   It will not arrive by itself in the form of an ‘€œend product’€.   This is not only the task of government officials ‘€“ it pertains to the thoughts, feelings, behaviour and language of every citizen even though we have different ways to view reality.

Some of us place for example great emphasis on the importance of social harmony and community life, expressed in, for instance, caring for fellow citizens, the joint development of solutions and belonging to the pattern or texture of the immediate experience.   For others efficiency and goals are worthy ideals, and therefore the ‘€œright’€ thing to do.   So they tend to sacrifice harmony in the immediate experience and rather shape their reality according to their ideals and desired outcomes.    To this group, the end result is what makes everything worthwhile, and they find meaning in having a sense of purpose.   There are of course also many hybrid versions of these paradigms.

None of such paradigms are right or wrong.   They are merely that – different paradigms.   Yet they are all valid, all offer strengths and weaknesses.   On the one hand, we need to reform the health and retirement industries in consultative ways to contribute to a dignified life for all, especially the poor.   Yet we also have to make sure that we deliver the right medicine and other benefits on time and to the right person in a sustainable manner.  

It is unfortunate that some of us have become confused along the way, lured away by power and greed.   We are currently challenged and have the opportunity to rise beyond our egos and our fights, beyond what is ‘€œright’€ and ‘€œwrong’€ and find an approach – and a solution – that reflect the reality we choose for ourselves.  In the words of one of the respondents who participated in the mentioned research:

‘€œWhen we sit down and talk to one another, although we differ, we realise we share the same ideals, it breaks down barriers, it builds bridges.   This social dialogue questions our values.   We grew up with certain values, now we’€™re exposed to new things in a non-threatening environment.   Together we’€™re creating a new value system, based on caring for one another.   We learn to respect one another and see each other as people, not as groups.’€ (labour sector)

Powerful leadership, informed by a mutually agreed upon set of values and principles and a process ‘€“ not only a solution ‘€“ of inclusivity are critical for the successful implementation of real social change.    

Marthie Momberg holds Post Graduate Diplomas in Education and in Theology as well as an MA degree. She wrote this article in her capacity as an independent communications consultant.