They come mainly from the Medical Schemes and those academics and health care professionals who support the Medical Schemes. I see few comments from Medical Scheme members and none from those, the majority, who will be the prime beneficiaries of the NHI.

There is a very real risk that the current debate on the NHI is and will remain very skewed. Yet whatever else the NHI is, surely it is a part of what might best be described as a social movement or at least a social institution. And 17 years after 1994, is it not time that South Africans built themselves better, more solid social institutions? And is health care not the place for a better, more solid social institution?

The Green Paper on the NHI is a worthy document. There are gaps; there are parts that need to be improved. Overall however the government is getting there. That is commendable since the health of South Africans, especially the majority poor, is badly in need of being improved. When the NHI comes, does anyone doubt that that will happen?

But let us step back to think what all of this is about. Currently there is much legitimate debate about what the NHI will cost. There are some who seem to doubt if South Africa can afford an NHI.

It can. The only real question here is whether it is willing to afford it.    

The NHI is about health, it is about fairness in the delivery of health and it is about efficiency in health care. First and foremost it is about the health of the people of South Africa. With all the hostile heat surrounding these issues at this time, it is remarkable how little is said about the health of the population! Currently it is for the vast majority so very bad. It is time to do better. Doing better in this context involves not just health services of course but also working on the key social determinants of health – poverty and inequality. If   the majority are to obtain better health, the government must address poverty and inequality. While improving health services is crucial it is not a complete answer. With respect to health services however the question is how best can the people of South Africa provide health services that will most efficiently (give value for money) and most equitably (in some reasonably fair way) promote the health of the people of South Africa?        

That is what the debate on the health care system needs to be about. Currently 43% of the health care spend goes to the healthier 16% of the population who are covered by the Medical Schemes. That in anybody’€™s book is grossly inefficient and grossly inequitable. What is needed first is to alter that balance in spending but second to improve the efficiency of both sectors albeit in different ways. The management of existing resources in the public sector is poor and at least some of the extra spend there in future needs to be used to improve both management systems and managers. The Department of Health needs to bring in some international experts in health service management and ask: ‘€œhow can we change management structures, the management culture and train better managers to ensure greater efficiency in the future?’€ That is one side of the inefficiency.

The other is the inefficiency in the private sector. Costs have risen enormously in recent years and so have members’€™ premiums. It is always difficult to judge quality of care but we can be very clear that quality has not risen as fast as costs. Total costs here are a combination of fees and the amount of services provided ‘€“ in other words P X Q i.e. price times quantity. Certainly fees have risen and almost certainly the quantity of services has risen (as a result of what economists refer to as ‘€˜supplier induced demand’€™). Whatever, the costs in the private sector give every indication of being out of control. Here is another case for expert evaluation. Why are costs rising? Are the rises justified? These are questions that must be addressed by internal or external experts. This can be done and it must be done.

That’€™s efficiency. Equity moves in the same direction. It is so clearly the case that the current setup is inequitable. There can be no moral justification in not moving to improve the health of the poor. This is especially the case when this can be achieved through an NHI, largely by giving better value for money to those currently in the Medical   Schemes. This issue of an NHI is relevant to all South Africans. That is the beauty of it. It is not just about improving the public sector. It is about providing decent health care for all South Africans. That is the justification in terms of morality and fairness. The economic justification is that it will provide more health for the health rand.  

I suppose however some may say, so what? Is health care not like any other good in the market? Wouldn’€™t we expect that the rich will do better just as they do with cars?

Put in these terms, in essence the equity argument (which has already been won in almost all decent societies across the globe) is a moral and ethical issue. I find it fascinating that this moral argument holds sway in the critically informed Australian population where time after time citizens with good information say they want a yet fairer health care system. And in a society which is often seen as racist towards Aboriginal people, critically informed Aussies want greater resources to improve Aboriginal health ‘€“ which is so much worse than non Aboriginal health.

Why do they want more resources for Aboriginal health? Why are these Australian taxpayers prepared to pay more to help to improve the health of these disadvantaged people? Well we don’€™t really know. Maybe they are compassionate towards Aboriginal people. My gut feeling however is that they see the dreadful ill-health of Aboriginal people as a national disgrace and want something done about it.

We in Australia have our ‘€œNHI’€. It is called Medicare and is a universal system with access by all. We also continue to have a separate private sector. The two run rather successfully together. We have had that for nearly 30 years now and there is continuing   debate about the balance between the two. There is no one however who wants to abandon Medicare. It is seen as part of the building of a decent society where the market is not left to determine who gets health care and who does not and everyone has access to good quality care.

Australians are proud of Medicare, their ‘€œNHI’€. They see it as morally right, as part of the building of a decent society. Perhaps there are lessons here for South Africans.

Gavin Mooney, Visiting Professor in Health Economics, University of Cape Town.