PHASA 2019 Reflections: The right to health after 25 years of democracy

The more than 300 bikes recently distributed to the province's community health workers are the first of many, say the North West Department of Health
A community health worker rides a bike during his rounds in the North West NHI pilot district, Dr Kenneth Kaunda. (File Photo)

The annual conference of the Public Health Association of South Africa (PHASA) took place from the 17th-19th of September in Athlone, Cape Town, with the theme The Right to Health: 25 years into our constitutional democracy gave space to reflections on both the gains that have been made in the past 25 years, as well as the worrying failures and persistent issues that have not been overcome. 

A look at both sides of the story presents a sobering picture, in which health inequity and economic inequality are inextricably linked at the heart of the struggle. As a number of panellists in the plenary session “Equity in health and health care: Has democracy failed the poor?” pointed out, the face of poverty in South Africa is still female and black and disparities in access remain starkly divided along racial and spatial — urban vs rural — lines. The theme also made clear that, with 25 years behind us, taking stock, learning from the past and mobilising experience and knowledge from across the health system will be critical – especially in the context of current policy reform towards National Health Insurance (NHI) and Universal Health Coverage (UHC). 

Using democracy and health as a lens highlights the fundamental importance of a citizen-led health care system, asking important questions about whose involvement the current system favours, whose involvement needs to be enhanced and how this can be achieved for a health system that encompasses all people. 

With the NHI Bill currently in parliament, three days of convening and engaging offered an important opportunity for the PHASA community to consolidate a shared commitment towards contributing substantively in this phase of participatory democracy. The organisers of the conference have worked speedily after its conclusion to put together a guiding statement for further action, the Athlone Declaration. 

PHASA members will also be making an official PHASA submission on the NHI bill in parliament. Beyond these more formal steps, there was a general sense of energy uniting the PHASA community to participate meaningfully (and politically) in the public democratic processes that will shape our health system. Many of the conference’s discussions extended beyond the sessions themselves, spilling into tea time and lunch breaks, as well as virtually into the Twitter-sphere.

Whole system change is needed

While there is broad consensus on the financial principles established in the NHI bill, many delegates expressed the sentiment that NHI as a financing mechanism alone will do little to bring about the kind of change we need in our health system. Indeed, there is a high likelihood that it could undermine what progress has been made in the past 25 years, especially in the public sector. Rather than just a financing mechanism, we need people-centric, whole system change that tackles a wide range of health systems issues. 

An example of this – and a recurring theme during the conference –  is community health systems and community participation in health. Not only do community health systems align firmly with the principles of primary health care, but they also provide valuable sites of learning for decentralization of the health system. Community participation thus becomes more than just a nice-to-have. It can build accountability, local responsiveness, and serve as a fundamental pillar for the further democratization and strengthening of our health systems. 

Trust in a strengthened public sector must be rebuilt

A vital component of NHI reform will be rebuilding the trust which has been heavily eroded over the years – especially in the public sector. Processes for building trust are important and need to be “deliberate, transparent, inclusive and ready to manage inevitable disagreement”. But building trust will only be a possibility if we make concrete gains in strengthening public sector services.

We need to recognise the quality of leadership where it does exist in the public sector and “grow this good”. The risk that the upcoming phases of NHI will undercut this potential is substantial. As Di McIntyre pointed out: we cannot have NHI conditional grants earmarked to purchase vertical interventions from the private sector, thereby cutting public sector budgets and perpetuating the narrative that the private sector can do things better. 

We need space to learn by doing

With 25 years of establishing our health system behind us, there is a wealth of experience and knowledge to be tapped into. Yet much of this knowledge is messy, complex and obscured by cumbersome processes of auditing, monitoring and evaluation that fail to consolidate responsive learning potential and space for reflection. One of the conference sessions led by CHESAI focused on embedded HPSR research, looking at how to grow “learning systems” where all kinds of knowledge, including experiential and tacit knowledge, are brought into the fold of what is considered “legitimate” evidence.

One of the things highlighted in this session is how much of this work is contingent upon building relationships of trust and accountability and putting people at the centre. Frontline workers and managers, in particular, have the potential to act as key intermediaries for successful implementation and should be supported in their capacity to learn by doing.

Public sector and civil society must shape the NHI conversation

Social solidarity through cross-subsidisation is one of the major principles underpinning NHI. Yet it has largely failed in being a driver of support for health systems change in South Africa. Instead, our fragmented and segregated society finds it immensely difficult to galvanise across race, class, generations and spatial regions – a weakness that is often preyed upon by private sector media to produce a narrative of NHI that is based on fearmongering and individualism and is highly counterproductive to meaningful engagement. While there is no need to sugar-coat the weaknesses of the draft bill, the average news headline on NHI would have us believe that the NHI is inherently doomed to fail. 

Currently, the dominant narrative is driven largely by the private health sector and is primarily concerned with middle class and elite interests. There is a dire need to counter these narratives in the media and present the pressing reasons why we desperately need this kind of reform – a complex set of reasons that need to be communicated simply and accessibly to widely variable audiences. Several sessions at the conference spurred on this conversation 

Galvanising our society around NHI will need a cohesive social movement for health – one that builds inter-generational, cross-class solidarity around health and stresses the urgency with which we must put “people before profit” when it comes to health. We must be able to engage the general public on the complexities and nuances of NHI and UHC – and generate a sense of public ownership of and participation in our health system and its reform. As described by a conference delegate and grassroots activist in response to one of the plenaries “We don’t care about all these alphabet letters – UHC, PHC, NHI whatever – what we care about is quality health care”. The People’s Health Movement has proposed a model for this with the “People’s NHI” – an idea that needs to be seeded in the broader public and media discourse on NHI. 

We need modes of collaborating, translating and communicating across publics in the interests of a just and equitable health system. This will take awareness building, organisation and concrete action – at the grassroots level, in our homes, and across the public health care sector. A policy reform as major as NHI is fundamentally about politics and power. As one panellist, Tracey Naledi, stated:now is time for the public health community to take back its power” and make ourselves heard. It is imperative that we convert these PHASA conversations into actions that engage the political forces who are currently dominating the shaping of the health system.

Manya van Ryneveld is a health systems researcher with training in social anthropology at the School of Public Health, University of the Western Cape. This piece was first published as a blogpost on the Collaboration for Health Systems Analysis and Innovation (CHESAI) website. 

PHASA is organising a parliamentary submission on the NHI Bill – please follow this link if you are a PHASA member and would like to add your comments deadline is Wed 2 October at 7pm. 


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