Acting president Paul Mashatile, and over 10 bodies representing civil society, academia, and trade unions, pushed ahead with the signing of the health compact today.

The event proceeded despite the stance taken by the South African Medical Association (SAMA) and Business Unity South Africa (BUSA) not to sign the second Presidential Health Compact. But Professor Alex van den Heever says the notable absence of these organisations negates the purpose of the pledge.  

Van den Heever, the Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, says it is not clear that the health compact can be regarded as a compact when major stakeholders withdraw. 

He explains to Health-e News that for a compact to be worth anything, it requires consensus across diverse interest groups and not just those who are affiliated to a single political party.

“The purpose of the health compact is to establish a wide social consensus on a particular issue or set of issues. Many social issues are affected by divided interests. A social compact attempts to bridge these interests and find common ground,” he says. 

The health compact is an initiative by President Cyril Ramaphosa that outlines a framework for various sectors of society including the government, business, labour, health professionals, and academia to work together towards addressing the most pressing health challenges facing the country. The first health compact was signed in October 2018. 

Van den Heever says typically, reaching social consensus requires intensive engagement and problem solving among all relevant stakeholders in a process convened by the government.

“Abdication by key social partners is indicative of a failure to establish social compact. While the government is free to publish any documents it wants, regardless of how ill-conceived or shallow, calling this document a compact stretches credulity and is plainly contrary to the rational purpose of a social compact.” 

Why we need a compact

University of KwaZulu-Natal, Head of Division internal medicine Professor Bulie Magula tells Heath-e News that the president identified a need for an intervention that draws on expertise in the field of health and diverse partners to strengthen the health system.

“The compact is a commitment to ‘Strengthening the South African health system towards an integrated and unified health system’. Achieving this goal would bridge the big gap of inequalities in South Africa, which are a legacy of the apartheid system, and enable universal health coverage that will ensure the provision of high-quality health services for all South Africans,” she says. 

South Africa currently has a two-tiered health system. The well-resourced and pricey private sector caters for around 16% of the population, while the public sector that caters for a majority of the population is underfunded and poorly resourced.

She says the point of the compact is to identify pressure points, areas of weaknesses and strengths. Thereafter formulate interventions for improvement. 

Some of the key areas that were identified in the first health compact include: development of human resources; improving access to medicine, vaccines and health products;  upgrading infrastructure; and improving the quality of healthcare. 

“However, the country still has a shortage of doctors and nurses. There are always going to be those that decide to leave the country. This cannot be stopped. Unfortunately, our rate at which we train doctors and nurses has been compromised by the reduction in trainers being trained. This has been exacerbated by the limitation to training only in the public sector, where the resource limitations dictate the numbers of those trained. Many young people have had to leave the country to train elsewhere but that is a problem as one cannot register to practise in South Africa without having passed SA Board examinations. SA has not kept up in the development of medical schools and nursing colleges with population growth and disease burden,” she says.

No sign of social consensus 

 The South African Medical Association Trade Union (SAMATU) and Democratic Nursing Organisation of South Africa (DENOSA) have  pledged their support for the second Presidential Health Compact. 

The unions say they are committed to the compact’s key objectives of enhancing health systems, strengthening the National Health Insurance (NHI) and ensuring sustainable high quality healthcare for all South Africans. 

“It remains our firm belief that the health compact brings the country closer to the realisation of universal health coverage, where every person will have access to quality healthcare regardless of their socio economic status,” reads the statement. 

BUSA says it will not sign the health compact because it  – and centres – NHI) Act. 

BUSA’s CEO Cas Coovadia says the references to NHI in the original compact were minimal. But the draft of the second compact that was shared with the business unit promotes the NHI as the foundation underpinning healthcare reform. 

“BUSA does not agree with this given the serious differences between us and the government as to the appropriateness of the NHI Act, let alone its feasibility as a legislative instrument to underpin universal health coverage,” Coovadia says. 

“Our concern is that the implementation of NHI is at the expense of immediate opportunities to expand and improve healthcare access. There are ways to achieve universal healthcare coverage other than implementing an unaffordable, unworkable and unconstitutional NHI,” he says. 

The business unit believes that the NHI Act has to be amended to ensure that the country is able to deliver healthcare reform and advance universal health coverage without damaging the economy and existing skills. 

SAMA too, says it would not sign the pledge because of the focus on the NHI. 

“SAMA has serious concerns about the current NHI model as the primary vehicle for achieving the goals set in the Presidential Health Compact. While we share the government’s commitment to universal health coverage, we believe that the NHI in its current form may not adequately address the complexities of our health system. It could inadvertently lead to unintended consequences that compromise both the public and private healthcare sectors,”  says SAMA chairperson Dr Mvuyisi Mzukwa. 

He says the association is concerned that the current NHI could strain healthcare resources, exacerbate existing inefficiencies and limit patient choice. 

“We call for an open and inclusive dialogue on the best path forward to achieve universal health coverage. We urge that future references to the NHI in the Presidential Health Compact be revised to reflect a broader spectrum of potential solutions and that stakeholder engagement remains a cornerstone of this ongoing reform process.” – Health-e News