Defend Truth


The origins of opposition to the NHI are rooted in the bigger problems of trust and competence


Ismail Lagardien is a writer, columnist and political economist with extensive exposure and experience in global political economic affairs. He was educated at the London School of Economics, and holds a PhD in International Political Economy.

A legitimate concern about the proposed National Health Insurance is the almost complete lack of trust in the state-government-elite axis to manage effectively anything more than rinsing a tumbler. The rest is simply ideological and disingenuous.

Taking legislative steps to establish a National Health Insurance (NHI) scheme is a principled, progressive and necessary move if South Africa is to continue working towards a more just, equitable, prosperous and healthy society. The most successful social democracies in the world established national/public health systems, and their societies have benefited enormously.

In the case of South Africa, today, the effort to establish a publicly funded national health system is a necessary step, but it is insufficient. The next, more difficult step is to expand the middle class – often ill-defined – who are the most important part of the revenue base. An even more difficult step will be to build trust in the state, the government and the ruling elite – the axis that has brought the country to where it is. 

Before we even get to that, we need to have a serious look at the ideological opposition to an NHI, an opposition that is driven by a seriously flawed set of ideas, beliefs and values imported from the US.

The monetarist, decidedly conservative politics and policies that took shape in the early 1980s and gained traction among free marketers and market fundamentalists began to erode belief in national health systems.

It is clear that this terribly conservative outlook seems to be the basis of opposition to an NHI in South Africa. Without purposeful support from the state, South Africa may drift further towards “the American model”, which is a product of ideological opposition – the power of corporate influence over the legislative process and a concern about “a nanny state” manufactured over time, and reproduced by various means of coercion and consent. It is worth looking a bit closer at these processes in the US. 

Myths, misconception and corporate lobbying

The US never quite put a national health system in place, mainly because of extreme individualism, that old dog Classical Liberalism with its (axiomatic) opposition to the state, and because of consent manufactured by large sources of funds from corporate lobbies, especially “big pharma”, to the media and legislators.

To be sure, it is not in the financial interests of the largest corporate donors to change the system, and society has, by and large, accepted this system as normal (it is the status quo) and, therefore, unchangeable.

“Big Pharma is trying to buy maintenance of the rigged status quo … The breadth of these contributions shows drug corporations have no intention of doing anything to lower their prices — they are lavishing millions in campaign contributions to protect their power to dictate high prices for prescription drugs,” said Ben Wakana, executive director of the advocacy group Patients for Affordable Drugs Now.

For what it’s worth, in the UK, the Conservative Party, especially, but also the Liberals (and Tony Blair’s Labour), have effectively been chopping up Britain’s NHS, with customary support from conservative corporate and ideological allies.

In both cases, “public opinion” is swayed by influential groups who peddle stories about “abuse” of the healthcare system by the poor (and more recently by immigrants and refugees) and who tell tales about people who are lazy or unwilling to just “get a job” or to work harder. And then there is the horror of the “nanny state”.

The so-called “nanny state” is largely a right-wing trope rolled out by Classical Liberals. The concept has some of its origins in distinctly sexist stereotypes and misogynistic references about “grand-maternal government” or a “grandmotherly government”, all of which helped shape lies and just awfully bigoted ideas about women in the 19th century. Women can simply not be trusted, or so the story goes… After that the argument was raised whenever the state instituted anything from speed limits to social welfare.

The “nanny state”, however, has been good for society. Simon Chapman, Professor of Public Health at the University of Sydney, identified at least 150 ways that the “nanny state” has been good for society.

He concluded, from his research and observations, that “nanny state critics are almost always self-interested. They’re rarely motivated by the freedoms they purport to defend. And invariably their arguments crumble under scrutiny”.

This makes it always important to open knee-jerk resistance to an NHI to scrutiny.

Myth of free and independent markets

In South Africa, opposition to an NHI is largely ideological. It rests on beliefs in free markets and innovation unrestrained by the state. It is also about race, entitlement and sanctimony. It’s that old set of beliefs – “we work hard for our money” and “why must we pay for them” to have a better life.

There is, also, opposition to a “nanny state” – terribly sexist, as it always has been,and simply just a smear. In South Africa, there is a bloc that tends to bang on about “lazy people” or people who supposedly don’t want to work (referring to black people usually) and who are dependent on “a nanny state”, and the misconception or convenient, partial panic that whites have to pay (tax) for (black) social benefits.

This is misleading, disingenuous and deeply ideological. It is misleading, mainly because working-class people also pay taxes, and the middle class, even the most impressive entrepreneurs rely, themselves, on state support. 

For instance, in the US, everything and everyone – from the late Steve Jobs to Elon Musk – has relied on direct or indirect state subsidies and interventions. The South African bloc’s favourite scion, Musk, has received billions of dollars in support from the state, and continues to rely on state concessions. Actually, Musk simply adopted a system that preceded him.

As Dean Baker, an economist and founder of the Centre for Economic and Policy Research, explained in his excellent book The Conservative Nanny State, conservatives and right-wingers (and those darned Classical Liberals) have always used the state to advance their own interests. Baker’s book opens up for scrutiny the enormous government interventions in the market in areas from trade, monetary and intellectual property to immigration policies. Most conservatives have aspired to making the wealthiest people in the US even wealthier. 

Baker’s opening gambit is this: “Conservatives want to use the government to distribute income upward to higher-paid workers, business owners and investors. They support the establishment of rules and structures that have this effect. First and foremost, conservatives support nanny state policies that have the effect of increasing the supply of less-skilled workers (thereby lowering their wages), while at the same time restricting the supply of more highly educated professional employees (thereby raising their wages).”

It is what some of us have described as socialism for the wealthy…

The actual problem is lack of trust in the state-government-ANC axis

While all the above are important and, of course, open to tantrums and conniptions, there is an opportunity missed. A legitimate concern is the almost complete lack of trust in the state-government-elite axis to manage effectively anything more than rinsing a tumbler. It is tragic that one may make that claim without pairing it with evidence.

While some of us don’t mind paying tax – it is never about personal, pecuniary gain and more about what type of society we want to live in – we cannot, not even for a moment, trust the axis to govern by consent and in the interest of the governed.

The “market” or private healthcare providers are barely to be relied upon to extend their services to the indigent, the unemployed or those who simply cannot afford healthcare. It is these citizens whom the state has a duty to protect – unless you’re a Classical Liberal who believes that the state has no business interfering in the lives of persons, except, so it seems, to provide benefits, concessions and support to the likes of Musk or Apple – notably when they were starting out.

Data has shown that the inability to pay medical bills is the primary cause of bankruptcies in the US, and an estimated 61 % were caused by medical issues, with people losing their homes because of medical debt burdens. This is the wealthiest country, with the “most advanced” and “sophisticated” democracy; yet it cannot take care of the poor, the weak – and the middle class.

The mild panic and hysteria around the NHI driven by ideology, misconceptions, misrepresentations and entitlement are a ruse to conceal opposition to paying for a public health service that others may use. This panic diverts attention from the need to put pressure on the axis. The real problem is not an imaginary “nanny state”. It is also not about lazy others.

All of these things have been proven to be rather specious. The overriding problem is the lack of trust in the state-government-elite axis.

Establishing a national health system as part of a more just, equitable, prosperous and healthy society is absolutely important and necessary, but the real battle, for the public, is trusting the axis; and for the axis, it is creating conditions for expanding the middle class.

If the past two decades are a prelude to the future, the axis is not worthy of trust – and we should probably stop before we end up like the US, and send people into bankruptcy and homelessness because they cannot pay their medical bills. DM


Comments - Please in order to comment.

  • Karl Sittlinger says:

    Oh so it’s got absolutely nothing to do with the fact that in this country less than 30% actually pay proper taxes and that they are expeced to not just pay for health insurance for everyone, but absolutely everything with ever increasing taxes, and ever decreasing service delivery, security, education (the list goes on) while having to finance all these topics in addition to the taxes that are meant for this a second time for themselves. Comparing us to any other country whilst ignoring key economic factors is a little disingenuous don’t you think? And yes this is in addition to a government that we absolutely know we cannot trust with our money, that we absolutely know will steal and waste it at every opportunity. This is a government that has shown pure ineptitude in just about every important decision, from energy and water to transport and security. You may find that many you are accusing of entitlement actually support universal health care, but not at the cost of their own livelihoods and health for themselves and their family. There is absolutely nothing wrong with that!
    Lets not forget that the very people that voted for the NHI ensured that they are exempt from it, just like they are exempt from all the other consequences their choices have brought us all to, from loadshedding to education to security.
    Oh, and we can soon expect to pay a universal income grant to, but yet again, just like the NHI, no one knows how to actually finance it. Very 1-sided article.

    • Willem Boshoff says:

      Agree Carl, our economy is broken and the government has already run out of other people’s money. Most readers here wholeheartedly support equity and justice, but that’s only possible in a growing economy where GDP per capita needs to reach a threshold to support all these social schemes. No amount of ideological sermonising will bring forth the funds required to run the NHI, even when in competent hands.

  • Philip Wernberg says:

    NHI is something we should be entitled to as tax paying citizens, I don’t see this working based on the history and collapse of everything run by the government. This will be another method to steal more money from South Africans and do nothing for the people who need health care. We still remember what happened with covid funding. “The mild panic and hysteria around the NHI driven by ideology, misconceptions, misrepresentations and entitlement are a ruse to conceal opposition to paying for a public health service that others may use.” NHI is an ideology in South Africa to enable more looting for the few in power who as we see currently do not care about people who need medical care or services. South Africans (all SA citizens) are starting to realise that we cannot rely on government anymore and have to fend for ourselves. (Electricity, water, security, transport etc)

  • Epsilon Indi says:

    It is disingenuous of the author to compare SA and the US in any way, they are just not comparable, not when it comes to healthcare nor when it comes to subsidies and their economies. The US has huge problems of its own but it is not being driven into the group by a cabal of corrupt cadres who prevent the state from functioning in almost every way. In SA we have a government and a ruling party that has no decency, no honour, no competence, no morals, no intelligence and no ability to administer anything beyond a tea party let alone something as complicated as an NHI. The author attempts to wave away the failures of the ANC as though they are nothing when in fact they will bring both an NHI and the country to its knees.

    • Gerrie Pretorius says:


    • Roelf Pretorius says:

      No the authors’ comparison of the USA & and the opposition in SA is valid. It is time that all of those opposed to the NHI start to investigate what racism has to do with this opposition. Fact is that SA is sitting on a time bomb – the gradual increase in violent unrest situations should be a warning about that, if the opposition would only start to use their brains. The reason for the incidents of unrest, and it includes the 2021 unrest in KZN and Gauteng, is that a significant part of society does not really have anything to lose by burning SA down. The NHI, and also other inisiatives like the socalled universal grant and so on, gives them something to defend, which is not the case when they don’t have it. It is time SA wakes up. The author however is also right with his reservation about the ability of the ANC to properly manage this. Why can’t the DA just for a change agree with the principle and only provides a better way of doing the same?

      • sue fry says:

        Thank you, i agree with your comment. So many in SA have nothing to lose – that is a crisis! How we proceed, i am not sure. But i am concerned about implementing NHI now, with our dismal state of governance – though i fully support the idea in princpile.

        • Peter Atkins says:

          Yes! Please dear DA and supporters, provide alternatives to the NHI, not just destructive criticism. Perhaps by forcing our medical companies to be inclusive rather than trying to re-invent what they do quite effectively.

    • Alan Hunter says:

      Spot on.

      Show me just one SOE that works. And they cannot even manage the hospitals and clinics it already oversees.

      NHI will destroy the Disease Care System. Even countries with NHSs have private hospitals and clinics. Leave ours alone and focus on fixing all the government’s messes.

  • Paddy Ross says:

    Citizens should pay their taxes but they should also have the right to spend their income on private health and private education of their children if they so wish.

  • Ed Rybicki says:

    So as taxpayers we relatively few ALREADY pay double for everything: we pay for reasonable education, security, health and power, when these SHOULD be provided by the State. Now they want to take a system that actually works – that is, private healthcare alongside the state-provided version – and “democratise” it, to make it more “fair”??

    Seriously now, people, South Africa is one of the only countries in Africa where a low-earning person can GET reasonable healthcare from the State – and if higher earners subsidise a private system AS WELL, what is the problem? I hope the NHI is litigated out of existence; as I approach my delayed retirement, I want people I know and trust looking after me!

  • Daphne Hodgson says:

    Just another trough for the ANC to feed at if implemented while the party is still in power.
    Fortunately there will be many years before implementation & hopefully all State Owned Enterprises will be in a much better state or privatised.

    Daphne Hodgson
    Brighton Beach

  • Miles Japhet says:

    Nothing wrong with the theory but everything wrong with the practice.
    I, for one, have worked hard to create choice and in the process employed many hundreds of people.
    Take away my choice for something as vital as healthcare and emigration for many highly skilled people becomes a real option with consequent job losses. The poor continue to get poorer whilst the ideologues play , detached from reality. Tragic

    • Paul Crosland says:

      The ANC have run the majority of government health services into the ground with administrative incompetence and corruption. They see Adrian Gore and his billions and have decided that they want that cake as well. They will destroy everything in sight and cannot be trusted with one cent

  • Lisbeth Scalabrini says:

    “The most successful social democracies in the world established national/public health systems, and their societies have benefited enormously.”

    I beg to disagree. In Italy you can wait until three or more months for an operation, the same in Denmark and those who can afford it have a private insurance. In Switzerland there is no public health insurance and the private one, which is very expensive, is mandatory. During the last ten years, there have been three referendums, but no! The population prefers to pay and keep something that works. (The people who cannot afford it get financial help from the state).

  • Lawrence Sisitka says:

    Unlike most other commentators here I am probably 95% in agreement with Ismail. Yes, we know the absolute disaster our current governing party has been for the past 20-odd years, and that for me is the only really justifiable objection to the idea of the NHI. As someone brought up with the good ol’ NHS (which did save my life on one occasion), I would be as big a hypocrite as Tony Blair (who he?) if for selfish reasons I saw fit to deny others access to good, if not exactly brilliant medical care. In a survey a few years ago (I forget where), to the question whether I would be prepared to forgo some of my privileged access to health care if it meant better access for others I responded ‘yes’. This is not to claim any spurious sainthood, just simply, if we believe in equality we must live by it, even if it does mean making some compromises. However the compromise expected of people moving from the world class service offered by most of the private sector – greedy though it certainly is – to the squalor of the public sector (despite many deeply dedicated health professionals trying to work in that sector) is not acceptable. I really don’t buy Nicholas Crisp’s claim that the dysfunction is all a matter of lack of resources, and there definitely needs to be a clearing out of the lazy, incompetent and often corrupt bureaucrats currently managing the public health system. But in principle, and I hope in time in practice, a universal healthcare system for all – YES!

    • Theresa Avenant says:

      I salute you Lawrence and wholeheartedly agree with you. Daily Maverick needs more readers like you. I commented yesterday in DM’s First Thing article on NHI. I realised (after it took quite some time for my comment to be published) that I was one tiny lone voice of socialism amongst about 50 or so right wing commentators. I was very despondent that there was no-one in the commentary section that would agree with me. It made me feel ashamed to be a South African. All people in South Africa have a constitutional right to (among other things) adequate health care. The level of inequality in South Africa is deplorably unacceptable. I say the government should bulldoze ahead with the NHI, the consequences be damned. There are many hospitals and clinics in the Western Cape that show that it can be done.

  • Gerrit Marais says:

    So, I can procreate without consequence as the government will take care of my needs, paid for by others that have no say in matter. In addition, this very same government puts every obstacle in place to prevent the ‘others’ to grow their businesses and create an economy that will provide me with an employment opportunity so that I no longer need to look at said government for support.
    How on God’s earth is there any sense in that?

    • Alan Hunter says:

      I have children staying with me who do not pay rent, food, water, electricity. I listen to their opinions but they do not have votes as they are dependents. If they could vote they would “demand” more than I could provide. Remember “Animal Farm”?

      Time to run our State like this. Minors = no vote. No rates and taxes = no vote. Dependent on the State = no vote. Employed by the State = no vote. Politician = no vote. Unredeemed criminal = no vote.

      • Ruby Delahunt says:

        This comment has broken my brain a little bit. What, so nearly half the country (people on grants) shouldn’t be allowed to vote? What about poor people with jobs? You only have to pay income tax if you make over R90k annually. And minors already cannot vote, so that is null and void. And you would deprive 1.2 million government officials (most paperwork filers) of their vote because… what? Some of them are dishonest? And please, let’s not bring Orwell into this.

  • Loreen Webber says:

    No one mentions that there already ARE state hospitals and clinics where the poor are supposed to have access to FREE Healthcare. But can’t thanks to the ANC. Whose solution is to ruin one of the best private Healthcare systems in the world

  • Andrew Denton says:

    I’m in Canada, where I presently have access to NHS. In this wealthy country, it has a shortfall of tens of thousands of healthworkers. Scheduled procedures are delayed for months and while ER treatment is excellent, getting GP services is almost non existent. After a 5 year wait, we got allocated a Family Doctor, a nice man from the Congo. With no private insurance to pay for private medicine, it doesn’t exist. The state provides almost everything, slowly and ponderously. It’s an ideology I support in theory, but in practice is deeply lacking. And this is where governance and funds are way better than SA and the population is smaller.
    I foresee the S.A NHI act being a precursor for experienced healthcare providers leaving to destinations where private medicine is practiced, and leaving a significant shortfall in SA’s ability to provide healthcare, much like Zimbabwe and Zambia. This is a reality where scarce skills are better rewarded and are mobile.
    The decimation of the middle class (BTW- a Marxist ideal) will accelerate.

  • Abel Mngadi says:

    NHI is a good idea but with this government it becomes a bad idea. How are the few taxpayers going to carry the whole country with the majority being unemployed, with the additional burden of illegal foreigners being the biggest beneficiaries of NHI? Government should have first sorted the mess we see in hospitals before embarking on NHI. Sort out Eskom and service delivery before taking on additional responsibilities that we all know they can’t deal with. Creating another cash cow after bringing Eskom, Denel etc to their knees. Shame on them

  • Steve Davidson says:

    Frankly, if the author would get off his high horse, stop using long words in the hope he might impress us (which he doesn’t), dump his anti-white attitude, and get off his butt and come to the Western Cape, he would learn that properly managed (ie non-corrupt non-ANC) provinces like here have public and private medical services working in reasonable harmony. Both my wife and I have been excellently served by both here and it grates to hear a supposed academic talking such rubbish. The ONLY problem in this country is the ANC (and their sycophantic mates in the EFF and other useless fake political parties) who need to be kicked out as soon as possible and the DA take over this Failed State (apart from the Cape).

  • Andre Du Toit says:

    Just show me the numbers. If you cannot put you plan in an Excel spreadsheet, you cannot explain or manage it. The government has failed to provide a budget that shows where the money is coming from and how it will be spent. There is therefore very good reason to be suspicious, besides the ANC’s proven track record of ineptitude and looting. This is nothing more than bribing the sheeple to vote for the ANC now that they have realized that T-shirts and food parcels are no longer doing it.

  • Lawrence Sisitka says:

    Yhoo! Some of the comments from Karl, Gerrit and Alan only reinforce the view that we are overpopulated here with rabid right-wingers. A little more reason and humanity please fellow commentators.

    • Karl Sittlinger says:

      “Some of the comments from Karl, Gerrit and Alan only reinforce the view that we are overpopulated here with rabid right-wingers. A little more reason and humanity please fellow commentators.”
      If that is the case, then please answer my comment with reasoned and non ad hominem attack response. Resisting the destruction of what remains of our healthcare system with no plan, no funds, no trust is by no means right wing nor inhumane. Awaiting a structured and reasoned response.

  • Mari Bekker says:

    What if services rendered by government, like education, transport and of course health, were of such quality and convenience that those who have the luxury of choice, would still choose to use them?

  • Caroline de Braganza says:

    I disagree that opposition to the NHI is “largely ideological”. If I were employed, I’d have no problem with a tax and NHI deduction on my salary slip, as happens in the UK. My objection is based on the fact that when I lived in the UK I had easy access to a GP, dentist or optician, which is not the case here.

    I and my wheelchair-bound husband have been unable to afford private health insurance for over 25 years and have many horror stories to tell about the broken state health system in South Africa that we have been subjected to. (The wheelchair was donated by Gift of the Givers who answered my plea for help after his stroke.)

    I have a litany of stories as I’m sure do the 45-million other South Africans who rely on state healthcare (a misnomer as care is notably absent).

    The Health Funders Association (HFA) states “While there are pockets of excellence, most of the health provisions and facilities in the public health sector do not meet the standards set by the Office of Health Standards Compliance (OHSC)”.

    The NHI can only be implemented once the standards are met, and should not preclude citizens from accessing private health practitioners, whether we have private insurance or not.

  • Rod H MacLeod says:

    “If the past two decades are a prelude to the future, the axis is not worthy of trust – and we should probably stop before we end up like the US, and send people into bankruptcy and homelessness because they cannot pay their medical bills.”

    What the hell does that even mean?

    Please, forget having a serious look at the ideological opposition to an NHI as your first step. And although “the effort to establish a publicly funded national health system is a necessary step” it needs to be preceded by “The … more difficult step … to expand the middle class – often ill-defined – who are the most important part of the revenue base” and by ” … [the] step … to build trust in the state, the government and the ruling elite – the axis that has brought the country to where it is.” Your own words.

    Anything else is putting the cart before the horse.

  • Belinda Cavero says:

    I would really like to see the NHI succeed in a way that quality health care services become more equally available to many more people. Our ANC led government has had many years to make this a reality but it has repeatedly allowed incompetence and corruption to fester and many clinics and hospitals are gangrenous wounds to the community. I mean, how does a hospital management get away with purchasing hundreds of skinny jeans? Those people who signed the cheques (and where are those jeans anyway?) should be named, shamed and fired on the spot. Come on!

    But another reason is personal. My family and I do not have private medical aid. Decent healthcare that is state funded would make me feel less anxious everyday about the dreaded “what if…”. There are also a lot of private health care providers who are fleecing the medical aids to fund their lavish lifestyles, which pushes up premiums and making medical aid more and more unaffordable. I’ve heard that these individuals (bordering on syndicates) are hotly opposed to the NHI and even threaten to emigrate. After all, levelling the playing (and paying) field could be less lucrative for their practices.

  • rmrobinson says:

    Really, a problem of trust? Its a problem of corruption, incompetence and pure evil. Read de Ruyter and get real.

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