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South Africa’s overburdened healthcare system is broken, we need the NHI to fix it


Zingiswa Losi is President of the Congress of South African Trade Unions, Cosatu.

Cosatu supports National Health Insurance as the best vehicle to achieve quality universal healthcare. The federation has worked closely with the Department of Health and international and domestic experts to draft a well-crafted and widely applauded NHI Bill.

We are 29 years into democracy and South Africa still does not have quality universal healthcare. Instead, we have two systems, public and private, and both are struggling to ensure that all South Africans have access to affordable and quality healthcare. 

Over 84% of the public, overwhelmingly working class, depend on public healthcare. The public healthcare system has over 400 hospitals and clinics, but despite massive state funding remains significantly under-resourced, with large numbers of critical vacancies, long queues and shortages. Patients are frustrated as they experience an over-extended and strained public health system lacking adequate funding, personnel, and maintenance. 

Private healthcare too experiences real challenges. It receives a similar amount of funding as public healthcare yet caters for only the 16% of society that is fortunate enough to have medical aid. While the quality of healthcare in the private sector is good, it is unaffordable for most people including even medical aid members.

Private hospitals are underutilised. Unnecessary treatments are often done in pursuit of profits. Many medical aid members run out of their day-to-day benefits halfway through the year. The Competition Commission shone a spotlight on price collusion in the private medical industry at the expense of patients and excessive profiteering. 

We are fortunate that we do not spend too little on healthcare. South Africa spends 8.5% of its Gross Domestic Product on healthcare. This is higher than many industrialised and peer nations. The challenge is that half of that is spent on the 84% of society dependent upon public healthcare and the other half on those who can afford private medical care.

This dilemma can only be resolved by creating a National Health Insurance guaranteeing all South Africans access to affordable quality healthcare. 

Why an NHI is important 

The NHI will offer all South Africans and legal residents access to comprehensive health. It will help prevent, identify and manage diseases and other healthcare needs through a focus on primary healthcare. This will be supported through community healthcare workers, school health teams, and district health facilities.  

South Africa continues to struggle to manage communicable and infectious diseases that can be better managed and prevented through primary healthcare, in particular tuberculosis, HIV/Aids and various pandemics. A strong focus on primary healthcare in our communities will reduce our high levels of maternal and child mortality.  

To our shame, we remain a society with unacceptably high levels of alcohol abuse, gender-based violence, road accidents and violent crimes. All of these require a strong public healthcare infrastructure accessible to the poor, and resourced to provide quality services.  

Chapter 2 of the Constitution stipulates that all South Africans are equal, have the right to human dignity and privacy as well as adequate healthcare. The state is thus obliged to ensure that this is made a reality for all citizens, and the only successful international model to achieve this constitutional right is through an NHI. 

Cosatu supports an NHI 

The Congress of South African Trade Unions (Cosatu) supports an NHI as the best vehicle to achieve quality universal healthcare.

The federation has worked closely with the Department of Health and international and domestic experts to draft a well-crafted and widely applauded NHI Bill.

We are pleased it was passed with an overwhelming majority in the National Assembly and was enthusiastically endorsed by the majority of the members of the public attending countless public hearings across all nine provinces. Cosatu looks forward to the bill being passed by the National Council of Provinces by November and then signed into law by President Cyril Ramaphosa. 

Cosatu and its 16 affiliate unions’ nearly two million members and their families face the brunt of our public and private healthcare crises on a daily basis. Workers spend hours in queues waiting to be treated by overstretched public healthcare workers. Nurses and doctors are exhausted from working overtime and covering for thousands of vacant posts. Paramedics are routinely targeted by criminals when entering townships. Nurses fear for their lives when gangs run amok through hospitals.

Workers who have medical aid run out of day-to-day benefits halfway through the year. They are saddled with unaffordable co-payments and are forced to delay necessary procedures and treatments to the next financial year because they cannot afford the excessive charges set by private service providers. 

Critics say an NHI is not affordable, but are silent on whether we can afford to continue to allow millions to die of easily preventable and manageable diseases. They are silent on the impact this has on the ability of workers to take care of their families and their capacity to work and thus enable their workplaces to be productive. It is ironic that the critics of the NHI fail to acknowledge the burden this causes to the fiscus and taxpayers. 

Opponents of the NHI have raised false alarms that it will result in massive tax increases. It won’t. We spend enough collectively on healthcare, publicly and privately. The point of the NHI is to combine those financial, personnel and infrastructure resources and ensure that all have access to them. 

Fearmongers claim the NHI will spark an exodus of healthcare workers. It is a pity that they are economical with the truth. This exodus has existed for decades. Nurses, doctors and other healthcare workers have been worked to the bone in a badly overstretched public healthcare for years and not only choose to leave for work for better pay and less stressful conditions in the private sector, but are also aggressively recruited to work overseas.

If we want to stem this loss of critical skills, then we need to ensure an equal distribution of patients to public and private healthcare facilities, combine resources and fill critical vacancies. The status quo is broken. It’s a pity the critics prefer that to fixing it. 

Cosatu is disappointed that some private service providers have chosen to misrepresent the views and frustrations of healthcare workers, the overwhelming majority of whom are members of Cosatu’s affiliates: Nehawu, Denosa, Samatu and Saepu.

Our members are clear. The system is not working. Workers are burnt out. Patients are being denied the care they need. Working-class communities are bearing the brunt, the economy is limping and the fiscus is bleeding. Workers came out in their numbers to the parliamentary hearings to express for themselves why they believe building an NHI is this generation’s moral imperative. 

Private healthcare facilities will continue to exist alongside public healthcare services. The change will be that they will be brought under the umbrella and utilised and funded through the NHI. 

We have a choice. We can continue as is and allow millions to die needlessly. Or we can be smart, show some moral rectitude and compassion and pool our resources together as a nation and ensure that we are indeed a South Africa that belongs to all who live in it.

Cosatu and its affiliates are clear: we choose to be on the side of history and to support an NHI which will meet the constitutional obligations of ensuring that all South Africans have access to quality and affordable healthcare. DM


Comments - Please in order to comment.

  • Miles Japhet says:

    Laudable sentiments, but like many ideologues, based on a lack of understanding of the implications of an NHI. The state of public health in SA is a direct consequence of cadre deployment and BEE leading to chronic mismanagement and corruption. COSATU should focus on fixing this rather than destroying a highly functional world class private sector. Whilst it may only serve the minority, the access to such care (interesting that the cadres all use it and most likely the writer too!!) is one key reason so many people with the ability to create jobs, remain in SA.
    You underestimate the knock on effects on employment when you support more dysfunctional state control.

    • Kerry van Schalkwyk says:

      Well said, 100% agree.

    • Nic Bosveld says:

      Agree fully. As the writer has said, more than enough money is spent on public health care. Problem is, a large chunk is stolen/”redistributed” to cadres. Fix that first, make every penny count, train more nursing staff and instill pride in the profession.
      Throwing much more cash at what is currently a basket case will definitely not make any difference.

    • Oliver Laubenheimer says:

      agree 100%, well said

  • David Farrell says:

    I feel the NHI plan is reasonable although doomed to failure, mainly due to corruption, malfeasance, mismanagement and lack of competent health care administrators, considering where the national health was and were it is now there does not seem to be light at the end of the tunnel as there has not been any improvement in government services since cr took over after the darkest days of jz

  • . . says:

    We have a choice. We can continue as is and allow millions to die needlessly. Or we can be smart, show some moral rectitude and compassion and pool our resources together as a nation and ensure that we are indeed a South Africa that belongs to all who live in it.

    We have several choices, I would be quite happy to pool resources as long as those resources are not uber the control of the ANC government.

    There are many much better mechanisms that could achieve a better and more equitable healthcare, the NHI is a choice that will result in a more equitable but much worse level of heath care

    • Loren Anthony says:

      The NHS has collapsed in the UK because of under-funding. It will collapse in SA because of a different type of under-funding: corruption and fraud. Baragwanath Hospital cannot even feed its patients because the fiscus has been stripped bare – a direct result of the graft system deployed by the ANC. For the ANC, NHI is simply an electioneering tool, to paint them in a positive light, but look at their administrative and procurement track record so far – it’s one corrupt tender on top of another, one unpaid supplier after another. So, Ms Losi, is this the entity you’re betting on to usher in our brave new world of equitable healthcare? Delusion and denial runs deep in SA – or maybe it’s the promise of another feeding trough?

  • Michael Forsyth says:

    Fix the damned system that is broken. If the current system is mismanaged, corrupt, inefficient etc what makes anyone think that the NHI can work.

  • Nathan Hunt says:

    A few lines in and there is already a point the writer should rather be investigating than just using as a reason for implementing NHI: “but despite massive state funding remains significantly under-resourced” – why is this I wonder? Where are those funds going to?

  • Alan Hunter says:

    Does everyone deserve to eat? So why not legislate that all those who have (excepting the politicians and their cronies) open their doors to all comers to eat to their hearts’ content?

  • Steve Stevens says:

    We already HAVE NHI. Why spend billions to restructure something that if properly managed and maintained could deliver quality healthcare. As to the private sector, I agree on price gouging and affordability, but has the author done the maths: 1 x pt + 1 x medical aid contribution = -1 x pt cost to the state – 1 x pt on waiting list.

  • Abel Mngadi says:

    Ms Losi you make a lot of sense and would wholeheartedly support NHI, but in your article you do not address the core problem that comes with the ruling party, thieves in our system that will erode funds in the NHI and totally collapse it and we would be back to square one. Look at Tembisa Hospital as an example. It had enough budget to cater for the community but thieves ran amok and they still aren’t behind bars, isn’t that an encouragement to steal public funds in NHI as well? We need NHI but not under this climate

  • Gretha Erasmus says:

    A single pooled fund is not the only way to achieve universal health care. Name me one middle income country except Cuba who has a single pooled fund as the system of universal health care. And the problem with Cuba is that it is a deeply undemocratic country whose people risk their lives on dinghies to escape and doctors abondon their families back in Cuba in the hope of creating a better life somewhere else by defecting when they get a chance. The only way Cuba as a low middle income country can do their version of NHI is by all medical workers having no rights, zero autonomy, breaking numerous aspects of our constitution. And as someone else noted, not even the UK, one of the 5th biggest economies in the world can afford their NHS. Most middle income counties who have a form of universal health care have some blend of compulsory medical aid cover for those who can, and state funding and public and private provision.
    What we should do is stop with this blind mindset of a single pool controlled by government cronies and look at what works at similar economies to ours and where there is a constitutional democracy.

  • Graham Nelson says:

    The NHI could work if run as a business for profit. That’s the only way to stop the corruption. How this could be implemented I don’t know.

  • anneke Niemand says:

    It’s impossible to continue with any credibility after these word “a well-crafted and widely applauded NHI Bill” in the first paragraph.

  • Scott Gordon says:

    Hilarious , East Cape has liability claims that exceed their budget .
    So with NHI I might get to meet the mayor at the local hospital ?
    Those that do pay for their own Med aid are saving the Govt !
    Given the time frame for implementation 10 years +- , will care less then 🙂

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