A properly implemented NHI can help bridge divides in a fractured country

In February 2018 President Cyril Ramaphosa announced that the country’s land redistribution programme would be accelerated. This included the proposed introduction of land expropriation without compensation. It sparked an intense public debate and brought to the fore questions of what is just and fair in a country built on oppression and social exclusion.

Last week, on Friday 24 August, the president’s address to the National Health Insurance (NHI) stakeholder consultative meeting in Gauteng generated very little public debate, and hardly even made the news. And yet the introduction of NHI is – like land reform – an attempt to fundamentally shift public policy and create a more just, cohesive South Africa.

One of the benefits of the consolidation of health funds into a single pool is that it allows for cross subsidisation of finances from rich to poor, healthy to sick, and young to old.

These include the understanding that health is a fundamental human right, not a commodity; that health and access to health care should be distributed equitably on the basis of need (and not ability to pay), and that this can only be achieved through cross subsidisation.

For those who may not have engaged with the NHI debate so far, here are five things the planned health financing system has in common with the government’s push for land reform.

Five things that NHI and land expropriation have in common

1. 
   

   Build social solidarity

   
   

Both land reform and NHI have the potential to build social solidarity across race, gender and class. Structural mechanisms of redistribution are vital to ensure we move beyond the ideals of transformation, towards a society that really does benefit everyone who lives in it.

Beyond the obvious point that a public health system is a public good, and that access to health is a fundamental human right, there is also a strong argument to be made that when people sit in the same queue to get their babies vaccinated, or share a hospital room while recuperating from an illness, they form human connections that bridge socio-economic divides. This creates an opportunity to build solidarity in our fragmented society.

2. 
   

   Address historical and current injustice

   
   

Both land reform and NHI seek to redress inequalities that are borne out of historical and current social injustice. These policies ask South Africans to recognise that the current distribution of social goods – such as health care and education – is unjust and is rooted in the idea that some lives matter more than others.

3. 
   

   Highlight uncomfortable tensions between the “individual” good and the “public” good

   
   

4. 
   

   Allow for the redistribution of wealth

   
   

Crucially, both land expropriation and the NHI are fundamentally about the redistribution of wealth in a society with one of the highest rates of inequality in the world.

5. 
   

   Run the risk of widening inequalities further

   
   

But, neither land reform nor NHI will come without risks. There is a chance they could widen inequalities even further – if, for example, there aren’t mechanisms in place to make sure land is redistributed equitably and fairly. In the case of the NHI, there is both the potential for widespread misappropriation of funds, and private capture (where private sector interests are over-represented in public decision-making forums).

So, why should you care?

There have been lively public debate and public hearings around land reform during 2018. It is important that the same level of engagement and discussion starts happening around the NHI and health care more broadly.

This needs to go beyond the media rhetoric of a health system in crisis, to include examples of people and systems that are working, despite significant challenges. It is critical to include both front line providers and the broader public in the NHI conversation, as it is these examples from which we need to learn.

The absence of platforms for meaningful public participation in health reforms is worrying. South Africans need to be more informed and more involved in shaping their health system.

The NHI brings us to a crossroads; if well designed and carefully implemented it moves the country towards socio-economic equality by prioritising a vision where the health system itself is a re-distributive mechanism, offering more than just health care. As with land expropriation, what hangs in the balance is the possibility for a more just and equitable South Africa. DM

This is an inter-disciplinary think piece in which academics from the fields of philosophy, education for social change, and health systems research, along with a public health doctor, share their thoughts.

Leanne Brady is public sector doctor turned health systems researcher, Health Policy and Systems Division, University of Cape Town. Injairu Kulundu is social practitioner researching transgressive learning for social change, Environmental Learning Research Centre, Rhodes University. Eleanor Whyle is health systems researcher with a background in philosophy, Health Policy and Systems Division, University of Cape Town.