Consensus, common purpose and unified commitment to SA healthcare reform urgently needed

By Brian Currin, Mark Heywood, Tracey Naledi, Krish Vallabhjee and Atiya Mosam

15 Sep 2024

There is a critical need for public sector and private sector healthcare reform that transcends political posturing and vested interests, and prioritises the health needs of all South Africans.

In the weeks leading up to the 2024 general election, the National Health Insurance (NHI) Act, signed by President Cyril Ramaphosa on the eve of the election, became one of the issues that polarised people in South Africa. Sadly, despite the formation of a Government of National Unity (GNU), the polarisation around health reform and NHI has continued. Most notably, Business Unity South Africa as well as significant sectors of the medical fraternity declined to sign the presidential health compact, because of its perceived uncritical endorsement of NHI.

Meanwhile, reports of the challenges and crises besetting the public health system mount.

A Facebook video of conditions at Johannesburg’s Helen Joseph Hospital made by the broadcaster Tom London went viral and caused widespread outrage and condemnation. A recent report by the Academy of Science of South Africa highlighted leadership instability, lack of transparency, insufficient accountability mechanisms and pervasive corruption as key challenges of the South African health systems.

In addition, growing waiting lists of patients for cancer treatment, medico-legal claims running into billions of rands, staff and medicine shortages and widespread corruption continue to plague the health system.

On the other hand, the challenges in the private health sector, especially unaffordability and cost escalations, have been well documented by, among others, the Competition Commission’s Private Health Market Inquiry (HMI). The high rates of Caesarean sections in the private health sector, recently highlighted by the South African Medical Research Council, raise concerns about clinical governance in the private health sector.

Given the heated ideological divides that seem to exist in the NHI debates you might be forgiven for thinking that finding consensus on healthcare reform is an elusive dream. You may not believe us when we argue that there is substantial common ground among medical practitioners, public health activists, government and the private sector.

This became evident in the findings of a research study conducted in 2021/22 by Concentric Alliance and SECTION27. In-depth interviews were conducted with 33 health sector leaders to “see what stakeholders in the health system (when they are away from the public eye) agree on, what they disagree on, and whether there is a possibility of bringing them closer together…”

The interviews revealed significant opportunities for alignment across these sectors, unanimously agreeing that universal access to quality healthcare remains the overarching goal.

This consensus underscores a critical need for public sector and private sector healthcare reform that transcends political posturing and vested interests and prioritises the health needs of all South Africans.

Nuanced perspective

The research indicated that public discourse on NHI has oversimplified opinions into “pro-NHI” and “anti-NHI” camps. Many stakeholders said they supported the Act’s fundamental objective of ensuring universal health coverage while expressing valid concerns about its implementation and scope (“NHI-hesitant”). This nuanced perspective challenges the polarising narratives and highlights a spectrum of viewpoints that deserve thoughtful consideration in policy deliberations.

Of course, the health system faces difficult challenges, but South Africa has the capability to run a high-quality healthcare system, if you take into account the skills and resources that exist across public, private, academic and NGO health sectors.

The interviews revealed that most public health leaders and activists believe there is room for practical collaboration on programmes and reforms that would fix health.

Some of the areas identified by interviewees include:

Addressing the significant failings in primary healthcare with a specific focus on disease prevention and health promotion;

Improving access to healthcare services in rural areas; and

Upgrading the infrastructure and systems of the public health sector, inclusive of health facilities, information and communications technology (ICT), procurement and logistics systems.

The research also highlighted opportunities for leveraging private sector expertise in ICT, procurement and logistics management to strengthen public healthcare infrastructure and processes. A collaborative approach could enhance efficiency and operational effectiveness within the NHI framework, paving the way for sustainable healthcare improvements across the public and private health sectors.

The research drew attention to those issues that divide us: concerns about the mechanisms by which NHI will be governed, the powers allocated to the minister of health, the future of medical aid schemes, and myriad other contentious issues within the Act.

Most interviewees felt the Bill (now Act) had failed to address the structural issues within the health system such as the massive inequalities in resources between the private and public health sectors and between urban and rural South Africa, the massive skills shortages, the need to strengthen primary healthcare services, the high costs of medicines and medical care, and the variability in quality and outcomes across the sector.

Missed opportunities

If there is so much consensus why aren’t we moving forward?

The reason is simple: we allow the issues that we think divide us (some real, some perceived) to paralyse us. The opportunities for collaboration are missed, particularly while the deep distrust between the public and private healthcare sectors is unaddressed.

This is why we believe there is an urgent need for all parties to deeply listen to one another, and compromise when necessary, to agree on confidence-building measures that bridge the trust deficit and foster effective partnerships for health sector transformation that is in the interest of all South Africans.

Health services, which form an important part of the social safety net for the most vulnerable sections of the population, are in serious need of urgent intervention.

Both sectors, notwithstanding challenges, collaborated well to serve the nation during Covid-19. There were important lessons to be learnt that should pave the way towards a more unified national health system. These include vaccines being procured for the country as a whole and supplied to both sectors, providers collaborating to ensure adequate coverage of mass immunisation on a scale not seen before, and a shared information system to track vaccine coverage and hospital bed utilisation.

The Concentric Alliance and SECTION27 report recommends two mechanisms to improve health services.

In the short and medium term, stakeholders should pursue an objective-driven approach that sets achievable outcomes for the private and public sectors. These could be partnerships on specific issues like revitalising primary healthcare, strengthening health promotion and overcoming logistics challenges within the health system.

They could be targeted at health outcomes such as improved postnatal care or eradicating backlogs and waiting lists in the treatment of dread diseases like cancer. Achieving objectives collectively will demonstrate commitment to mutual goals and build trust.

In the longer term, there is a need for a consensus-building process to reconcile divergent perspectives and foster constructive evidence-based dialogue and policy options without compromising fundamental principles of equity, equality and universality.

The purpose of such a process should be to address the health system’s structural issues and realise section 27 of the Constitution, which says all in South Africa have the right to access healthcare services. Such a process must be political and technical. Technical leaders should be responsible for developing solutions to structural and technical problems, while political leadership should be reality-testing such solutions to ensure they have buy-in and support. Academic leaders should evaluate the impact of these solutions.

Seize the moment

The GNU and the debate around NHI (despite being polarised) is a once-in-a-generation policy window of opportunity to fix and cohere our health system. We dare not miss it.

The agreement between the political parties serves as a basis for renewed engagement on health reform and the mechanisms by which access to universal and quality healthcare can be achieved. Failure to seize this opportunity now will result in years of legal battles over the NHI Act and will continue to stymie the attainment of urgently needed health reform.

The implementation of the NHI will take several years. This creates the space for sequencing steps over the years as described in the NHI Act. If pauses of certain clauses in the NHI Act are required, this should be considered at a political level, to create the space to find consensus and common ground.

Amid the mud-slinging, a pivotal opportunity to advance the objectives laid out in the Constitution has emerged. The inclusive governance structure of the GNU also calls for a unified commitment to improving key health system objectives — a mandate transcending partisan interests and personal agendas.

The urgency for reform in the health system is measured in lives lost or saved, disease prevented and dignity and equality of opportunity protected.

There is still significant underutilised capacity within the private health sector, including specialist capacity, beds and expensive health technology, while the public sector is significantly strained by the huge and increasing service demands.

The repercussions of inaction and failure to collaborate could be profound, underscoring the critical need for stakeholders to engage earnestly and proactively in shaping the future of healthcare in South Africa. DM

This is the third in a series of articles proposing viable pathways for reform, and arguing for renewed collaboration and a common purpose in fixing SA’s public and private health systems. Read more:

For universal healthcare and NHI to succeed, SA needs effective health promotion programmes and institutions

What would it take to turn NHI into universal healthcare?

Brian Currin, an executive director at Concentric Alliance, is an international mediator involved in political consensus-seeking and peace-process facilitation. He writes in his professional capacity and as a co-author of the Section27/Concentric Alliance report. All other authors write in their personal capacity.

Mark Heywood is a co-founder and former executive director of SECTION27 and an adjunct professor at UCT’s Nelson Mandela School of Public Governance.

Tracey Naledi is a public health medicine specialist, an associate professor of public health medicine, the deputy dean of social accountability and health systems at UCT and chairperson of Tekano Atlantic Fellows for Health Equity South Africa.

Krish Vallabhjee is a public health medicine specialist, an adjunct associate professor at UCT’s School of Public Health and a technical adviser to Clinton Health Access Initiative.

Atiya Mosam is a public health medicine specialist and an independent consultant and founder of Mayibuye Health.

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Nuanced perspective

Missed opportunities

Seize the moment