Don’t exclude foreign nationals: Universal health coverage in South Africa

South Africa’s two-tiered health system based on wealth inequities must end. The concepts of the rich subsidising the poor, the young the old, and the healthy, the infirm or ill are lauded as sound principles on which to deliver health to our people. Let us not perpetuate a two-tiered health system by gating foreign nationals from the right to health and universal health coverage in its totality in South Africa. We support universal health coverage and a financing mechanism that eradicates the way we deliver health in South Africa.

The National Health Insurance (NHI) has gone on a circuitous journey from its original, much-heralded vision of ensuring universal access to healthcare. Now there are signs that the NHI — in the form of the NHI Bill of 2018 and the language of the teams charged with designing implementation — has the potential not only to be hijacked by commercial interest groups, but is tumbling down the slippery slope of xenophobia, as it pertains to those who are eligible as beneficiaries.

In recent months there have been a number of xenophobic attacks on poor foreigners and township foreign traders. In each instance the xenophobia — the hatred of foreigners — has been prompted by rival interest groups who do two things — first, they are selective as to which foreigners to hate and second, they couch their actions in terms of something that appears to be universally acceptable.

When the crowds attacked Somali traders in White City, Soweto in August they were prompted by assertions from rival township traders and their commercial backers that Somali traders were selling food that was past their sell-by-dates.

There were no equivalent mobilisations when the listeriosis outbreaks were found to be causally linked to well-known brands of processed meat nor were there violent attacks on supermarkets selling American chicken products that were dumped on the South African market after being embargoed elsewhere — it was all handled politely by our Department of Trade and Industry as part of the ongoing African Growth and Opportunity Act negotiations with the US.

So the point about xenophobia is that it is recognisable by the following characteristics:

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  It is the selective targeting of poor foreigners and foreigners from poor, African and other communities in the global south;

  
  


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  It is not some kind of primordial attitude in all of us, but is invariably driven by vested interests for whom the presence of these foreigners poses economic threats;

  
  


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  It is a phenomenon that dare not speak its own name… so it couches itself in the language of “standards to be maintained” or some public interest.

  
  

Overseas the refrain from unscrupulous politicians is that foreign nationals “take our jobs”, whether this is about Polish workers in Britain, Syrian and North African refugees entering Europe or Mexicans in the US.

Now in South Africa, there has been a variation on this theme in recent years and this has to do with foreigners taking “our hospital beds”. Anecdotes of major hospital labour wards being “filled with foreigners” have thoughtlessly become part of the narrative of what drives the health crisis and is even creeping into the policy language of the National Health Insurance (NHI) in 2018.

When the NHI was first mooted in a Green Paper in the early 2000s it was seen as a set of reforms in healthcare that would ensure universal access to healthcare. It would do so by generating a pot of money from forms of taxation of employers and the employed — which sum of money could be used to procure medical services and drugs from both the public and the private health systems, without people paying out of pocket up front or having to pay to belong to a medical aid scheme.

Straight away there was a brouhaha from a variety of vested interests — let’s say on the right side of the political spectrum — on the one hand, and from health and social justice activists — let’s say from the left side of the spectrum — on the other. From the latter side the NHI was criticised for its modesty and for leaving the private hospital firms and medical aids untouched and not ensuring the necessary investment to improve the public healthcare system first.

The attacks on the NHI from vested interests — the medical aids lobby, private doctors, private hospital companies — stirred the pot of anxiety of the wealthy and the middle classes for whom the fear was that universal healthcare access would cause overcrowding and lower standards. The state of public healthcare was used as a bogeyman to scare public opinion, as is now the case with the narrative that foreigners and overpopulation are causing the crisis in the public health system.

The fingering of foreign nationals and their so-called “abuse” of the healthcare system is a superficial analysis of the drivers of the crisis in healthcare and is a dangerous narrative that feeds into the overall narrative of xenophobia that is engulfing the country.

In many quarters the crisis in the public healthcare system gets blamed on overcrowding — as if the poor are to blame for their own health misery. But there is no justification for the xenophobia — albeit disguised under the concerns about the affordability of the NHI — saying that South Africans are simply over-populating and foreigners are crowding our hospitals.

The facts tell a different story…

The collapse of health services is foremost due to the poor leadership, governance and management, the lack of well trained and supported human resources, ageing and dilapidated infrastructure, inadequate financial planning and the under-resourcing of the public sector in part due to tight fiscal policies and the favouring of private sector investment. This has been compounded by the looting of state coffers, especially over the last decade.

And the 2014-2016 Triennial Report on Perinatal Mortality in South Africa tells us that South Africa’s birth rate is in decline. There has been a year-on-year decrease in the total number of deliveries since 2012.

Against this the population has now risen to 57 million, largely, the data shows, because there has been a slow but sustained decrease in all important mortality areas over the past three triennia.

Of all deaths recorded on the Perinatal Problem Identification Programme in South Africa, 98.1% of babies are born alive and of these 98.9% survived until discharged from hospital.

This debunks the notion that South Africans are making too many demands on public services by a growing population. The increased demands are coming from our protracted demographic transition and our quadruple burden of disease: the demands of managing chronic ailments attributable to non-communicable diseases such as hypertension and diabetes; maintaining our important antiretroviral programme and controlling tuberculosis, as well as attending to the collateral damage of violence and injury that fill up our emergency rooms.

It is important for all health workers to remind themselves of the higher calling in the ethical prescripts of their professions and to remember that they have an obligation to practise their professions to the highest standards possible.

The needs of the patient that is in the emergency room, labour ward or hospital bed in front of you must come above all else and personal prejudice and preference or how a health system is financed must be put aside.

But far from the government itself taking an unequivocal leadership stance against the xenophobia narrative emerging, the latest incarnation of the NHI — the 2018 NHI Bill — seems to stray into accepting the xenophobic blame game.

In terms of the NHI Bill, the fund created to deliver healthcare has restrictions on those who can access it:

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   You need to be a South African citizen or a dependant of a citizen, as defined in the South African Citizenship Act, 1995; or

   
   


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   You need to be a permanent resident or a dependant of a permanent resident in South Africa as defined by the Immigration Act and documented in the population register by the Department of Home Affairs; or

   
   


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   A child over 12 and below 18 who has not been registered as a user; or

   
   


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   An inmate as provided in section 12 of the Correctional Services Act.

   
   

If you happen to be a refugee or asylum seeker who does not have refugee status as defined in the Refugees Act, you only have a right to:

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  Emergency healthcare services;

  
  


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  Services for notifiable conditions of public health concerns;

  
  


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  Paediatric and maternal services at a primary healthcare level.

  
  

Does this mean that a child of a foreigner who presents with pneumonia, who requires admission to hospital for intravenous antibiotics and oxygen or requires ventilation, will only be entitled to receive primary healthcare, which essentially translates into out-patient care and oral antibiotics?

Or if a foreign woman in labour requires a caesarean section, or high/intensive care for pre-eclampsia, will she languish in facilities not equipped to manage complicated labour, and not triaged as is the norm?

Or if a foreigner or their child has cancer, referral for radiation therapy, surgery or chemotherapy may not occur?

The NHI is silent on the triage into care beyond primary healthcare for foreigners with no status in our country and this needs to be urgently clarified if the intent is to implement protocols to avoid exclusion of services.

The NHI Bill states that people seeking health services from accredited health services must be a registered user of the fund and must present proof of such registration to secure healthcare. Does this mean exclusion if you are not registered, even in emergencies?

There is the perpetual fear that street-level bureaucracy imposed by clerks or other gate keepers at primary healthcare level will impose restrictions on foreigners, those who have not been accredited or those who have no evidence of accreditation on hand. Assurance is needed that the basic tenets of universal health coverage will be employed to all those seeking care.

And then to compound the sin of latent xenophobia, the 2018 NHI Bill inverts means and ends: It abandons the goal of equity contained in the language of commitment to universal access to healthcare — and speaks the language of the NHI being essentially a fund.

It has been noticeable how since the Green Paper stage there has been quite a shift from many of the vested interest anti-NHI lobbyists — from hostility to enthusiastic acceptance. Much of this shift has been prompted by a new readiness to embrace the policies of these erstwhile critics.

This shift was noted by retiring UCT Professor of Public Health, Di McIntyre, who remarked in her valedictory retirement speech in 2018 that the latest NHI Bill has made a “180 degree turn”.

Dr Louis Reynolds of the People’s Health Movement – one of several health activist groups calling for more time for public submissions on the NHI Bill — has been even more explicit:

“If composed as the National Department of Health proposes, these bodies (whose central task is to shape our future health system) will be dominated by powerful groups with vested interests in healthcare: the corporate private sector, technocrats, and other special interest groups — medical schemes, the Actuarial Society, private hospitals, academic and research organisations, and elite professional associations. Key constituencies have been left out. Community health workers and nurses — the backbone of the primary healthcare system that forms the foundation of the NHI — are excluded. Civil society is included in only one group.

Why does the department’s establishment of these structures to assist the “implementation” of the NHI in this way represent a retreat from constitutional principles and values fundamental to the NHI?

Furthermore, the new structures’ terms of reference appear to be full of contradictions; the NHI that emerges is not the NHI that the department envisaged originally. For example, every version of the NHI policy including the final White Paper has been clear about the need for a single payer system of financing. Yet, by some sleight of hand, the ToR of the National Advisory Committee on the Consolidation of Financing Arrangements (one of the new structures) prioritises mandatory medical scheme membership for people in formal employment.”

The NHI has indeed shifted — from its claimed goal of equity and universal access — to becoming the sum of the concerns of various commercial groups, while excluding the most vulnerable and alienated foreign nationals.

This shift includes ignoring the concerns of health activists, researchers and academics who have entered the debate on the side what critics on the left have long identified as an essential problem with the original conception — the failure to prioritise bolstering and radically investing in and upgrading the public healthcare system to ensure that it could be accredited as a provider of quality health services.

The fact that only six public hospitals have been accredited by the Office for Health Standards Compliance requires urgent attention to avert the continued degradation of our health system. Similarly, the pilot projects commissioned since 2011 have shown how much leeway still exists in ensuring that the public healthcare system is functional enough to implement the NHI.

This attention to the detail of what would be required to ensure that the public healthcare system is fit for purpose has been a recurring theme among academic research groups and other well-meaning groups.

But one man’s meat is another man’s poison… the crisis in the public health system can mean that the NHI becomes a vehicle for a new scale of money-making — for medical aids, private commercial health and drug companies and private hospital monopolies.

In this veritable gold rush to now welcome the NHI as a site for accumulation, what is also coming through are vested interests for whom playing the “lets defend South Africans first” card is the slippery slope tumbling into xenophobia.

This is extremely ironic for South Africans, an irony noted by many commentators, who have drawn attention to the solidarity and support given by many African countries to host our exiled liberation movements.

But there are many other reasons which often escape comment.

Two important ones are, first, that disease and pathogens know no political boundaries and, consequently, nor do the health interventions required to address disease.

And, second, this country was built by foreigners from all over southern Africa who worked the gold mines on which this country’s industrial and social infrastructure is built. It is for these reasons that our Constitution makes no distinction in the Bill of Rights between South African citizens and foreign nationals who reside within the boundaries of the Republic of South Africa.

We need to emphasise the adverse implications of continuing a narrative that systematically disenfranchises foreign nationals and ensure that universal health coverage is just that: a healthcare system that knows no boundaries. DM

Glenda Gray is the president of the South African Medical Research Council, Fareed Abdullah is the director of the Office of HIV/TB Research at the SAMRC and Leonard Gentle is a consultant