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

Zingiswa Losi
By Zingiswa Losi
27 Jul 2023
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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

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