For Now Is The Time For Your Tears.

A couple of decades ago, the American cartoonist Dan Piraro drew something which seemed funneh at the time. It showed a little knot of men in suits wearing construction hard-hats and carrying clipboards squinting at a patch of land while their leader gestures. The joke lay in the caption, which was to the effect of “OK, what we do now is put a fence around this field and dig a big hole, then some people will come and put a building in it and some flowerbeds at the front — all we need now is money”. Back in the 1990s this was a joke; nobody believed that people really behaved like that.
But this is exactly how the National Health Insurance has been treated!
The call for National Health Insurance was raised at Polokwane. Like most of what was raised at Polokwane (apart from doling out jobs for Zuma cronies) it was vague and questionable. What would National Health Insurance entail? (That is, if we dig a hole, what kind of building are they going to put in it?) What effect would National Health Insurance have on the national healthcare crisis? (Unanswerable while the first question went unanswered.)
The answer to these questions seems to be that nobody went to Polokwane with any intention of answering such questions. The idea of National Health Insurance was taken directly from the platform of the American Democratic Party — in other words, it had no connection with anything South African at all. It was presented in an effort to show that the Zuma faction had ideas for solving the South African mess, and that was all. Once it had been safely presented, the idea went back to the bottom of the bottom-drawer of the filing-cabinet in the spare room, along with the used condoms and empty booze bottles, where it belonged.
But then, unfortunately, COSATU began flexing its little muscles. Its leaders began denouncing everybody again, because its membership were not getting any return on all their rhetorical efforts to create a make-believe left-wing policy. Rather than confront this titanic toddler, the ANC and SACP decided instead to distract it by offering it some pabulum. (Note that this did not happen under the relatively sane and coherent leadership of Kgalema Motlanthe, but only burst into prominence like a titanic pustule after the Zuma regime, that empty khanga held up with a strap-on dildo, came into being.) So the National Health Insurance was launched as a solid policy, albeit with no idea what that policy meant. Someone, in the fullness of time, would come and put a building in it.
The person in charge of this is Olive Shisana. Olive was, no doubt, once a worthy person. However she is a darling of the white liberal community, which is always a fatal sign. She earned her stripes by nebulous denunciations of Thabo Mbeki, which ensured that she would be supported under the Zuma administration. Meanwhile, she turned the Human Sciences Research Council into a corporate propaganda organ (admittedly many people working for the HSRC were useless, lazy frauds, but although she fired some of these she imported many, many more and turned the whole institution into a consultancy mill). This rather indicates her favoured path of operations, and indeed it has been so. We do not know what kind of building they will put in the hole, but it will, whatever form it takes, be a “public-private partnership”, meaning a structure devoted to stealing taxpayer’s money and shovelling it into the pocket of businesspeople — like the HSRC itself these days.
“All we need now is money” — yes, indeed, and this is essentially the only thing which Shisana and her hand-picked corporate hand-job team have come up with. They have decided what they intend spending on the thing whose nature and structure is yet to be determined. When you come across any business plan with a series of headings all bearing under them the legend “TO BE DETERMINED” and then you find that there is a very specific number under the “Budget” heading, you should immediately put both hands in your pockets and walk away very fast. Unfortunately, because this process is not under our control, we can’t do that; Zuma’s hands are both in our pockets and our ankles are chained to an immense iron ball with the logos of all of South Africa’s Medical Aid Schemes embossed on it in platinum letters.
The amount of money required by Shisana & Cie Plc Gmbh dot-com is a fairly large sum. In 2012 it is supposed to be of the order of R120bn. By 2020 it is expected to rise to R250bn. That is, presumably, annual sums. The former figure is approximately 5% of gross domestic product. The latter figure is approximately 10% of gross domestic product. At present, the government’s Health budget is 3,4% of gross domestic product. Therefore, National Health Insurance will raise the cost of state-sponsored healthcare by 47% over two years, and by no less than 194% over ten years.
That’s a lot of moolah. It is, proportionately, a greater spending commitment, by 2020, than the U.S. military budget at the height of the Cold War in the early 1960s. It is much more than the military budget of the apartheid state at the height of apartheid’s dirty wars. Supposedly, we are going to finance this through increased taxation, and one of the original suggestions raised has been that the poor can be made to pay for it by increasing VAT.
Before we say that this is unaffordable, we must notice that it is perfectly affordable provided that it offers enough benefit to the state system. What the system will do, for instance, is to include the entire current medical-aid system, which entails a large part of South African healthcare for the affluent, into one national system into which all private medical aids will feed. The difference is that everybody will be paying for this, not just the affluent. Particularly, middle-class people will be subsidising the healthcare of the rich as well as of the poor, unless the poor are compelled to subsidise healthcare through VAT, in which case the poor will be subsidising middle-class healthcare as well as healthcare for the rich.
Put that way it doesn’t sound like a very good idea.
There are at present three healthcares in South Africa. There is the extremely expensive, extremely well-funded private healthcare. There is the rather expensive, decidedly ill-funded public healthcare provided in cities and towns. And there is the extremely cheap, desperately underfunded public healthcare provided in villages. The idea of the National Health Insurance is that these three completely different systems, with completely different purposes and different histories, should all be folded into one system funded from one source. This is not exactly like the unification of the different education departments of apartheid South Africa, because they all derived from the same origins and had really been funded from the same source even though their mission statements and structural systems pretended otherwise. What Shisana’s gang are proposing to do is much more like the reunification of East and West Germany. We all remember how quickly that was completed, how cheap the process was to pursue, and what a triumphant success it ended up being.
How is all this going to be done? It appears that the start of the process, which seems sensible enough, would be to revitalise rural primary healthcare. One feels nostalgia for this, because it was what was attempted by Nkosazana Dlamini-Zuma during her five-year term as Minister of Health. However, the whole plan was destabilised firstly by GEAR, which forced cutbacks in new infrastructure and new staff hires, and then by the campaign against Dlamini-Zuma which led to her replacement by Tshabalala-Msimang — a much less dynamic figure — and then by the need to divert funds into the gigantic AIDS treatment programme. After all this there was nothing left for rural primary healthcare. So, it seems like a welcome and sensible manoeuvre to plough funding into rural primary healthcare.
But that’s not going to be sorted out by 2012, which is when the system is supposed to come into operation, when the South African government will assume responsibility for all funding of all healthcare activities, both public and private, in the whole of South Africa. And when there will undoubtedly be a critical financial shortfall, because there always are in these projects — because the initial funding proposals are always underestimates so as to lure people into committing themselves. But, incidentally, it is quite likely that 2012 will be a recession year which follows four years of increasing budget deficits, so that suddenly National Health Insurance will feel like a drain on the fiscus equivalent to the bottom falling out of the money bucket. How is this to be met?
At that stage, the biggest single budget item will be the health budget and the biggest portion of it will be National Health Insurance which will constitute virtually the whole of the health budget. There would be screams if education, policing or social services were significantly cut. Cutting any of these would entail cutting existing, well-established programmes with powerful backers in politics and the trade unions. In that case, would it be possible to cut back cautiously on the health budget itself?
Obviously, not on the section of the health budget funding the big rich urban medi-clinics. Those are the hospitals to which the political and commercial elite go. What about the section of the health budget funding the big impoverished urban public hospitals? But those are the hospitals where NEHAWU and MASA members work. Furthermore, those are the hospitals to which members of active ANC branches with contacts in the Zuma administration are likely to go if they can’t afford the big rich urban medi-clinics. Those are also the hospitals at which the media and the DA point the figure when they fail, and it would be extraordinarily bad politics to slash their funding for they would then have cast-iron excuses for their failure.
So, in that case, it would be logical to put the recapitalisation and expansion of rural primary healthcare on ice, to save a few billion a year by not finishing the new clinics, not providing the additional staff, and not supplying the public transport which people in rural areas need to get to clinics which may be 20 or 30 kilometres from where they live. Rural people are not going to vote DA, and rural clinic staff, even if they belong to NEHAWU or DENOSA, are in no position to toyi-toyi where the TV cameras are watching, nor do any journalists venture so far away from the tarred road.
It is thus a 10-1 bet that National Health Insurance will not serve the interests of the rural poor, and will thus not actually improve access to healthcare.
Of course, it may improve access to healthcare in urban areas. The very poor living in the cities will all have their National Health Insurance cards with which they will be able to travel to the underfunded urban public hospitals. (It is virtually certain that they will be referred to these rather than to the well-funded urban private hospitals.) That could be an improvement — although, of course, those are the hospitals to which they try to go anyway, pleading desperate poverty, and this is why those hospitals are so understaffed, underequipped and underperforming. But now they will do it with National Health funding, which will presumably be directed to the hospitals through the National Health Insurance system.
How will that funding be directed? You arrive at Castro Hlongwane General, with, let’s say, a simple broken arm. A broken arm requires X-rays, setting, a day or so’s observation and medication, and then release with a later appointment for examination and removal of any cast, stitches, etc. You can work out how much that costs and set a flat fee for a simple broken arm which is paid to any hospital wherever it is. But in that case, with a flat fee, any hospital can gain extra money by just doing as little as possible. Why have more than one X-ray? Why provide unnecessary medication? Why not just wrap the arm in bandages to immobilise it? (That was how the Creator’s paternal ancestor on Earth lost his leg through gangrene.) Then the doctor in charge can afford a Porsche instead of a Mazda.
Alternatively, the NHI can make allowances for probably lousier care at Castro Hlongwane General as opposed to the Mamphele Ramphela Medi-Clinic, and therefore provide lower subsidies to the former than to the latter for the same treatment. But in that case, Castro Hlongwane will continue to be subsidised at a lower rate than Mamphele Ramphela, and in consequence the township-dwellers will continue to get the shitty end of the stick as compared to the gleaming cleanliness of the suburbanites.
The whole thing will be controlled by the National Health Insurance system, with the Ministry of Health reduced to a body transferring the funds provided by the Treasury to the NHI, which will be essentially an organisation of administrators, bureaucrats and accountants. Therefore, this body will stand between any healthcare programme desired by the government, and the situation on the ground. This body will also consist almost entirely of people who go to suburban private hospitals. It isn’t hard to guess what their funding priorities would be, and it isn’t hard to see how difficult it would be for the Ministry of Health to order them to do anything else, even if it wanted to. Or, as Steve Earle put it, “accountants wielding scalpels and counting out the pills”. An enormous bureaucracy whose purpose is to ensure that someone else’s money is sent to the places where the bureaucracy wants that money sent, with no reference to public need, since the bureaucrats are neither elected nor responsible in any other way.
The place to have started would have been to try to get the actual health service right, of course. But that wouldn’t have made money for the system. The pretense is that the NHI is modelled on the British National Health Service. Actually, the NHI is modelled on what New Labour has tried to turn the NHS into. It looks like being a cracking success for the accountants.

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