1

Universal health care in southern Africa

Policy contestation in health system reform
in South Africa and Zimbabwe

Edited by
Greg Ruiters and Robert van Niekerk
 Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Introduction
Inequality and health systems in context . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Greg Ruiters and Robert van Niekerk

PART 1: UNIVERSAL HEALTH COVERAGE: THE BATTLE OF IDEAS . . . . . . . . . . . . 19

Chapter 1
Competing policy choices and the debate on national health
insurance in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Greg Ruiters, Shepherd Shamu, Robert van Niekerk and Di McIntyre
Chapter 2
The historical roots of a national health system in South Africa . . . . . . . 41
Robert van Niekerk
Chapter 3
Health policy reform in the last days of apartheid and the dilemmas
facing the ANC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Robert van Niekerk

PART 2: HEALTH CARE IN SOUTHERN AFRICA . . . . . . . . . . . . . . . . . . . . . . . 65

Chapter 4
Public and private health care in southern Africa . . . . . . . . . . . . . . . . . . 67
Greg Ruiters
Chapter 5
The growth of private health care in Zimbabwe up to 2008 . . . . . . . . . . 82
Elijah Munyuki and Shorai Jasi
Chapter 6
Medical aid societies and equity in Zimbabwe, 2008–11 . . . . . . . . . . . . . 97
Shepherd Shamu, Rene Loewenson, Rangirirai Machemedze
and Auline Mabika

PART 3: PRIVATISED HEALTH CARE IN SOUTH AFRICA . . . . . . . . . . . . . . . . . . . 119

Chapter 7
The growth of the private health sector in South Africa
up to 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Yoswa M. Dambisya and Sehlapelo I. Mokgoatsane
Chapter 8
The political economy of the health industry and the private
health funding crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Di McIntyre

PART 4: THE WAY FORWARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Chapter 9
Proposals and prospects for national health insurance in
South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Di McIntyre
Chapter 10
Lessons from international experience for national health
insurance in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Di McIntyre
Chapter 11
Towards universal health coverage in southern Africa . . . . . . . . . . . . . . 186
Greg Ruiters, Di McIntyre, Rene Loewenson and Robert van Niekerk

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Inequality and health systems in context 1

INTRODUCTION

Inequality and health systems in context

Greg Ruiters and Robert van Niekerk

IN SOME DEMOCRATIC countries, the right to a healthy life and healthy

environment are entitlements of citizenship. This is also the case in post-apartheid
South Africa, where these rights were written into the 1996 constitution. The
former national liberation movements that have risen to power in South Africa
and Zimbabwe have long held strong social democratic and universalist views.
Despite having implemented neoliberal structural adjustment policies, their
approaches to health policy cannot be divorced from their broader ideas about
social inequality and legitimate privileges.
At its national policy conference held at Polokwane in Limpopo in December
2007, the African National Congress (ANC) – the dominant member of the ruling
Congress Alliance – returned to its earlier left-of-centre policy orientation. Its
members had begun to criticise the compromises struck at the constitutional
negotiations in 1993, and the slow pace of change under former president Thabo
Mbeki (Ruiters 2011). Regarding health policy, the ANC argued that the increasing
disease burden, caused by poverty, high levels of unemployment and apartheid
backlogs in service delivery and worsened by the HIV and AIDS pandemic, had
put extreme pressure on public health facilities and their staff, while the private
health system had become less affordable. Having exhausted their annual
allocations by mid-year, members of medical aid schemes who could not consult
private practitioners or be treated in private hospitals were thrust back onto the
public health system (Mkhize 2009).
Against this background, the conference resolved that education and health
should be key priorities, a national health insurance (NHI) system should be
implemented, a reliable single health information system should be developed,
the government should intervene in the high cost of health provision and the

1
2 Universal health care in southern Africa

ANC should explore the possibility of a state-owned pharmaceutical company

that would help to curb medicine prices. It also resolved that the revitalisation of
public hospitals should be accelerated, among others by ‘innovative solutions
that accommodate partnerships’. However, it resolved that ‘caution should be
exercised when deciding on PPPs [public-private partnerships] as a solution for
the delivery of health services’ (ANC 2007).
In January 2009, a major article on NHI in ANC Today stated that the 2007
resolutions:

Acknowledge that the South African health system has challenges that
can only be addressed through a comprehensive transformation of the
system. The implementation of the national health insurance plan means
transformation of the funding model for health as well as reorganisation
of health care delivery. Universal access to health services can only be
achieved through a simultaneous and two-pronged approach. First,
significantly strengthen the public sector so that it becomes the provider
of first choice. Second, design mechanisms for ensuring that scarce and
critical health service resources in both public and private sector are shared
and optimally used by all to maximise social value.

In November 2009, the Minister of Health, Dr Aaron Motsoaledi, announced a

25-member Ministerial Advisory Committee on NHI, tasked with advising the
Ministry on formulating and implementing NHI policy. In August 2011, the
Department of Health released a Green Paper entitled ‘NHI for South Africa’.
It notes that South Africa is in the process of introducing an innovative system
of health care financing ‘with far-reaching consequences for the health of South
Africans’. NHI will ensure that everyone has access to appropriate, efficient and
quality health services. It will be phased in over a period of fourteen years, and
will entail major changes in service delivery structures as well as administrative
and management systems (DoH 2011: 4).
According to the Green Paper, the South African health system is divided
between a well-resourced private sector serving a minority of the population and
a poorly resourced public sector serving the majority. As a result, the health
system is inequitable, with a privileged few having disproportionate access to
health services. ‘This system is neither rational nor fair. Therefore, NHI is intended
to ensure that all South African citizens and legal residents will benefit from
health care financing on an equitable and sustainable basis’ (DoH 2011: 5).
Inequality and health systems in context 3

Against this background, this volume examines private health care and health
financing in South Africa and Zimbabwe. These two countries have the largest
private medical sectors in sub-Saharan Africa. In Africa as a whole, private medical
aid schemes cover only 1 per cent of the population. In 2006, the Board of
Healthcare Funders (BHF) reported that there were 108 private medical aid
schemes in South Africa, 20 in Zimbabwe and nine in Namibia.
The role of the private sector in South African health care is well known.
However, Zimbabwe is also characterised by a system of highly fragmented medical
aid societies, which (unlike their South African counterparts) have themselves
become direct providers of health care as well as owners of hospitals, pharmacies,
training systems and emergency transport services. In this country, mandatory
national health insurance has been discussed for three decades without any
conclusion being reached or any new system implemented. This option, which is
now being implemented in South Africa, needs to be revisited as the economy
stabilises and confidence in governance improves. In both countries, sound health
care is becoming more and more expensive, moving increasingly beyond the reach
of ordinary citizens (see Chapter 9). Those still able to pay for membership (about
15 per cent of South Africans and 10 per cent of Zimbabweans) belong to one of
the many fragmented private medical aid schemes.
The NHI system proposed for South Africa aims to provide all South Africans,
regardless of socioeconomic status, with access to affordable, efficient and good
quality health care (DoH 2011: 4). Moreover, Motsoaledi has stated that health
care reform should realise the principle that health is a public good and not a
commodity (Motsoaledi 2011). In this context, major features of the proposed
scheme are universal access to a basic package of services for both the rich and
poor, increased funding for the public health sector and pooled resources for the
health sector as a whole, all aimed at creating a common institutional platform
for improving health outcomes. According to the Green Paper, NHI will improve
the nation’s health. Healthy people are more productive and live longer, which
will help the economy in a number of ways. Less money spent on health care
means greater demand for other goods and services.
Perversely, the growth of private health care during the 1980s was driven by
the cash-strapped apartheid state on the one hand, and corporate capital,
particularly the Rembrandt Group (which has major tobacco interests) and the
mining houses on the other hand. The new for-profit general hospitals that sprang
up throughout the country drew doctors and nurses away from the public sector.
In the early 1980s, 40 per cent of all doctors worked in the private sector; a
4 Universal health care in southern Africa

decade later, 62 per cent of general doctors and 66 per cent of specialists had
shifted to the private sector. In 1985, ‘over 85 per cent of the white population
was privately insured . . . but only eight percent of blacks held private insurance;
their coverage also tended to be less comprehensive’ (Naylor 1988).

The public good and universalist social policies

Public goods are not defined only in physical and technical terms (see McDonald
and Ruiters 2012 for a critique of technical neoclassical definitions), and the
boundary between public and private goods varies from one country to another
and also over time (Nathanson 1996). Public goods can range from public
broadcasting to the nationalisation of various economic sectors as well as financial
bailouts aimed at reducing economic uncertainty (as in the United States in the
recent past). Feminists, too, have broadened the idea of public goods to include
households – a traditionally sacred ‘private’ sphere (Mohanty and Miraglia 2012).
Ultimately, public goods help to deepen social cohesion and give substance to
the democratic process, since markets will do so unequally and in ways that distort
the general interest and impede social cohesion. The contributors to this volume
support the idea that unified public delivery systems will help to build better
societies and more sustainable democracies. But good policy design is essential.
In recent years, policy analysts have stressed that the design of public policy
carries implicit messages and is crucial for the formation of public arenas and
citizenship identity (Ingram and Schneider 2010). Well-designed public delivery
systems based on collective, universal provision are fundamental to citizenship
formation and enhanced democracy. As noted by Ingram and Schneider in the
Oxford Handbook of Public Policy (2010: 178–9):

Policies carry messages by socially constructing the intended targets in

positive and negative terms . . . different targets for policy are treated
differently and come away with distinct identities as citizens and sharply
contrasting orientations to government . . . [T]hey implicitly signal who is
important to national welfare and who is not . . . result[ing] in two-tiered
citizenship.

In contrast to the neoliberal approach, public policies based on inter-class solidarity

between the poor / working classes and middle classes deepen a sense of trust and
a shared fate, both nationally and internationally, and promote dignity, inclusive
citizenship and social cohesion (Deacon 2010; Van Niekerk 2011).
Inequality and health systems in context 5

NHI promises to be the ANC’s most important universalist policy yet, signaling
a shift towards a politics of solidarity that does not separate the poor from the
rich. If the overall goal of post-apartheid South African public policy is social
integration, dignity and reduced social apartheid, we need to ensure that the
interests of the middle class (black and white) are served by inclusive public delivery
systems. The proposed NHI scheme constitutes a shift away from the targeted
poverty alleviation approach, which has been the stock in trade of the past three
decades of neoliberal policy design (including the Millennium Development Goals),
and treats the poor as a residual problem, towards a more inclusive approach.
The current two-tiered health citizenship reflects South Africa’s ongoing social
fragmentation, lack of national social cohesion and residual apartheid mentality.
It also reflects a continuing bias towards privatisation as well as continued support
for the idea that the state is incapable of sound service delivery. The implicit
message is that the poor majority should continue to seek (inferior) health care
from the state, while the wealthy minority should avoid the state and purchase
(superior) private health services.
Contrary to this segregated conception, a well-functioning and rational health
system can be defined as a cohesive set of policies, processes, actors and co-
operating institutions delivering high-quality health services to all people, when
and where they need them. Policy for national health instruments such as NHI
need to stimulate the power of civic claiming, provide effective accountability
mechanisms and prepare for resistance from hostile interests groups, including
street-level bureaucrats who might seek to thwart the policy’s intentions.
We argue that the success of an NHI scheme can be eroded by an unregulated
and aggressive private sector that sees patients as commodities and competes
with the public sector. There is more to a health system than technical, material
and human resource issues. Entrenched but narrow economic groupings such as
insurance companies, private hospitals and pharmaceutical corporations skew
the system away from prevention, introduce structural irrationalities and increase
social costs so that wider national imperatives are compromised (Leys 2001).
Exclusionary forms of privatised service delivery may be vociferously defended
by mobilised middle-class elements (in the South African media, for example)
and the wealthy may even – in the name of constitutional rights to ‘free’ choice
and anti-statist market fundamentalism – reject calls to impose larger or perhaps
more public rationalities (see Chapter 1).
The dominant anti-statist neoliberal mindset with its bias towards privatised
services tends to measure success and efficiency in narrow terms, which understate
6 Universal health care in southern Africa

collective interdependencies and hide broader costs in terms of a lack of social

cohesion and trust between citizens (Elson 2004). The privatisation bias, as Elson
calls it, ‘has profound and disturbing implications for the organisation of social
reproduction . . . [it] ignores non-market costs [and] . . . implies a false economy’
(2004: 71). The much-vaunted ‘rollback of the state’, which has been impossible
to realise (Poggi 1990) and has in fact failed spectacularly, as demonstrated by the
2008 financial crisis, has been inimical to social cohesion.
Political cultures and social values are vital to the way in which a nation
formulates and implements policies (Dobbin, cited in Nathanson 1996). In
countries such as the United States and South Africa, which share an affinity
with privatised health, public sector agencies are more decentralised, thereby
making policy implementation more cumbersome than in centralised states such
as France (Kitschelt 1986: 64). In those two countries, health is a contested terrain
with many powerful interests trying to maintain its status as legitimate businesses;
and promoting the political culture that health is a private responsibility and that
the state must leave it to individuals to make choices. In South Africa the pro-
private health lobby believes it is efficient to use more than half the country’s
health resources (human and physical) to serve 16 per cent of the population.
However, the neoliberal mantra of ‘free choice’ has increasingly been challenged
by those who put social cohesion, substantive democracy and social policy at the
forefront of development strategy (Chang 2004; Elson 2004).
Harvey observes: ‘[R]esidential areas provide distinctive milieus for social
interaction from which individuals to a considerable degree derive values,
expectations, consumption habits, market capacities and states of consciousness
. . . linked to a whole set of attitudes, values and expectations as well as distinct
skills’ (1989: 118).
Social welfare and other elementary services to the poor have conspicuously
failed to change the racially determined spatial structure of South Africa’s cities
and towns and inequitable access to its public services. As Arrighi (2007) explains,
the particularity of South Africa lies in the spatial isolation and extra burdens
suffered by black workers confined to life in township ghettoes; this form of
reproduction of labour has contributed to making South African workers among
the cheapest but also among the most unskilled and unproductive in the world.
Jeremy Cronin, Deputy General Secretary of the South African Communist Party,
has similarly argued that spatial separation remains in place and continues to
reinforce inequality and exclusion:
Inequality and health systems in context 7

In 15 years of democracy, we have failed to transform the spatial patterns of

apartheid. Our social geography continues to reproduce grotesque levels of
racialised inequality and separation. Where you live determines what education
you are likely to get, what possibilities you have of future employment . . . We’ve
abolished pass laws, influx control and group areas, but a grossly inequitable
property market continues to separate poor from rich with as much severity as
any apartheid-era pass office functionary. Throwing more deliverables at
townships will not, by itself, transform these spatial realities.1

In short, in the ‘new’ South Africa little has changed in the social geography of
race and class. The middle class has walled itself off from the poor who experience
unemployment, overcrowding, bad roads, pollution from indoor fires and long
travel times – a system of compounded dis-welfares. These remain specific features
of the punishing and shortened lives experienced by blacks in townships and
rural areas (SACN 2003). It is impossible to find a private hospital or decent
amenities in most townships, which were designed as a solution to the ‘native
question’ (Mamdani 1996) and as dormitories and places of confinement
(Robinson 1995). Therefore, social and health citizenship cannot be discussed
without referring to the ongoing re-segregation between black townships and
informal settlements subject to faltering public services on the one hand, and the
largely white suburbs marked by the growing privatisation of services and space
on the other hand.
As suggested in this volume, to break down this culture of exclusion and
replace it with one of a sharing of space will require a number of interventions –
including the building of an integrated health system in the place of the existing
two-tier system. The NHI, as Mooney notes, ‘must be part of the South African
social fabric’ (2011). New ways of overcoming apartheid spatial legacies alongside
major improvements in housing, water supply and working conditions, and access
to a more rational and effective health care system focused on reinforcing the
confidence and capacity of the poor to make claims, need to be explored and
advanced.

The social context of privatised health care

In Zimbabwe, health care is split between the public and private sectors (including
a number of non-profit mission and non-governmental organisation [NGO]
facilities, which in health policy literature are generally regarded as part of the
private sector). The government owns about 70 per cent of health facilities, while
8 Universal health care in southern Africa

the private sector (as defined above) owns about 30 per cent. There are 30 medical
aid societies in the country, covering about 10 per cent of the population of 13
million who can access private for-profit facilities (AHFoZ 2009). Ten of these
schemes are restricted to employees of particular firms, while the rest are open to
anyone. Unlike their South African counterparts, though, Zimbabwe’s medical
aid schemes have been allowed to acquire hospitals, pharmacies and laboratories,
which permits them to directly control these facilities and services as part of their
managed health care plans. Levels of infant mortality (58 per 1 000 live births)
and life expectancy of close to 50 years are similar to those in South Africa.
Health system reforms are often compared across countries, but each country
has its own sets of institutions, historically conditioned forms of citizenship
segmentation and denigration, and specific ways of constructing social problems,
public issues and solutions. In South Africa and Zimbabwe, both former colonies,
spatial segregation shielded white settler communities from experiencing the
poverty of the black majority, or sharing a common fate. It profoundly distorted
ideas about whose interests counted as public interests, since only white privileges
mattered. The ongoing inequalities in the distribution of infrastructure and the
existence of racially isolated, vastly unequal residential areas have sustained such
social and ethical distancing and made it very difficult to set a common public
policy agenda. The politics of universalism means that the middle class needs to
be brought back into public services.
South Africa remains an extremely unequal society, marked by huge disparities
in wealth between a largely white privileged minority and a largely black poor
majority still forced by financial circumstances to live in risky and less healthy
living spaces and to undertake the most dangerous and menial jobs.

The poorest 20 percent of the population earns about 2.3 percent of

national income, while the richest 20 percent earns about 70 percent of
the income. As a result, South African society is as divided and unequal
today as it was at the transition to democracy, and even under apartheid
(National Planning Commission 2011: 9).

Life expectancy at birth is 49 years, up from 42.45 in 2007, but down from 51.1
in 2000, and is the fifth worst in the world. The only countries in the region with
worse figures are Swaziland (48.66) and Angola (38.76).2 According to one estimate,
the life expectancy of white and black South Africans differs by more than
20 years (SAIRR 2009). The life expectancy of white women is 50 per cent longer
Inequality and health systems in context 9

than for black women (Coovadia et al. 2009).The infant mortality rate (deaths in
the first year per 1 000 live births) has improved from 58.8 in 2000 to 43.2 in
2011, but remains far worse than the figures for Zimbabwe (29.5) and Botswana
(11.4), and places South Africa among the worst 25 per cent of countries in the
world.3 Infant mortality rates differ markedly across race groups, from 7 per 1 000
live births among whites to 67 per 1 000 live births among blacks – a difference
of no less than 900 per cent (Coovadia et al. 2009). Mortality of children under
five per 1 000 live births is 61.9, down from 81 in 2003, but virtually the same as
in 1990.4
The efficacy of the post-apartheid state has been reduced by inherited socio-
economic problems, the limits of the negotiated political settlement involving a
quasi-federal governmental structure and self-imposed problems such as the current
elite use of the state and black economic empowerment as vehicles for rapid
capital accumulation. The medical-business complex (comprising pharmaceuticals,
private hospital groups and medical aid schemes) is also a prominent feature of
South Africa’s health landscape. By the mid-2000s, Coovadia et al. (2009) argue,
‘these capitalist institutions ha[d] influenced the political economy of South Africa
and its health system to a greater extent than in most other post-colonial African
and Asian countries’. Moreover, they are defended vociferously by white privileged
groups and members of the new black middle classes, such as Mamphela Ramphele
(and almost all the eminent ANC political families with investments in private
health). Ramphele, ex-director of the World Bank and vice-chancellor of the
University of Cape Town, has warned against ‘destroying the private [health]
sector’, suggesting instead the need to ‘leverage what the sector has to offer’.5
The private health care system itself has begun to play a major role in
reproducing class and racial inequality. Together with private education, private
security and so on, it has played a major role in perpetuating social apartheid.
South African society remains extremely unequal, yet it has one of the world’s
most commercialised health systems (McIntyre et al. 2004). Forty-four per cent
of money spent on health care is spent on medical aid schemes, which provide
private health care for some 16 per cent of the population. A key challenge facing
the private health sector is how to deal with the rapid increase in contributions
to, and spending by, medical schemes.
In 2010 expenditure on the public health sector comprised about 4 per cent
of gross domestic product (GDP), and 14 per cent of the national budget. South
Africa’s public sector in general is becoming increasingly dysfunctional, with
immunity for corrupt officials and an almost demoralised citizenry that has given
10 Universal health care in southern Africa

up on the state and resorts to violent protests (Public Service Commission 2010;
Sole 2005). Immediate reasons for poor health outcomes include poor state
planning; a quasi-federal system with a confused division of responsibilities among
levels (or spheres) of government; generally weak implementation capacity in the
public sector, especially in provinces incorporating former ‘homelands’; an
inability to prioritise and sustain basic services such as a universal supply of clean
water and sanitation; inadequate evaluation of state programmes; an urban and
curative bias in state health spending (80 per cent of government spending is on
hospitals); and a flight of medical skills. The public health sector employs more
than 250 000 people, but there are severe shortages of specialised personnel as
well as nurses.
The dynamics of a parallel private and public health sector have been
intensively debated in South Africa and elsewhere. Thus, the Centre for
Development and Enterprise, a vocal policy think tank close to big business, has
declared:

There is a widespread tendency . . . to dismiss the contribution of the

private sector to overall health outcomes, to be suspicious of the motives
of private health sector players, and to challenge the very legitimacy of
private health provision. The Green Paper on NHI reflects these mixed
messages, blaming the private sector for the ills of the public sector, making
gestures towards a constructive relationship with private stakeholders, but
falling well short of spelling out what the private sector might offer and
how its contribution might be maximised. Constructive debate about the
role of the private sector in South Africa’s overall health care system has
not been helped by widely held beliefs based on misconceptions about
whom the private sector serves and who works in private health care (2011).

The demand by the powerful few for curative health care diverts resources away
from primary health care and national welfare. Moreover, the private sector has
a mixed record in respect of health care, with poor performance including low-
quality care, overprescribing, limited reach beyond higher income groups and
barriers to access due to user charges and the fragmentation of risk pools. As
McIntyre et al. have argued, ‘the fragmentation of the health system between the
rich, insured and still largely white users of the private sector and the poor,
uninsured and still largely black users of the public sector has deepened over
time’ (2004: 444). More importantly, the private health sector limits the ability
Inequality and health systems in context 11

of the public sector to achieve the income and risk cross-subsidies required to
achieve universal health coverage, which the World Health Organisation (WHO)
has called on all member states to pursue. As a new frontier of class apartheid,
the private health sector continues to be reinforced by a landscape of increasing
social polarisation where the select few literally wall themselves off from the poor.
The private sector has appropriated skills and concessions from the public
sector, and the fundamental principle of social solidarity and universal coverage
via cross-subsidisation between the rich and poor and healthy and ill people is
not being honoured. As Maureen Mackintosh has noted, bad health care systems
‘contribute profoundly to people’s experience of what it means to be poor. To
have fear cumulated when at one’s most vulnerable – to be denied care – is at the
core of social exclusion’ (2003: 185). State support for the private health sector
not only legitimises inequality, but also reduces social commitment to cross-
subsidisation.
A recent WHO report has tried to explain why it has been difficult for
countries such as South Africa to improve their health care. It cited three main
reasons: ‘hospital-centrism’, or the idea that many health issues can or should be
resolved in a hospital; ‘deep fragmentation’, which is particularly problematic in
South Africa, given its history of segregated health systems; and commercialism,
which becomes problematic when it is dominant and ‘uncontrolled’ (WHO 2008).
All three of these maladies exist in South Africa and are overlaid by politically
explosive race-class polarities.
The existence of an extensive private health sector in any country distorts
that country’s public health system. For example, in the United States the profit
motive is the driver of an expensive, commodified health system that focuses on
selling medical treatment rather than health care. As Motsoaledi has stated, private
medical aid schemes provide a ‘source of effective demand for expensive and
arbitrary private treatment’.6 Moreover, in the 1990s, ‘open’ schemes were
permitted to exclude high-risk individuals from membership and engage in risk-
rating. As a result they ‘skimmed off the cream’, leaving the public health sector
to care for South Africans with the greatest health needs, namely the mostly poor
citizens euphemistically and degradingly labelled as ‘high risk’. When members
of medical aid schemes deplete their annual benefits, they often revert to the
public sector for specialised and hospital-based care. The impasse facing the South
African health system is the growing disparity in the public-private mix and the
magnitude of resources (financial and human) located in each sector relative to
the proportion of the population served by each.
12 Universal health care in southern Africa

By contrast, the United Kingdom has a comprehensive public health system

– the national health system (NHS) – which provides free health care at the point
of need to all permanent residents. The social settlement represented by this
system incorporated a rejection of certain kinds of social inequalities and an
acceptance of the notion of universal access to health (Mackintosh 2003: 183).
Most health care is provided by the NHS; fewer than 10 per cent of British residents
belong to private medical aid schemes and many use them only as top-ups.
Numerous citizens also believe the NHS is a major embodiment of the public
good and oppose neoliberal attempts at privatisation (Leys 2001). The middle
class in particular has rallied in defence of the NHS, demonstrating that social
solidarity involves an awareness of the value of a collective public good not only
among the poor but also among the affluent. In other words, if the public good
is defended by all, services will improve, thus benefiting all members of society,
not only the privileged. This holds clear lessons for South Africa.
This volume focuses on a specific social problem: health care – life and death
and the differential treatment of the body – in contemporary southern African
society. We seek to explain the consequences of the marketisation of health care
by placing health reforms in historical context, analysing the views of key
stakeholders and reflecting on proposals for improved health financing and better
and more people-centred health systems. It straddles different disciplines: politics,
social policy, economics, development studies, public health and history. While
there is a large literature on South Africa’s democratic transition and its ongoing
‘developmental challenges’, it is often technocratic, ahistorical and apolitical. By
contrast, the literature on Zimbabwe tends to focus on the collapse of the state.
‘Progressive’ but technocratic reforms that routinely speak to ‘equity’ and being
‘pro-poor’ often fail to genuinely address the issues of power in a society dominated
by a robust middle class whose expectations of entitlement are inversely
proportional to its commitment to promoting social solidarity, to the benefit
of wider society and ultimately themselves. This study shows that current
‘health care’ in both South Africa and Zimbabwe institutionalises the social
disempowerment of the poor majority. It reverses the goals of social transformation
and social solidarity, and is both a cause and effect of reproducing class and racial
structures (see Chapters 7 and 8).
It urges readers to consider both ethical and socioeconomic arguments for
transforming health systems in these countries. Their political settlements have
not succeeded in addressing the fundamental inequalities, abuse and oppression
suffered by their poor majorities. Ultimately, it seeks to show how universal health
Inequality and health systems in context 13

coverage can be established, and an inclusive humanism introduced, in two

southern African countries with legacies of segregation and social exclusion.
The contributors argue that the proposed South African NHI scheme is far
more than just a proposal for creating an integrated fund for financing health
care for all, and that ‘national health insurance’ is a partial misnomer. It has far
wider transformative objectives and may in fact be more akin to a national health
service. Explicit statements by Motsoaledi that the NHI will be based on principles
of social solidarity and universalism are historic and unique. For the first time in
South Africa’s history, a government has committed itself to establishing a
redistributive system of health care that will force the insured middle class and
wealthy, who disproportionately benefit from government tax incentives, to help
shoulder the burden of providing health care for all in a more equitable way.
The proposed NHI opens the door for re-thinking the inherited race-class
architecture of public service delivery in South Africa and the nature of its social
settlement. As such it could contribute significantly towards improving social
citizenship and ultimately consolidating democracy. However, some concerns
remain, including:
• How will the NHI address the fragmented, two-tiered nature of health care
in South Africa, given the uneven administrative capacity of the state, the
power of vested interests in the medical commercial complex and the
tendency of the National Treasury to take pro-big-business positions and
water down progressive policies?
• How will the state strengthen the capacities of the poor to take greater
ownership of the process of their health care provision – to complain,
express frustrations, reject indignities and demand high standards of care?
• How will the public mobilise on the proposals for extending health care to
disadvantaged areas in order to ensure that the radical social-democratic
possibilities underpinning universal provision based on social solidarity
are not muted by a powerful private sector lobby?

This volume asks and seeks to answer these and numerous other questions,
including the following: What historical precedents exist in South Africa for a
national health service; can the NHI succeed and be made to function effectively,
given the poor state of the public health sector and the low morale of its workforce;
and if so, what other changes are needed?
How will the powerful private sector respond to its own internal problems
and to NHI? Will NHI cover all high-end services as well, or leave some to the
14 Universal health care in southern Africa

private sector? Could it, perversely, boost the private health sector by purchasing
services from it as well? And, how much political insurance does the black
ownership of private hospitals (under black economic empowerment schemes)
buy the largely white-owned private medical sector?
What regional consequences might there be? How have South African
companies responded to the NHI, and might they not attempt to escape regulation
by moving their operations to neighbouring countries? What are the entry points
for new capital?
The book is divided into four parts. Part 1 provides an overview of the battle
of ideas on the notion of universal health care. Chapter 1 examines competing
views of the good society and the related policy positions adopted by various
political parties and social movements in the current South African debate on
health care and the NHI. Chapter 2 examines earlier debates about national
health insurance, notably the Gluckman Commission of the early 1940s, and
claims made by the ANC under Dr A.B. Xuma. Chapter 3 examines health
policy reform in the last days of apartheid and the dilemmas facing the ANC on
health issues as it prepared to assume power.
Part 2 examines health care in southern Africa, notably recent trends towards
its commercialisation. Chapter 4 focuses more broadly on public and private
health care in the region. Chapter 5 explores the development of medical aid
societies in Zimbabwe up to 2007. Chapter 6 examines their development since
then, as well as issues of equity raised by their prominent role in providing medical
cover.
Part 3 deals with privatised health care in South Africa. Chapter 7 considers
the rise and consolidation of private health care from the early 1990s up to 2007.
Chapter 8 focuses on their subsequent development, the political economy of
the South African health industry and the current crisis in the private health
sector.
Part 4 examines the way forward. Chapter 9 analyses the debate on the
proposed NHI in South Africa and Chapter 10 reviews this debate in the light of
international experiences and best practice. Chapter 11 reflects on prospects for
achieving the goal of universal health coverage in the southern African region.
Inequality and health systems in context 15

Notes
1. http://www.news24.com/Opinions/QAndA/Cronin-vs-Leon-Service-delivery-protests-
20090806.
2. http://www.indexmundi.com/south_africa/life_expectancy_at_birth.html.
3. http://www.indexmundi.com/south_africa/infant_mortality_rate.html.
4. http://www.indexmundi.com/south_africa/infant-and-child-mortality.html.
5. Sunday Times, 20 April 2008.
6. Cited in The Daily Dispatch, 30 June 2011.

References
Association of Healthcare Funders of Zimbabwe (AHFoZ). 2009. ‘Register of Medical Aid
Societies as of April 2009’. Harare.
ANC. 2007. ‘52nd National Conference: Resolutions’. 20 December. http://www.anc.org.za/
show.php?id=2536#social.
———. 2009. ‘National Health Insurance: A Revolution in Health Care’. ANC Today 9
(3). 23 January.
Arrighi, G. 2007. ‘Labour Supplies in Comparative Perspective: The Southern Africa
Paradigm Revisited’. Paper presented at the Institute of Social and Economic Research,
Rhodes University.
Board of Health Care Funders. 2007. ‘KPI Report 2006’. http:/wwwbhfglobal.com/files/
KPI%20REPORT%202006.pdf.
Broomberg, J. 2009. ‘Bring the NHI Debate into the Public Domain’. http://wwwhealth-e.
org.za/news/article.php?uid=20032322.
Centre for Development and Enterprise. 2011. ‘Reforming Health Care in South Africa’.
CDE Research No. 18. http://www.cde.org.za/article.php?a_id=413.
Chang, H. 2004. ‘The role of social policy in economic development: Some theoretical
reflections and lessons from East Asia’. In Social Policy in Context, edited by T.
Mkandawire. Basingstoke: Palgrave Macmillan.
Coovadia, H., R. Jewkes, D. Barron, D. Sanders and D. McIntyre. 2009. ‘The health and
health system of South Africa: Historical roots of current public health’. The Lancet 374
(9692): 817–34.
Deacon, B. 2010. ‘From the global politics of poverty alleviation to the global politics of
welfare state rebuilding’. Crop Poverty Brief. June. University of Bergen.
Department of Health (DoH). 2011. ‘National Health Insurance in South Africa’. Policy
Paper. Pretoria.
Elson, D. 2004. ‘Social policy and macroeconomic performance’. In Social Policy in Context,
edited by T. Mkandawire. Basingstoke: Palgrave Macmillan.
Harvey D. 1989. The Urban Experience. Oxford: Oxford University Press.
——— . 2005. A Brief History of Neoliberalism. Oxford: Oxford University Press.
Ingram, H. and A. Schneider. 2010. ‘Policy analysis for democracy’. In Oxford Handbook of
Public Policy, edited by M. Moran, M. Rein and R. Goodin. Oxford: Oxford University
Press.
16 Universal health care in southern Africa

Kitschelt, H. 1986. ‘Political opportunity structures and political protest’. British Journal of
Political Science 16: 57–85.
Leys, C. 2001. Market-Driven Politics: Neoliberal Democracy and Political Interests. London: Verso.
Mackintosh, M. 2003. ‘Do health care systems contribute to inequality?’ In Poverty Inequality
and Health: An International Perspective, edited by D. Leon and G. Walt. Oxford: Oxford
University Press.
Mamdani, M. 1996. Citizen and Subject. Cape Town: David Philip.
Marek, T., C. O’Farrell, C. Yamamoto and I. Zable. 2005. ‘Trends and Opportunities in
Public-private Partnerships to Improve Health Service Delivery in Africa’. Africa Region
Human Development Working Paper Series. World Bank/Sara Project, Washington,
D.C. http://siteresources.worldbank.org/INTAFRICA/Resources/wp93_health_
service.pdf.
McDonald, D. and G. Ruiters (eds). 2012. Alternatives to Privatisation: Public Options for
Essential Services in the Global South. Cape Town: HSRC Press.
McIntyre, D., S. Thomas and S. Cleary. 2004. ‘Globalisation and health policy in South
Africa’. Perspectives on Global Development and Technology 3 (1–2): 131–52.
Mkhize, Z. 2009. ‘Zweli Mkhize on the NHI’. http://www.health-e.org.za/news/article.php?
uid=20032347.
Mohanty, C. and S. Miraglia. 2012. ‘Gendering justice, building alternative futures’. In
Alternatives to Privatisation, edited by D. McDonald and G. Ruiters. Cape Town: HSRC
Press.
Mooney, G. 2011. ‘Lessons from Australia’. Paper presented to NHI Conference: Lessons
for South Africa. Midrand. 7–8 December. http://www.doh.gov.za/docs/reports/2012/
nhiconfrep.pdf.
Motsoaledi, A. 2011. ‘Keynote Address’. NHI Conference: Lessons for South Africa. Midrand.
7–8 December.
Nathanson, C. 1996. ‘Disease prevention as social change’. Population and Development Review
22 (4): 609–37.
National Planning Commission. 2011. ‘Diagnostic Overview’. Department of the Presidency,
Pretoria.
Naylor, D. 1988. ‘Private medicine and the privatisation of health care in South Africa’.
Social Science and Medicine 27 (11): 1153–70.
Poggi, G. 1900. The State, its Nature, Development and Prospects. Cambridge: Polity Press.
Public Service Commission. 2010. ‘State of the Public Service’. Pretoria.
Department of Finance. 2010. ‘Medium Term Budget’. Pretoria.
Robinson, J. 1995. The Power of Apartheid: State, Power and Place in South Africa. London:
Butterworth-Heinemann.
Ruiters, G (ed). 2011. The Fate of the Eastern Cape: History, Politics and Social Policy.
Pietermaritzburg: University of KwaZulu-Natal Press.
Sole, S. 2005. ‘The state of corruption and accountability’. In State of the Nation, 2004–5,
edited by J. Daniel, R. Southall and J. Lutchman. Cape Town: HSRC Press.
South African Cities Network (SACN). 2003. ‘Urban Renewal Overview’.
Inequality and health systems in context 17

South African Institute of Race Relations (SAIRR). 2009. ‘Annual Survey of Race Relations’.
Johannesburg.
Van Niekerk, R. 2011. ‘The policy context and consequences of fiscal decentralisation’. In
The Fate of the Eastern Cape: History, Politics and Social Policy, edited by G. Ruiters.
Pietermaritzburg: University of KwaZulu-Natal Press.
World Health Organisation (WHO). 2008. ‘World Health Report: Primary Healthcare:
Now More Than Ever’. Geneva.