The Devil and the NHI

Susan Erasmus quite liked Health Minister Aaron Motsoaledi until he said that her point of view on the NHI reflected 'self-interest and greed that would shame the Devil'.

I have never had very strong religious views, but if push came to shove, I suspect  I would rather not go with the Devil. He's had some very bad press for about 3000 years. In his case there is something such as bad publicity.

But back to Minister Motsoaledi. The context in which this was mentioned was his speech in Parliament on the proposed National Health Insurance (NHI), in which he urged everyone, from those who are ardently awaiting better health care, to self-interested devils like myself, to be patient. Just like Rome, it appears that the NHI is not to be built in one day.

I would love for all South Africans to have good health care. I would also love our schools to be well-equipped, our tertiary institutions not under-funded, our pensioners not living below the breadline. I would love everyone to have decent housing. In short, I would love there to be an end to poverty of all kinds. But these are not things to be achieved with a signature on a piece of paper.  They involve decades, if not centuries of planning, organic growth, attitude changes, and political will on an ongoing basis – and heaps and heaps of cash. Which we just don't have. Certainly not with the millions disappearing on luxuries and state corruption.

In fact, our health spending is already relatively high – the problem is that much of it doesn't reach its intended target, owing to poor management and dishonesty.

In a country such as SA, where registered taxpayers are few and far between, and 13 million people receive some sort of state grant, cash is not exactly in overabundance.

With very few exceptions, all people have to budget carefully for huge transport and housing costs, food, soaring electricity bills and school fees. Not to speak of medical insurance.

NHI in 2012

Originally 2012 was bandied about as the time when the NHI would be introduced. Given the enormity of the undertaking, I did think it was a tad optimistic, but then what do I know about medical matters?

On the issue of footing the bill for all of this, just the following: I am no economist, but there has to be a direct correlation between what a country can spend, and the money coming into state coffers via the different revenue streams, much of which is a variety of taxes and levies and VAT.

To look at things on a purely domestic level: my car is 16 years old. I would love a new one. In fact, I would love a Mercedes. They are safe and a pleasure to drive. I think I deserve one. Who doesn't? Now for the crunch: if I were to buy the model I fancy, it would mean spending 65% of my monthly income on car repayments. Something else would have to go. Housing costs? Petrol? Electricity? The choice is mine. But clearly it isn't really a choice. It just can't be done.

The figures

And it's the same with state finances. If you have X amount of money coming in, no matter how you structure things, in order to spend more on health, you are going to have to cut spending on something else. Child grants, pensions, MPs' salaries, education, or the police? The choice is yours. My guess is that it also isn't really a choice.

The figures speak for themselves: spending on the health sector was expected to grow from the current R102.5bn to R113bn in 2011\12, and R127bn in 2013/14 - an average annual growth rate of 7.5%. These are not paltry amounts.

There is only so much that can be squeezed out of already overburdened taxpayers.  A hike in VAT was proposed by Finance Minister Pravin Gordhan in his budget speech in February this year. The other charming possibilities were a payroll tax (payable by employers – read employees), and a surcharge on individuals' taxable income. Both of which make my toes curl. I already spend far more than half my income on taxes of various natures. Of these three options, the VAT increase is probably preferable. In that way everyone who ever buys anything contributes according to their spending capacity. I think that's fair.

Private health care

Of course there is a problem with the exorbitant fees private hospitals and doctors charge. Medical inflation is high, and clearly there are problems in the medical scheme sector. I do not dispute these things. I have contributed huge amounts of money over the last 25 years to medical schemes, and claimed very little. (I know, I know – a bus could run me over tomorrow etc. etc.)

What would make sense to me though is a huge overhaul of the state medical system. Much of the infrastructure is there. Good management, a crackdown on corruption, and decent training could go a long way to revitalising a sad system.

Maybe if we start there, even our MPs would want to use the state hospitals which they run when they get ill themselves. Not like a previous Health Minister who had a liver transplant in a private hospital, not in any of the hospitals which she was tasked with running. That says it all, doesn't it? That's a bit like a Minister of Education whose kids go to a private school, or a caterer who does not want to eat the cake he himself has just baked.

Jack up the state system first, then I might have faith in this government to overhaul the entire health system. And I am sure even the greedy and self-interested Devil could see the logic in that.

(Susan Erasmus, Health24, June 2011)


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