R.W. JOHNSON / Aaron Motsoaledi’s appointment as minister of health for the second time was not greeted with much enthusiasm by those familiar with his first period in the job. Veteran clinician and health researcher at Wits, Prof. Francois Venter, commented:
“Motsoaledi came into power (ie. as Minister of Health) in 2009, with lots of promises and a ten-point plan. However, none of the ten points were implemented. He instead blamed foreigners and NGOs for the multiple management failures under his administration.”
Prof. Venter added that Motsoaledi, who was minister for ten years, left the health ministry significantly weaker than when he found it. All true, but Motsoaledi was also responsible for the greatest progressive achievement of the Zuma government, the complete reversal of all the mad policies of Manto Tshabalala-Msimang – dictated to her by Thabo Mbeki – on Aids. All Mbeki’s nonsense was thrown out – it had cost over 350,000 lives – and ARVs were made widely available.
Thanks, ironically, to the enormous generosity of George W. Bush, large funds poured in through PEPFAR (the President’s Emergency Plan for Aids Relief) which Motsoaledi was able to use in a vast anti-Aids campaign. The ANC never mentions Bush – a Texas conservative – but he was by far their greatest benefactor.
At the same time, Motsoaledi hatched NHI, but it was all very vague. There was no suggestion as to how this enormous project could be funded and how it could work, given the already solid opposition of health professionals and the fact that many of its measures were flatly unconstitutional.
One needs to understand the way the ANC makes policy. Typically, there is a strong ideological background, such as “land to the people”. An agricultural reform policy can then be forced through with minimal attention paid to crucial detail. If the land is given to “the community”, as often happens, the assumption is that it will be run as a collective farm, although this model has never worked anywhere in the world. So virtually all such farms end in disaster, today producing nothing.
But if land is given to an individual black farmer, he is never allowed to have the freehold which would enable him to raise the capital necessary to farm. So more disasters occur. Above all, it is just assumed that if you give black people land they will farm successfully despite the fact that they have never attended agricultural college and have never studied modern farming techniques or farm management. Amazingly, the ANC still seems to believe that farming is simply “in the blood” of Africans and that once land is given to an African, farming will result.
In other words, the ANC often legislates on ideological principle, and is aghast that it doesn’t work. It also frequently commits itself to legislation with no idea as to its cost. During the recent election campaign, the ANC fervently committed itself both to the NHI and to a Basic Income Grant by 2026. Yet these two measures alone would cost at least R1 trillion a year, and no one has any idea how to find that money.
The Treasury has made it clear for some time that such programmes are simply not feasible and that all such money bills should, in terms of the constitution, go through the Treasury first – but there is no sign that ANC politicians are listening. Should they actually try to implement those two programmes, the rand would collapse, bond rates would go through the ceiling, no one would lend to South Africa, and the IMF would have to be called in.
However, there is a fanaticism about many NHI supporters. The SACP supports it 100% without any concern about its cost. If challenged about the cost, the cry is just that “you must find the money!” Nicholas Crisp, Deputy Director General for NHI in the Department of Health, is an NHI ideologue, and frames every argument with the claim that anyone who opposes NHI doesn’t want the poor to have health care. Motsoaledi similarly has attempted to liken those who oppose NHI to those who raised the cry of “swart gevaar”: that is, they are racists fighting against democracy. These are simply ways of trying to disqualify NHI opponents from being allowed into the argument at all.
What is absurd about the claim that only NHI can provide universal health care is the fact that, when the ANC took over, the entire urban population was served by public hospitals, many of which were excellent. True, this was not universal coverage, but the problem of how to reach far-flung rural populations will continue to exist under any system. Today, only in the Western Cape do public hospitals continue to provide good care to one and all. In the other provinces, ruled up to now by the ANC, the public hospitals have been reduced to a state where the public avoids them.
This way to the disaster zone … signpost outside the Helen Joseph Hospital in Johannesburg. Image: X.
This destruction of the public hospitals’ care function is one of the greatest tragedies of ANC rule. When the ANC arrived in power, these hospitals were run by qualified managers (who were white) snf who largely reflected the will and needs of the doctors, particularly the senior specialists. That is, there was a hierarchy almost exclusively made up of whites and Indians, often males.
This was unacceptable to the ANC and the white managers were got rid of and replaced by loyal cadres, usually at the behest of the powerful Cosatu unions within the hospital. The result was hospitals run by managers who were completely underqualified. These cadres had no idea how to manage a hospital, particularly since they were often dominated by the unions which had forwarded them.
In all too many cases they then resorted to huge corruption, selling off linen, blankets, drugs – anything with monetary value. (The murder of Babita Deokaran, who dared to blow the whistle on corruption amounting to R332 million in the Gauteng Health Department showed the scale of this corruption as well as the ruthlessness of those profiteering from it.) Within the hospital, discipline fell away, and nurses and doctors often behaved badly. The old hierarchy had worked; the new hierarchy simply didn’t.
However, this is not just a historical fact. If NHI were to be pushed through, one would expect the same destructive forces to be unleashed upon the private hospitals where the old-style hierarchies are still in place. For the fact is that most hospitals in the world are structured in the same way. If you want the best health outcomes, you have to allow the doctors a strong voice.
The NHI advocates have, from the first, adopted an all-out aggressive strategy of pushing NHI through despite the vast number of objections to it. Ramaphosa, similarly, signed the NHI bill into law, saying that NHI was coming “whether you like it or not”. Now Nicholas Crisp has announced that the Health ministry will go ahead with new rules and procedures for NHI, an absurd position considering that the whole scheme is still under discussion and there is still no word on how this vast scheme is to be financed. On top of that, Motsoaledi has insisted that all medical aids must be scrapped and threatened that the GNU itself could be dispensed with if NHI is blocked.
Alarmed by this bluster, John Steenhuisen said that perhaps the DA should withdraw its legal case against NHI and instead rely on the DA and ANC “finding one another” through talks within the GNU. This is absurd and dangerous. True, Ramaphosa said there would be talks with business about NHI. But what business has actually got from that is “the Motsoaledi roadshow” in which Motsoaledi denounces opponents of NHI as racists. There have been no constructive talks at all. Which is to say that it is folly to rely on vague promises from Ramaphosa.
In fact, the worst thing the DA could do would be to withdraw its court case against NHI. The point of the case is that NHI is unconstitutional. Already the courts have thrown out the notion that every doctor should be required to have a ”certificate of need” in order to practise – a key NHI requirement. But NHI ruthlessly centralises all authority over health to the Ministry of Health in Pretoria – with flagrant disregard for the fact that the Constitution says that health is a provincial competence.
It is difficult to see that any court can avoid striking down the entire centralised basis of NHI. Or again, the NHI has many rules about how, where and on what terms a doctor may practise. This too is bound to be struck down as impermissible restraints upon an individual’s right to freely ply their trade. There are many other parts of the NHI Act which are unlikely to emerge unscathed from challenges before the Constitutional Court.
Instead of being bullied by the bluster of Motsoaledi, Crisp et al., the DA needs to stay on course with its legal challenge and see what remains of NHI at the end of the judicial process. But it needs to do more than that: it needs to publicise the fact that no hospitals under ANC administration work properly, and that in the Western Cape public hospitals still work and that they will cease to do so if NHI is implemented. Many black voters happily believe that NHI will give them a private health level of care – free. Indeed, during the eloection campaign, Panyaza Lesufi expressly promised this to voters. These dreams need to be dispelled.
Now, however, Ramaphosa has met with business representatives who have again made it clear that they see NHI as a major threat. There is, after all, no doubt that if they are deprived of access to private medical care for themselves and their families, a large number of South Africans of all colours would emigrate – and that includes many business executives. There would also be a massive emigration of doctors and other medical workers. The result would be a huge blow to the South African economy and to its health system.
Ramaphosa now says that there must be proper discussions, and has apparently told Motsoaledi that he must be prepared to make compromises. It is already clear, though, that no deal either with the GNU parties or with business will be possible unless access to private medical care is preserved for those who pay their way. It is difficult to see the SACP and other left-wing ideologues agreeing to that.
In other words, if Ramaphosa is to reach a deal acceptable to his GNU partners and the business community, he will have to choose to go with the DA against the SACP. This is a showdown which has been a long time a-coming. Indeed, this has always been the fundamental choice on which the GNU rests.
Ramaphosa has argued that Solly Mapaila, the SACP leader, is actually just speaking for himself when he opposes the GNU because, after all, the SACP still has ministers in the government and none of them are opposing the GNU. What this really points to is that the SACP is eating its cake and still having it. It will come under pressure to withdraw its ministers – but what then will the SACP amount to? A small sectarian group without any leverage, just whistling in the wind. The SACP will not want that and will have to find a formula under which it can provide at least provisional support for the GNU.
The other problem Ramaphosa faces is that any compromise which is acceptable to the business community and the DA is bound to be unacceptable to Motsoaledi, the original author of NHI and a man who has been campaigning for it for 15 years. Ramaphosa will want to keep Motsoaledi in his cabinet, but squaring that circle won’t be easy. It would be sensible to start by pointing out that the Constitutional Court is bound to strike down large parts of the NHI Act, so in any case the best that can be hoped for is a compromise patch-up.
The DA has warned Ramaphosa that it has red lines both where the BELA (education) Act was concerned, as well as NHI. Ramaphosa has cobbled together a quasi-compromise on BELA, but he had better beware. BELA is of concern mainly to Afrikaans-speakers with children in school, a small subset of DA supporters. NHI, on the other hand, is a life and death matter for huge numbers of DA voters and for the entire business community. A Ramaphosa shimmy with his usual smoke and mirrors won’t be enough when it comes to NHI.
FEATURED IMAGE: The entrance to the Charlotte Maxeke Hospital in Johannesburg. Image: Facebook.