The NHI is an opiate not a cure

Michael Edmeston says we should be thinking critically about how to fix public healthcare

A troubling development following the Department of Health's (DoH) release of the Green Paper on a NHI for South Africa relates to the way in which subsequent health care discourse is so readily, even automatically, channelled to the prospect of the implementation of the proposed system.

The attention that many of the well known problems in the public health sector are now receiving, despite having been explicitly visible to the eyes of government for almost two decades, is being branded under the rubric of the NHI.

For example, on Thursday 22 March Health Minister Dr Aaron Motsoaledi outlined 10 pilot districts that were identified "for the phased piloting of the National Health insurance (NHI) due to start on 1 April." Furthermore, in pointing out its intent to improve hospital management - perhaps the most pressing issue in terms of dealing with the public health sector - the Department released its policy on regulating the management of hospitals (2nd March) while strongly invoking the NHI.

These examples are quite simply marks of government's blatant use of propaganda in an attempt to sell and further entrench the idea of the NHI in the minds of the public as the ideal remedy to the failing health system. Why is it propaganda? Because the NHI does not exist. Identifying pilot sites for improving the health system are one thing; announcing them in the context of the NHI amounts to a crude political tactic aimed at instilling confidence in a system that is animated only in the form of a Green Paper.

It is important to remember that it is not the NHI, or any other theoretical construct in itself, that will change the condition of our health care system, but ultimately better governance, accountability and greater political will within the DoH. Marketing policy is very different from implementing it and take note: the louder the marketing the more suspicious one ought to be of the actual content of the policy.

Certainly, the result of this semantic play poses the risk of diverting attention away from discussing rational solutions to the actual problems of the health system and conflating real action with the passing of an arguably politically motivated policy proposal. This is particularly troubling as it indicates that the debate around health care is being framed by certain assumptions which are, no doubt, testament to the government's success in having essentially reframed the health care debate on its terms.

Rather than to have put forward an intent to improve the health system in unpretentious terms, government has effectively appropriated the concept of "National Health Insurance" or NHI and turned it into something synonymous with the health care system itself. The World Health Organisation (WHO) has explicitly stated that "it is the combination of institutional arrangements and legislation relating to revenue collection, pooling and purchasing/provision that determines how equitable and efficient a system is rather than the name that is used to describe it".

In short, the NHI is simply a proposed financing mechanism and should not be conflated with the health system itself. To do so is to attach ideology to the concept and lose sight of rational solutions to the health care crisis plaguing the country. Indeed, the complexity of the language used to describe the government's plan is something about which we must all be aware.

Words and phrases are not neutral and do not simply describe concepts or objects in the world. Instead, they are often imbued with rhetoric and emotion and thus can be inherently ideological and self-serving, particularly when spoken within the political domain. As George Orwell remarked in his essay entitled The Politics of Language, "When there is a gap between one's real and one's declared aims, one turns as it were instinctively to long words and exhausted idioms".

As a consequence of deceptive and disingenuous use of language, the framework in which improvement of the health care system now gets discussed, particularly in the public domain, has been curtailed and limited to that prescribed by the Green Paper on the NHI. The idea of the health system being an institution that should ultimately service the population in the most effective and efficient way, regardless of how it is done, has been lost.

At this crucial juncture in our history, we should be discussing and debating various ways which might be effective in upgrading the public system and making better use of the otherwise exclusive private health sector. Instead, we are talking in terms of an all-encompassing policy model, handed down to us by a government department failing in almost every aspect of its mandate.

Nor is the public and civil society beyond reproach in what has fast become a political contest amongst stakeholders, against an otherwise a commonly accepted ideological backdrop. Evidence of this can be found in many of the public submissions responding to the Green Paper. To a large extent there seems to be general consent for the conceptual idea of the NHI, even in the midst of concerns regarding the Green Paper's lack of detail and clarity and numerous contradictions. This suggests that many commentators are not even aware of what it is they are agreeing upon or disagreeing with.

If the foundations for the proposed NHI are not laid out clearly in the Green Paper, how can the concept of a NHI even be given consideration? It is almost as if such criticisms are a shallow means of hedging bets against the possibility that the proposal offers nothing but false hope for the regeneration of the health system. Unfortunately, the truth is that any policy proposal couched in ideological terms is, by its very nature, less about actual improvement and social development and more about serving the agenda of those drafting the policy.

There is one broadly cited criticism aimed at the Green Paper, however, that begins to shed light on the problematic nature of the proposal: within the Green Paper itself no case is put forward claiming that a NHI model is the best option. Unfortunately, this flaw is neatly swept away and we are tempted into ignorance through the use of compelling, yet ultimately empty, rhetoric such as "The NHI is intended to bring about reform that will improve service provision. It will promote equity and efficiency so as to ensure that all South Africans have access to affordable, quality healthcare services regardless of their socio-economic status."

Such phraseology is ultimately meaningless because the NHI is not necessary to improve service provision, efficiency or access to health care. These are issues which cannot be dealt with through sweeping policy changes, but rather require targeted action. For example, improving service provision simply requires putting organisational processes in place that ensure only qualified, competent candidates are placed in management positions. Increasing access means ensuring hospital infrastructure is maintained, that equipment is procured in a transparent manner and improving the transport system for those living in rural areas and who have to travel long distances to receive treatment.

While the term NHI carries an air of authority and authenticity, it is but air alone. If the health care system in South Africa is truly to be improved, there needs to be a rethinking as to how we say things and how we listen to what others say. In a world of much talk and little action, saying what one means is as important as doing what one says. The task for civil society in response to the Department of Health's proposal is not to get caught up in the rhetorical whirlwind, but rather to be aware of the implications of the complex, yet vague and meaningless words and phrases used to describe its intentions.

Proposing the implementation of a national insurance model for improving health care in a Green Paper is, to use an exhausted idiom, to put the cart before the horse. It is therefore urgent that the government's proposal be brought back to the drawing board, where policy decisions can be deliberated over by all stakeholders devoid of ideological constraints.

Michael Edmeston is a researcher at the Helen Suzman Foundation.

27 March 2012

This article was originally published on Politicsweb