Democratise healthcare

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RANT: Author John W. Fredericks commented on service at hospital

When Louis Washkansky was operated on by Dr Christiaan Barnard in Groote Schuur Hospital in Cape Town in 1967 to become the first beneficiary of the world’s first heart transplant, he did not have to worry about who would pay for the cost of the operation. Washkansky did not even have to know how much the operation would cost. The operation was conducted in Groote Schuur Hospital, performed by a team of doctors, led by Barnard, all of whom were paid for by the state. Actually, the total cost, including the salaries of all the health professionals who worked on the operation was borne by the state.

About two weeks ago, Professor Mashudu Tshifularo and his team at Steve Biko Academic Hospital performed another world first. Tshifularo successfully conducted a middle-ear transplant on a patient who had lost hearing. After the operation that lasted a few hours, the patient’s hearing was restored. What an achievement and a scientific miracle?  Again in this case, the patient did not have to know how much the operation would cost. The entire operation was funded by the state.

Advanced 3D-printing technology was used to print the bones – the hammer, anvil, stirrup (the three ossicles) that make up the middle ear. In both cases, if the patients were forced to pay for the procedures, either they were going to fail to do so with disasterous  consequences to their health or were going to have to sell most of their lives’ savings with catastrophic outcomes to their financial health. In simple language, they would have been forced into poverty just in order to save their lives. These are no real choices and nobody should be put in such a situation.

The irony is that in the same year that Barnard performed this world first, another event took place in our country which would have the effect of cancelling the benefits that Washkansky enjoyed from extending to every South African who needed such help. For it was in 1967 that the first Medical Schemes Act was proclaimed, ushering an era where you have to have a certain level of income before you can get good quality medical care, otherwise you perish.

It was such an interesting coincidence that Tshifularo’s 10 years of research climaxed in March, the month during which we celebrate human rights. Our Constitution identifies access to healthcare as a basic human right. When the ruling party adopted the National Health Insurance (NHI) in its Polokwane conference and endorsed the NHI in the subsequent conferences in Mangaung and Nasrec, the main reason was to give meaning to the Constitutional obligation that identifies access to healthcare as a human right. In the same breath, the United Nations adopted the Universal Health Coverage (UHC), for the same reason, that is to make sure that nobody suffers catastrophic expenditure when they need to use the health services.

This is why people who understand the Constitutional imperative of healthcare as a right are quite unflinching in their resolve that NHI need to be implemented. The introduction of 1967 Medical Scheme Act, at face value, looked progressive and looked like progress in a developing country. But in essence, it was laying the foundation of the worst form of inequality in healthcare that the world has ever seen. This is because while the Constitution says that healthcare is a basic human right, which must be accessible to all South Africans in our country, the Medical Scheme Act on the other hand was saying that firstly you have got to be employment, and also earn a particular level of salary in order to access that healthcare.  

The consequences of that act is the gross inequality in healthcare that we see today. The realisation of this phenomenon was reflected as far back as 1978 at the World Health Organisation’s Alma-Ata Conference. It was at this conference that a declaration was adopted, which among other things stated: “The existing gross inequality in the health status of people between developed and developing countries and within borders of the same country is politically, economically and socially unacceptable and is of common concern to all.”

Unfortunately at this present moment, South Africa is the one country where this form of gross inequality as described by Alma-Ata Conference is the most glaring of all countries in the world.

As we remember the victims of Sharpeville massacre, who should inspire us to create a more equal society, we should also reflect on how, as a country, we are ensuring that healthcare is a indeed a basic human right that can be accessed by all without regard to social or economic status. Our position as the Department of Health is that NHI is the equaliser of the unequal factions of our population, those who have medical aids can access healthcare anywhere, in both public and private settings, whereas those without are restricted as to what healthcare is available to them.

It is understandable why organised labour is lambasting the Department of Health for what they perceive to be delays in the rolling out of NHI. After all, unions represent the working class who should benefit hugely when we introduce a system that will ensure that the doors of access to health in both public and private are opened to all regardless of socio-economic status, just as prescribed by the Constitution.

Just as Washkansky did not have to bother about the cost of his heart transplant, so should all the people of South Africa about their healthcare needs. Patients should not be worried about who will settle their medical bills because this would have been settled else-where but not at the point of care where it is needed urgently. We are aware that many are worried as to who would pay for the poor. 

But NHI or UHC is based on the principle of social solidarity where the rich must help the poor, the young must help the old, and the health must help the sick. This is not a new principle at all, for medical schemes are using exactly the same principle, except that it is done for a selected few who are actually better off. Universal Health Coverage as the concept implies is that this principle of solidarity must cover everybody and must not discriminate. And when we do that, we can say with a clear conscience that we are honouring the legacy of those who gave their lives so that we can have human rights.


Dr Aaron Motsoaledi is the Minister of Health.