NHI discourse and the forgotten man

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(in pic - Minister of Health, Dr Zweli Mkhize addressing guests during public debate on the NHI) Minister of Health, Dr Zweli Mkhize and The Elders participate in a public debate on the NHI reforms at the Charlotte Maxeke Hospital, Johannesburg. 02/09/2019. Jairus Mmutle/GCIS

The type and formula of most schemes of philanthropy or humanitarianism is this: A and B put their heads together to decide what C shall be made to do for D. The radical vice of all these schemes, from a sociological point of view, is that C is not allowed a voice in the matter, and his position, character, and interests, as well as the ultimate effects on society through C’s interests, are entirely overlooked. I call C the Forgotten Man.

For once let us look him up and consider his case, for the characteristic of all social doctors is that they fix their minds on some man or group of men whose case appeals to the sympathies and the imagination, and they plan remedies addressed to the particular trouble; they do not understand that all the parts of society hold together, and that forces which are set in action act and react throughout the whole organism, until an equilibrium is produced by a readjustment of all interests and rights.

The debates on the National Health Insurance (NHI) have exposed some stereotypical phenomenon, where the majority for whom the very pursuit of NHI is intended are silenced and forgotten.

In 2002, C.K. Prahalad and Stuart Hart wrote their seminal article “The Fortune at the Bottom of the Pyramid” that preceded the publication of Prahalad’s book by the same name. The article highlighted that the poor warrant the attention not only of the state or NGOs who seek to provide for their needs, but also of commercial entities, who can serve them as worthy customers.

The concept of the bottom of the pyramid is particularly pertinent in our discourse and pursuit of an all-encompassing healthcare system. As the term suggests, the “bottom of the pyramid” is used to describe the large group of consumers living at the bottom of the economic or wealth pyramid. Prahalad estimated that there were approximately four billion people globally living on less than $4 per day. His income per capita measure is a fairly standard basis for measuring poverty by global entities such as the World Bank and the UNDP, although the cut off of $4 per day that Prahalad used is controversial.

More typically, those who live on less than $2 per day would be considered poor. Critics claimed that the opportunity he saw was in fact a mirage created precisely because he had included more ‘middle class’ consumers in his definition.

Nevertheless, a per capita measure is a useful one. In contrast to household income it explicitly accounts for household size; a household comprising two people that earns R2 000 per month is demonstrably better off than a household comprising four people with the same income. Assuming we use Prahalad’s threshold of $4 per capita income we would need to translate that into a meaningful Rand equivalent. Exchange rates have fluctuated fairly significantly, reaching a high of R14.76 on 09 September 2019.

In South Africa, nuclear families account for just 12% of households who earn less than R3 500 per month, compared to 44% in higher income segments. Household formation is often in itself a response to poverty; spouses may live apart in response to the availability of economic opportunity or children and grandchildren may live with an old age pensioner precisely because she or he earns a state pension.

Using a cut off of R40 per capita income for instance would give us a market of roughly 28% of the 15.7 million households in South Africa in the Bottom of the Pyramid. This equates to 19.6 million individuals living in 4.4 million households according to the latest AMPS data (2016).

Too often, we wish to be seen as the friends of humanity. We like to start out with certain benevolent feelings toward “the poor,” “the weak,” and others of whom we make pets. We generalize these classes, and render them impersonal, and so constitute the classes into social pets. We turn to other classes and appeal to sympathy and generosity, and to all the other noble sentiments of the human heart. Action in the line proposed consists in a transfer of capital from the better off to the worse off. This is the underlying intent of the NHI!

As we argue the merits and demerits of the NHI, we ignore entirely the source from which we must draw all the energy to employ in crafting our solutions, and we ignore all the effects on other members of society than the ones we have in view – usually those with whom we share comforts of the current arrangement.

When a millionaire gives a rand to a beggar the gain of utility to the beggar is enormous, and the loss of utility to the millionaire is insignificant. Generally, the discussion is allowed to rest there. There always are two parties. The second one is always the Forgotten Man, and anyone who wants to truly understand the matter in question must go and search for the Forgotten Man. He will be found to be worthy, industrious, independent, and self-supporting. He is not, technically, “poor” or “weak”; he minds his own business, and makes no complaint. Consequently, the philanthropists never think of him, and trample on him.

We must be careful that the NHI discourse has taken a terrible turn where it is used to patronize “the working classes” savour of condescension. The vocal voices are impertinent and out of touch in this free democracy. NHI has become a discourse that demoralize the working people, flattering the vanity of one and undermining the self-respect of the other.

The NHI is about all of us, not one or the other. When we see a drunkard in the gutter we pity him. If a policeman picks him up, we say that society has interfered to save him from perishing. “Society” is a fine word, and it saves us the trouble of thinking.

The industrious and sober workman, who is mulcted of a percentage of his day’s wages to pay the policeman, is the one who bears the penalty. But he is the Forgotten Man. He passes by and is never noticed, because he has behaved himself, fulfilled his contracts, and asked for nothing.

The fallacy of all prohibitory, sumptuary, and moral legislation is the same. A and B determine to be teetotalers, which is often a wise determination, and sometimes a necessary one. If A and B are moved by considerations which seem to them good, that is enough. But A and B put their heads together to get a law passed which shall force C to be a teetotaler for the sake of D, who is in danger of drinking too much. There is no pressure on A and B. They are having their own way, and they like it. There is rarely any pressure on D. He does not like it, and evades it. The pressure all comes on C.

The question then arises, who is C? He is the man who wants alcoholic liquors for any honest purpose whatsoever, who would use his liberty without abusing it, who would occasion no public question, and trouble nobody at all. He is the Forgotten Man again, and as soon as he is drawn from his obscurity we see that he is just what each one of us ought to be.


Chris Maxon is a public servant in health services with over 24 years of working experience. He holds various management qualifications and is currently finishing a Master of Philosophy: Development Finance with Stellenbosch Business School.