National Health Insurance and Lesufi’s honest appraisal of public health failures

Martin van Staden / Midjourney
Martin van Staden / Midjourney

This article was first published by Mail & Guardian on 14 May 2024

Gauteng Premier Panyaza Lesufi made some incredulous announcements last week regarding the as yet un-birthed National Health Insurance (NHI). In full-blown campaigning mode he claimed in support of NHI: “After 29 May, any citizen can go to any hospital, private or public, to receive the best treatment and that afterwards government will pick up the bill”.

Such shameless populism tells observers that panic is enveloping senior ANC politicians, who are fearing that the electorate is no longer buying their false promises.

Confessions from a politician

But Lesufi’s subsequent verbal contortions consequently became major confessions on how bad public health services are.

His rhetoric subsequently escalated into the following pearls: Gone are the days that if you don’t have medical aid that you must die, along with, Gone are the days that if you don’t have medical aid that you must be mistreated in our hospitals, and finally, Gone are the days that if you don’t have medical aid that you are even scared to go to hospital.

In this regard Lesufi is being honest, confirming the horrors that citizens experience when going to public hospitals. In particular, his word choice in the confession that citizens are mistreated in our hospitals is extremely revealing. I would have to assume that he inadvertently ended in a verbal cul-de-sac with such an honest appraisal of how poorly the ANC has managed the country’s public health services.

The NHI’s dishonesty

However, where he is being entirely dishonest is following the ANC party line on NHI. The origin of his statements is founded in the false notion dreamt up during the NHI policy process; that the reason public health facilities are in such a mess is that the private sector ‘steals’ all the healthcare resources in the country. Hence Lesufi’s inferences that you are ok as long as you are covered by a private medical aid.

Nonetheless, given this populist NHI policy position the ANC must therefore destroy the private health sector, raise substantial new taxes, and take full control of all health services, private and public. As far as populist and socialist policies go it doesn’t get much worse than the NHI.

However, what this policy stance conveniently conceals is what resources have been available to the government and how they have subsequently performed with them. The picture is far from pretty.

Public sector resource boom

Contrary to the narrative of understaffing, from 2006 to 2019 the ratio of public sector medical personnel per 10,000 population improved in all but 3 out of 28 clinical disciplines. This was achieved on the back of public health budget increases that far exceeded CPI and population growth each year from 2000 to 2020. Only in the last few years have budget increases come in lower – a result of our burgeoning debt levels and budget deficits – but they still remain above CPI.

For a country of our upper-middle income development, our current total public health expenditure (4.1% of GDP) falls squarely in line with the average for all upper-middle income countries (also 4.1% of GDP). If you add further tax-funded health expenditures such as the Workmen Compensation and Road Accident Fund, and also consider that the new infrastructure and maintenance budgets for public healthcare facilities are allocated to the Department of Public Works, SA’s total public health expenditure is closer to 5% of GDP. In monetary terms, our per capita public health expenditure ranks 17th highest out of 51 upper-middle income countries, whereas our clinical outcomes rank amongst the worst of this peer group.

Our clinical outcomes have deteriorated to such an extent that nationally medical malpractice claims against the state exceed R80bn as of March 2023.

It is very telling to note that the medical malpractice claims of the Western Cape, managed by the DA provincial government, are nil. Their maternal and infant mortality rates are also substantially lower than every other province. These outcomes are not due to better resources, since the provinces operate on equal per capita budgets, where the national health budget is distributed proportionally using the provincial equitable share.

The Western Cape achieves substantially better outcomes based on the same per capita budget and with the same institutional design as all the other provinces. It amply proves that better health outcomes can be achieved within existing healthcare resources.

The NHI and elections

Nonetheless, given Lesufi’s leveraging of the NHI during his election campaigning, one must conclude that President Ramaphosa’s promise to sign the NHI into law before the elections is one of a few that he will keep.

Preceding this point, the passage of the NHI Bill through the National Assembly and the National Council of Provinces (NCOP) was a complete farce, as any objections against NHI or even interrogations underpinning its reasoning were rejected outright by the ANC dominated health portfolio committees. Even advice from the Parliamentary Legal Advisor that the NHI Bill is not constitutional was ignored. The ANC needs the NHI for these elections more than it ever has, and it is no coincidence that the NHI Bill was rammed through both houses of parliament last year.

Once Ramaphosa puts pen to paper, the games will commence, as a slew of lawsuits are in the pipeline ready to outline the NHI’s many fatal flaws.


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The views expressed in the article are the author’s and are not necessarily shared by the members of the Foundation. This article may be republished without prior consent but with acknowledgement to the author.




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