Mantavanni and my father

One of my beautiful cherished moments with late father, was listening to Mantovanni (Annunzio Paolo Mantovanni) from an old grammmaphone record late at night when everyone was sleeping. We would make ourselves a huge teapot with milk, play ‘Mantavanni and His Orchestra’ on a very low volume. We used to keep the house lit up by the brightness of a paraffin lamp and a good aroma of a steaming teapot. We would sit in our sofa for hours until I fall asleep and he would carry me to my bed. As a young man, there is still a lot I do not know about a lot of things, but my dad left me a fairly good blueprint on fatherhood.


The laborious journey to Universal Health Coverage in South Africa


Achieving universal health coverage is the Holy Grail for any effective  government that is serious about improving the health of its people. For South Africa, currently in the stress of the pragmatics of its National Health Insurance (NHI) scheme, the potential rewards are enormous so is its risk of failure without the buy in of the private health care sector. This is a country that continues to suffer poor health outcomes despite it`s  large spending on healthcare, due to chronic inefficiencies and under performances within the system. Breaking this cycle of inefficiency and under performance represents a huge opportunity and challenges for South Africa. But there are no easy fixes and turning NHI from a concept into reality will represent one of the biggest policy challenges facing the government today.

Universal health access is a particularly difficult goal to achieve in South Africa for three multiplex reasons. First, the apartheid system that institutionalized inequalities between the races created economic and social distortions that two decades of democracy have not  been able to obliterate. South Africa remains one of the most unequal societies on earth with a Gini co-efficient of 0.7 (closer to 1 being the most unequal society) and the health system reflects this reality. A well-resourced private healthcare system offers first world care and treatment that is out of reach for most black South Africans. The per capita spending on the private health sector is almost 10 times that of the public sector. Human resource personnel allocations is no also reflective of this inequality. South African medical schools are not enough in supplying the country with properly qualified professionals to meet the demands of the healthcare system.With only a mere 1,200 medical students graduates each year. Of the 600 who decide to practice in South Africa, only 150 end up in the public sector, these bottlenecks create the illusion that Universal Healthcare access is unattainable.

Second, the overwhelming and growing weight of South Africa’s quadruple burden of disease is placing immense pressure on the health system. South Africa is struggling with four separate health burdens, a deadly mixture of developing and developed nation health problems. Infectious diseases are rampant, notably HIV/AIDS and tuberculosis; maternal and child mortality is on a par with some of the poorest African nations; non-communicable diseases are on the rise; and chronically high-rates of violence and injuries continue to scourge the lives of many South Africans.

Finally, there are humongous doubts surrounding  South Africa’s ability to finance NHI. Although South Africa is now a middle-income country, the national economy has been in the doldrums for several years and there’s little hope of a recovery any time soon. Corruption is driving our nations economy to remain bloodless, the mining sector is on life-support, and the country’s creaking infrastructure has led to power outages that have cut production and costed retails a lot of rands and cents.

These economic and structural challenges add urgency to the task of restructuring South Africa’s health care system so that it is financially sustainable and improves the quality of care it delivers.

South Africa has toyed with the idea of introducing some kind of national health insurance scheme since the 1920s. The current effort began in 2011 and has become the flagship  Dr Aaron Motsoaledi.

The government’s policy document was finally gazetted last December , the documents admits there’s a shortage of billions of rand if the NHI is to work efficiently,conveniently, that white paper doesn’t say exactly how much NHI will cost, or where the money is expected to come from. In the meantime, reforms are under way in the health system that are intended to lay the foundations for NHI. These improvements are targeted at creating a a unitary system, financed through a central fund, where patients can select from a package of care offered by accredited health facilities, whether public or private.

There is a long way to go. Many of South Africa’s public health facilities are in bad shape. The physical infrastructure is poor, drug supplies are unreliable, caring staff are in short supply. There is a huge  focus in the reform of primary health care system; clinics are the natural entry point to the health system but they are underutilized by patients who have little faith in the quality of care they receive there and prefer to enter at the hospital level, causing bottlenecks in the system.

Few details have been given about the all-important issue of financing NHI. The basic concept is that the government will set up an NHI fund that will be funded by employers and taxpayers’ contributions. The fund will cover a range of healthcare services that will be free at point of delivery and can be accessed through the public or private sector. The problem is that South Africa’s tax base is already small and burdening its taxpayers.


Countries that have free health care have bigger tax bases and less unemployment, while only 39% of South Africans have jobs, in Mexico this figure is 59%, in Norway 62%, Brazil 65% and South Korea 75%. This will be a  tough sell to tax payers and NHI critiques. Undoubtedly additional sources of funding will be required; one possibility is would be increasing ‘sin’ taxes on unhealthy products such as cigarettes and alcohol and re-introduce sugar tax, which is among some of the reasons we are in this problem in the first place.

The planning and piloting phase drags on and six years into the 14-year timetable for NHI implementation, the deadlines already looks overly ambitious. There has been tussles between the Departments of Health and National Treasury, which must cooperate if NHI is going to work but they appear to have different visions for the initiative. Meanwhile, the private sector has been on the sidelined in these processes. The government may be missing a trick by not engaging more closely with some of South Africa’s largest private companies, which have long experience in providing health care to their employees and could, play a role in funding and managing projects and improving hospital infrastructure.

One thing is clear, much is riding on the success of NHI and the political costs of failure are high for the ruling party.The ANC is under more pressure than ever before to start delivering meaningful improvements to the lives of poor South Africans, the majority of whom are too young to remember the liberation struggle.The NHI scheme has the potential to address some of this unease by offering affordable healthcare options to even the least well off. To get there, however, will require a monumental planning efforts, intellectual firepower, sustained political will, and a little bit of luck from our economic fortunes.