The Union Buildings this week saw the signing into law of the National Health Insurance (NHI) Bill by President Cyril Ramaphosa. Rarely have laws been signed with that much fanfare. The signing of a noteworthy social compact, the national minimum wage (NMW) agreement, took place in a Cape Town conference hall with just government media in attendance.
In recent memory, no bill has been assented to in public in the manner we saw with the NHI one. This indicates the seismic importance of the law being introduced. NHI is like a red-hot knife cutting through butter. The line has been drawn between firms invested in private healthcare services and others. Some see them as uncooperative and greedy naysayers with white monopoly capital characteristics. Stories about super-profits aside, financial and intellectual capital has been deployed in these firms, and it serves no political purpose to erode it, as experience tells us that in South Africa there is no correlation between a decrease in the value of capital and a rise in the quality of public services.
In the middle, we have health practitioners and bureaucrats trying figure out how they can make the system work given all the capacity challenges they face. At the other extreme, we have those gloating — for them, this is like Bastille Day or the October Revolution of 1917. Thankfully, there is general agreement that the country must progressively work towards achieving universal health coverage.
Of all the public policies I have worked on, NHI might be the most complex. That is because it involves the entire national health (and insurance) system, both public and private. Some of the past projects I was involved in were the NMW, the 2010 Fifa World Cup, the now-defunct E-tolls scheme, and the national Aids response programme, especially policies for rolling out antiretroviral treatment, and introducing medical male circumcision (MMC) as a public healthcare intervention.
Now that I am no longer involved in direct policy programming, I can sit back and ask myself some critical questions: Can the NHI be as successful as the setting up of the South African Social Security Agency, which was done by officials without the help of any big consulting firms? What will it take for the NHI not to become “E-tolls 2.0”? Though I had no dealings with it, I wonder whether NHI will be another Square Kilometre Array (SKA) project, a mere “show and tell” public policy in the third decade of democracy.
First, I accept that three of the programmes (the World Cup, the SKA project, and the national Aids response) are not germane to this discussion. The first was a time-bound project (by the end of the first week of June 2010, every stadium had to be ready). While SKA could teach those designing and implementing the NHI a great deal about building, managing and evaluating the success of a huge project, it did not involve providing a nationwide service to millions of citizens. It was dependent on hardware, software and skill in studying the universe. As for the Aids treatment plan and MMC, the success of these policies was a result of their rapid integration into the primary healthcare system.
To the delight of some, E-tolls were recently switched off after having been in operation since December 2013. The E-tolls project would also have been operationally different from NHI because all it needed to work optimally was systems efficiency and interoperability, compliance by users, and enforcement by authorities.
Perhaps I should compare the NHI to the NMW agreement, which required notable changes in labour relations arrangements and cost of production models. However, I soon came to see that sectoral determinations had laid a solid foundation for the national minimum wage. In fact, since its introduction in 2019, compliance has been the norm.
The state neither intends nor has the constitutional authority to close down the private healthcare system ... Its demise will come about only when there are positive breakthroughs in public healthcare
But, to return to the main enquiry, will NHI be the biggest test of statecraft in the fourth decade of democracy? My pedestrian understanding of statecraft is that what follows might constitute the minimum requirements for NHI to be successfully implemented.
We need to establish specialist high-level teams to plan implementation using a phased-in approach. The current capability is vastly inadequate to meet the Herculean task that lies ahead. For example, China — where the state sector is efficient, big and dominant — has partially liberalised healthcare to allow for private firms targeting the upper middle class, albeit under stringent win-win conditions that leverage resources without weakening the universal healthcare system. Companies such as Discovery are growing in the UK, given the inefficiencies of the National Health Service (NHS), undermining the idea of universal health coverage.
In short, we will require multiskilled people to plan and implement NHI. They must include data scientists, health economists, physicians, public health practitioners, actuarial scientists, town planners, engineers, strategic communicators, pharmacists, social workers, public finance experts, designers, scenarios planners, accountants, lawyers, sociologists, demographers, strategic procurement specialists, and a wide range of other people whose skills are needed to undertake such a huge project.
Success will depend on rolling out a huge infrastructure build and improvement programme as part of the core priorities of the seventh administration. The people will embrace NHI as a game-changer if facilities meet the minimum requirements for a healthcare facility and look suitable for patient care. The project will create jobs and boost the construction sector, thus linking economic and social objectives.
Creating the most sophisticated information and communications technology (ICT) department with the best computer engineering, data science and cybersecurity expertise money can buy will set NHI apart. The government may collaborate with companies that already have advanced ICT capabilities.
Seasoned experts who have mastered their craft could be seconded from organisations such as the South African Revenue Service, the SKA project, and the Council for Scientific and Industrial Research to conceptualise the data architecture needed to make NHI succeed. Appointing relevant teams will be critical to protect day-to-day operations and prevent potential malfeasance, such as fraud and corruption.
An effective stakeholder management, public engagement and mass communications programme is required to win the battle against misinformation. It is well understood that capital will not accept NHI lying down — they have declared as much. After all, the state neither intends nor has the constitutional authority to close down the private healthcare system, since NHI is not a proposal for the nationalisation of, for example, Bonitas, Discovery and Netcare.
As in communist China, the private healthcare system will persist. Its demise will come about only when there are positive breakthroughs in public healthcare. In countries such as Sweden, Rwanda and Singapore, it makes no sense to set up a private school because public education is of such a good quality.
However, NHI will collapse if it is unable to meet the expectations of the majority of South Africans. An effective communications programme requires money, not for meaningless advertisements and shoddy public relations products, but a “love-back” investment that is sustainable, credible, trustworthy and transparent.
Meanwhile, we should not believe those who think citizens’ rights of access to universal healthcare can be restricted in a liberal democracy. Public policymaking is not a randomised control trial where variables can be lined up, tracked and accounted for. Government is a vortex that requires a balance of professionalism, patriotism and courage to survive. The efficacy of the public healthcare sector, not government policy, will shrink the private healthcare system.
Fortunately, all parties agree it will take years, if not decades, to build the NHI into a flourishing system. If we learn from some of the notable programmes the government has implemented over the past few years, we will make noteworthy breakthroughs in the next decade. That is what statecraft is about: understanding your limitations and increasing your means, all of which are consequences of learning.
• Ngcaweni writes from Fudan University in Shanghai, where he is a visiting professor. He is the director-general of the National School of Government. The views expressed here are his own.
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