Phakamile Hlubi-Majola: NHI can succeed if we follow Cuba’s lead

Cuba has established the best healthcare system in the world, free of charge to all its citizens by totally overhauling the profit based system of healthcare, writes Phakamile Hlubi-Majola.

Cuba has established the best healthcare system in the world, free of charge to all its citizens by totally overhauling the profit based system of healthcare, writes Phakamile Hlubi-Majola.

Published May 20, 2024


By Phakamile Hlubi-Majola

The signing of the National Health Insurance (NHI) bill into law by President Cyril Ramaphosa was a missed opportunity for the governing party.

It could have genuinely transformed healthcare for the majority of South Africans. Don’t get me wrong, I support the noble principle of universal healthcare for all and it must be defended. But I’ve got some reservations.

The NHI is the ANC’s attempt to fulfil a promise it made 30 years ago. It is possible that it will result in an improvement in healthcare, but with the involvement of the private sector, I am doubtful that the poorest of the poor will truly benefit.

The South African health care system is extremely unequal. It has two tiers — one made up of the private sector, and one public sector service. The public sector services about 80% of the population in old, dilapidated, crumbling state facilities which have a dire shortage of doctors and nursing staff. It is drastically under-resourced and grossly understaffed. The infrastructure of the buildings is falling apart because the state has been driving austerity, and cutting back drastically on healthcare spending.

Every day, there are chronic shortages of medicine and essential items. Patients are often stripped of their dignity because the conditions are terrible. We must salute the healthcare workers who carry this broken system on their backs, and ensure that some measure of service delivery is given to the people, despite the government’s senseless decision to choke it, through crippling austerity measures.

South Africa’s ‘Wealth-care’ system

The private sector on the other hand, caters to a fraction of the population, less than 20%. It has an abundance of specialists and doctors, and its facilities are world-class and designed to serve a minority of people, who are lucky enough to be employed, and are able to afford medical aid.

Right-wing organisations are lining up to rush to court. The bill was “rushed” and “haphazard” they say; “So it must be scrapped altogether.” Their real agenda is to deny quality healthcare to the masses. They are fighting to preserve their privilege and the profits of the private sector.

Some of the hysteria around this is fuelled by racism and also the worst form of elitism. The outrage machine of the traditional media is in full force amplifying the voices of the well-heeled members of the middle class, who are clutching at their pearls in horror at the very idea that they have to share the same hospital ward with their domestic worker.

The manufactured moral panic reminds me of the hysteria I witnessed in the early 90s when white people in South Africa realised they would have to share their pristine public schools with African students, towards the end of apartheid. Suddenly, there was a mass exodus of white children from public schools. These are people who have an ideological, or racial aversion to democracy, and get a kick out of burning flags. The lunatic fringe.

The NHI act: 30 years in the making

There are genuine concerns about how NHI will be rolled out. People are rightly cautious about corruption and mismanagement of these funds, given the destructive history of the governing party when it comes to managing public finances.

And there are others, like me, who question the sincerity of the state to end inequality in health. The NHI act still intends to rely heavily on the private sector for the provision of healthcare. And this is where the problem lies. Allowing the private sector to participate in the system will recreate the very same conditions that led to the status quo.

It is unforgivable that the working class has been locked out from accessing quality healthcare services for the last 30 years, on the basis that this government chose to promote the profits of private capital, over the well-being of the majority of people.

After the end of apartheid, in 1994 the South African state had an opportunity to set a framework which would lead us to genuine universal healthcare access for all. According to the Parliamentary Monitoring Group, as early as 1994, various iterations regarding the kind of healthcare insurance were discussed and debated by parliament. The report states:

“The possibility of introducing some form of mandatory health insurance and after the 1994 elections; there were several policy initiatives that considered either social or national health insurance.”

Fast track to 2009 which culminated in the formation of the Advisory Committee on the National Health Insurance and subsequently the release of the ‘White Paper’ on the NHI which was released by the Health Department in 2015. And the rest is history.

The NHI act has taken an extremely long time to be passed, and in that time, the private healthcare sector has entrenched its dominance. One of the most disturbing aspects about private healthcare in South Africa is the cost. According to a report compiled by the World Health Organization and the Organization for Economic Co-operation and Development (OECD) published in 2018 found that:

“South Africa spends 41.8% of total health expenditures on private voluntary health insurance - more than any OECD country - but only 17% of the population - mostly high income citizens - can afford to purchase private insurance.”

The study found that we spend as much on healthcare as France and Germany despite having the lowest per capita GDP of the countries sampled in the research. To add salt to the wound the state subsidises the private medical aid industry with billions in tax credits.

The Cuban healthcare standard: A socialist success story

If we want examples of what access to universal healthcare looks like, we must learn from Cuba. Despite being subjected to crippling sanctions by imperialist America and its Nato allies for decades, it has managed to establish the best healthcare system in the world, free of charge to all its citizens. It achieved this by totally overhauling the profit based system of healthcare, and training an army of healthcare workers to take care of the community.

The Cuban health system is built on the Socialist principles of providing quality healthcare to all. It focuses on prevention and is based on primary healthcare, accompanied by social involvement. According to Newsweek life expectancy in Cuba is higher than that of the US Cuban health workers have eliminated polio, and the country has the lowest rate of HIV in Latin America. Malnutrition is lower among Cuban children than it is among American children. Cuba has achieved this incredible feat partly because it has the highest doctor-to-population ratio in the world, with approximately 8.4 doctors per 1,000 people.

There is a Family Doctor and Nurse model, which is a healthcare team that lives in the community, keeping meticulous records of ailments and treatments, whilst offering primary healthcare services. The system depends on volunteer brigades building mini-polyclinics all over the country.

In addition, Cuban health workers contribute their services to the world by providing much-needed medical assistance during natural disasters and other catastrophic events. Some countries are happy to receive the assistance that they get from Cuban doctors, without acknowledging that it is Cuba’s Socialist system that produces the best outcomes. Cuba is able to focus its meagre resources towards training and equipping health workers because it values all human life.

The success of the NHI, as it currently exists, is in question. By ignoring the Cuban healthcare model of not involving private healthcare providers, the government risks perpetuating the inequity of the two-tier system that exists today.

That fact, combined with an ill-defined implementation period, makes it seem that once again, the ANC government is doing its utmost best to accommodate business interests at the expense of all South African citizens.

* Phakamile Hlubi-Majola is a socialist and former journalist. She writes in her personal capacity.

** The views expressed do not necessarily reflect the views of IOL or Independent Media.