Critical Health Perspectives People’s Health Movement, South Africa , 2005 Number 6 Draft Charter on Private and Public Health Care in South Africa Louis Reynolds, Leslie London, David Sanders - People’s Health Movement The Department of Health’s recently released Draft Charter of the Public and Private Health Sectors (CPPHS) aims to address the legacy of apartheid restraint on access to health care for all South Africans. It commits public and private sectors to create “a health care system that is coherent, cost-effective and quality driven … for the benefit of the entire population” and to work together “to improve the scope, accessibility and quality of care at all levels”. For these laudable goals we give our wholehearted support. The CPPHS specifies four “key areas” of transformation: access to health services, equity in health services, quality of health services, and Black Economic Empowerment (BEE). The first three – access to, equity in, and quality of health care services, are essential (though not enough) to meet the goal of health for all South Africans. The fourth area is problematic. BEE aims to address the imbalance of apartheid in terms of ownership and control of “business and economic activity in the health sector whether for profit or otherwise”. In commercial terms this seems fair and even desirable, since it allows formerly disadvantaged and excluded investors to access the substantial profits generated in the private health sector. Since most South Africans fit into the “formerly excluded” category of investors, this sounds like a substantial expansion of the private sector. While equity in ownership is good, private ownership of health care institutions appears to contradict the Charter’s other, more fundamental goal of improving people’s health and access to health care. To achieve this, it aims to address “the compelling need to effect transformation throughout the South African Health Sector in order to remedy the wrongs of the past”. Private ownership implies a fundamental conflict of interest between meeting the needs of people's health on the one hand, and having to provide profits for shareholders and owners on the other. By its very nature, this market-based approach commodifies health services, creates and widens inequities in access between rich and poor and is anathema to the ideal of health as a fundamental human right. The recent report on health care financing and expenditure by Doherty and others shows how market operation in health care is widening inequities in access and service delivery between the private and public sectors in South Africa. South Africa spends around 8.8% of GDP, a relatively large percentage on health services with 3,6% and 5,2% in the public and private sectors respectively. Less than 20% of the population use the full range of services in the private sector, yet it accounts for 60% of health care expenditure. The Draft Charter acknowledges these inequities (2.2.7 (b)), but neglects to mention that they are growing: while the dominance of expenditure in the private sector increased over the past decade a growing proportion of the population became reliant on public health services. The two central goals of the CPPHS are irreconcilable. This attempt to achieve a more equitable investor profile by race, conflicts directly with the goal of equitable access to care for all. We believe that health is a fundamental human right. A South African Health Charter should reflect the right of all South Africans to the highest possible standards of health and well-being, regardless of colour, ethnic background, religion, gender, age, abilities, sexual orientation or class. We also disagree with the CPPHS’s narrow focus on health care alone and the statement that “health outcomes and life expectancy for the poor and medium income groups are generally worse than those for high income groups due to inequity in health services”. Health status depends on a range of social, economic and political factors that lie beyond mere health care. While equitable access to appropriate health care is essential for removing inequalities in health it is not sufficient. Health for all can only be achieved through a broad, intersectoral, comprehensive primary health care approach that entails people's full participation as embodied in the Declaration of Alma Ata of 1978, the South African Reconstruction and Development Programme of 1994, and in the People's Charter for Health adopted by the People’s Health Movement. This intersectoral approach is also embodied in the South African Constitution, which guarantees not only the right of access to health care, but also the rights to housing, sufficient food and water, social security, information and a range of other social and material needs essential for good health. A South African Health Charter must commit all parties, especially the state (since it carries primary responsibility), to the progressive realisation of the social and economic rights enshrined in the Constitution. The aim of health sector transformation should be to develop a health service that functions at all levels of health care delivery within the broader context of a comprehensive primary health care approach. It needs to explicitly incorporate a constitutional obligation to provide emergency care. This system must make no distinction in access and quality between those who can afford to pay for private health care and those who cannot. We welcome the Draft Charter’s concerns relating to human resources, in particular those related to the training, distribution, range of skills, and conditions of service of health personnel. However, it should recognise the health of health care workers as a good in itself rather than a mere requirement for efficient functioning of the health service [2.3.4]. Instead of lamenting what it calls “lack of respect for the human dignity and freedom of patients on the part of many health care personnel” it should make a commitment towards investigating and improving the poor working conditions in the health sector that lead to such behaviour. The fundamental flaw in the CPPHS is that it is preoccupied with health care and the privatization of health care rather than a commitment towards people’s health. Inequalities in health are fundamentally the result of social, economic and political inequalities which may have been rooted in apartheid but are now being fostered by a macro-economic policy based on the neoliberal orthodoxies espoused by global financial institutions like the World Bank, the International Monetary Fund and the World Trade Organisation. As a result, social and economic inequalities in South Africa are increasing rather than decreasing. The level of income disparity between African households (as measured by the Gini Coefficient) rose from 0.3 in 1990 to 0.54 in 1998, approaching the national figure of 0.58. Inequalities in wealth are the foundation of inequalities in health. Since extended privatization of health care as proposed in the Draft Health Charter is an integral part of the free market paradigm it cannot address inequalities in health or wealth. The Charter fails to recognize that it is impossible to reconcile the market with equity in health. Achieving health for all depends on the involvement of the community, civil service and government at all levels in an open, participatory process to address the root causes of ill health. If the health sector is to make a meaningful contribution it is the public sector, and not the private sector, that needs to grow. * This is an edited version of an article published in the South African Medical Journal: Reynolds L, London L, Sanders D. The Draft Charter of the Private and Public Health Sectors of the Republic of South Africa: health for all, or profits for few? South African Medical Journal 2005;95:742-743. We thank the editors of the SAMJ for permission to publish.