Conference of the Democratic Left (Western Cape) Draft Report on the Public Meeting on the National Health Insurance 30 August 2009 1. BACKGROUND AND INPUTS On Saturday, 22 August 2009 the Western Cape Interim Steering Committee of the Conference of the Democratic Left hosted a successful public meeting on the ANC’s proposed National Heath Insurance (NHI). This meeting was held at the SAMWU Hall in Athlone. More than 100 activists (at least 103 people signed the attendance register) attended this important public meeting. These activists were drawn from a wide range of communities and organisations. Amongst others, these included NEHAWU, SAMA, PAWUSA, the People’s Health Movement, the Treatment Action Campaign, the Social Justice Coalition, Amandla, Conference of the Democratic Left, Lorna Mlofana Campaign, Iinkanyezi Zangomso, BWA Women of Action, Isakhumzi, the New Women’s Movement, SANCO (Delft), WOSA, CEJ, the Delft Integrated Network and individual members of the ANC. The meeting received introductory inputs (slide presentations) from Professors Di McIntyre and David Sanders who have both contributed significant preparatory research expertise for the ANC and COSATU affiliates on the envisaged NHI. Prof. McIntyre is Associate Professor in the Department of Public Health and Primary Health Care at the University of Cape Town (UCT) and is the Founder and Director of the UCT Health Economics Unit since 1990. She has done extensive research on the question of inequalities in health and health sector reform. Prof. Sanders is a leading health activist with the local and international Peoples Health Movement. He has also for many years been the head of the School of Public Health at the University of the Western Cape (UWC) and has enjoyed widespread international recognition for his work on the socio-economic and political determinants of health. In summary, the inputs covered the following aspects: i. Key South African population and health indicators comparative to other countries; ii. The state and political economy of health-care financing (public vs. private sectors) and an overview of health-care financing trends since 1994; iii. Key aspects of the health policy framework relevant to the NHI policy debate; iv. Problems that characterise the deep systemic public health crisis in South Africa - human resource issues in public and private health sectors, hospital management failure, shortages of drugs in public health facilities, urban versus rural inequalities, etc.; v. The political economy of the social and economic determinants of health; vi. Key features of the proposed NHI, how it fits to the analysis of the above issues and how it can potentially address the identified problems. The meeting noted that these introductory inputs were limited by the fact that both speakers could not speak to an actual policy document that had been released for public discussion. The meeting also noted that a version of the ANC NHI policy discussions had been leaked to the private sector. Having noted these, both introductory inputs suggested the following as key features of the proposed NHI: i. The expansion of health coverage to all through the removal of financial barriers to accessing health care, equal coverage to access comprehensive & quality services and the provision of free health services at the point of use with no upfront payment; ii. The provision of a comprehensive set of health services – i.e. in primary care, inpatient & outpatient care, dental, prescription drugs & supplies - provided on a uniform basis at all health facilities; iii. Publicly and privately delivered health care – i.e. under the NHI, health services will be provided by private & public sectors, paid for by NHIF. All providers will be accredited to meet quality standards. The NHI is envisaged to be a publicly administered single-payer fund which will receive & pool fund from which it will pay services on behalf of the entire population; iv. The achievement of social solidarity wherein services delivered will be based on need rather than on ability to pay. This is seen as ending the dependency of health on access upon employment status. Those who can afford to pay for health care will subsidise those who cannot; v. Funding for the NHI is proposed to be a combination of current sources of public health spending (including removal of tax subsidy for medical schemes), a mandatory or compulsory contribution by employers and employees which will be equally split. The mandatory contribution is aimed to be less than what workers and employers pay to medical schemes. Certain categories of workers, due to their low income status, will be exempted from the contribution; and vi. Implementation – the NHI is envisaged to be implemented in a number of stages in next five years. Before implementation the government promises to consult with all sectors affected, especially the workers, employers, health care providers, suppliers and health funders. These inputs were followed by lively and critical debate from the gathered activists as well as an extended input from the floor by Mark Heywood of TAC who had especially traveled from Johannesburg to attend the meeting. In summary, Heywood’s input was: i. The NHI is an opportunity to advance public sector health reform and investment and sensible private sector regulation if approached properly and strategically. Therefore, the NHI should be supported in principle. It is important to keep progressive forces in the NHI discussion in order that they are heard and not misrepresented; ii. The proposed NHI intention of increasing cross-subsidisation by the wealthy of the poor to the whole system (rather than just within medical aids) is necessary; iii. The NHI is premised and dependent upon radical and rapid reform of the public sector, combined with regulation of the private sector; iv. On its own (as a health financing mechanism), the NHI will not automatically deliver quality health care. It is possible that it could increase inequality because although there will be a single funding pool, much of these funds will go back to the private sector if the public sector is not able to compete in quality and access of services by the time it is introduced - further deepening inequalities; v. The NHI could potentially distort the public health system as people are more likely to choose the better public services as their 'provider of choice' and once again it will leave people in rural areas in the cold because they will not have providers if the public service is not improved; and vi. Unless the public health sector is drastically improved, the NHI could lead to workers and middle class people paying three times for health care (through tax, the mandatory NHI contribution) and then still remaining with the need to purchase medical aid. 2. APPROACH TO THE NHI In summary, the key points that were raised as constituting elements of a progressive left and popular response to the NHI proposals were as follows: i. It was unfair and disabling that the ANC is withholding its NHI policy discussions from the people who are meant to be its beneficiaries. This can have the effect of some of the progressive aspects of the NHI document being diluted and compromised by the time it is released for public debate. It is even possible for it to be reconfigured to rescue and subsidise sections of the private health care sector. Even before NHI policy documents are released publicly, the private health care industry has launched major attacks on the proposal fearing that their capacity to profit from health will be curtailed. ii. Together with recent and ongoing health worker and community struggles around working conditions and the standard of the public health services, the NHI policy discussions have helped to wake up poor people and the progressive left to health reform struggles and issues. iii. The potential advantages and disadvantages of the NHI were noted. The NHI has the potential to provide affordable health care for all. This would be a major step forward in improving the lives of the majority. No one can be under the illusion that such a plan could work without being accompanied by major initiatives to improve our collapsing public health care facilities, funding, staffing and management. iv. The NHI debate gives popular and progressive forces an opportunity to actively promote and demand public health sector reform towards an efficient and decommodified national public health system that is necessary for the NHI model to have any chance of working. The meeting supported the notion that the NHI debate must be broadened way beyond a limited focus on health care financing to also include the structuring of health human resources. Specific discussion referred to the importance and roles of community health workers, nursing assistants and the need for a health worker education system and programme that are relevant and effective. v. Other key issues that came up in the discussion are noted as possibly including: a. What the NHI seeks to address current challenges in the public health system; b. Whether the nationalisation of the private health sector may be the ultimate solution to the public health problems discussed; c. In the long-term, the need and importance of a wider struggle on health that focuses on the right to health as encompassing the entire set of social and economic determinants of health; and d. Whether there will be universal coverage for all living in South Africa or whether non-nationals may be excluded. vi. Popular forces and the left need to impose their stamp on the NHI policy debates to ensure its radical potential is realised and the meeting of other progressive public health reforms. 3. DECISIONS Following the above discussion, the public meeting took the following decisions: i. Available documents on the NHI policy discussions must be released and circulated widely; ii. There must be a public campaign that mobilises popular (community and worker), progressive and left voices on the NHI. The campaign must build from existing community and worker struggles on health issues. The campaign must be driven by community organisations, trade unions and shop-stewards organised around local health facilities; iii. The campaign must also focus on, and link the NHI to demands an efficient and decommodified national public health system; iv. The campaign must also take the format of mobilising, soliciting and consolidating conscious and informed input from ordinary people who use the public health system – their experiences, energies, interests and aspirations must be brought to bear on the campaign as well as the ultimate form and content of the NHI policy document; v. Progressive and left research and popular documents on the NHI and the health crisis must be produced and disseminated widely as part of the campaign; vi. As part of the campaign, there must be a People’s Conference on the NHI and the Public Health Crisis. This conference must discuss and develop policy proposals, build solidarity and ongoing campaigns behind the overarching demand and goal for an efficient, decommodified and universally available public health system. The meeting directly called on the Treatement Action Campaign, the People’s Health Movement of South Africa and health sector trade unions to work with those at the meeting thereby bringing their social weight and resources in organising such a conference and working on the proposed campaign with a wide range of progressive forces. vii. The meeting formed a Campaign Committee that met briefly after the meeting and decided to hold its campaign planning meeting on Saturday, 5 September 2009. Amongst other things, this meeting will also finalise this draft report.