TEN YEARS after the end of apartheid, only limited moves have been made to tackle the entrenched inequalities of a health care system designed to deliver state of the art treatment to rich whites, but only the most rudimentary services for poor blacks. JOHN LISTER reports from Durban. W hat progressive reform that has
taken place has been restricted to introducing free primary care services, and free treatment for pregnant women and children under six.
But with many of the more isolated rural areas lacking even the most basic facilities, the country's over-blown private health care sector, with its emphasis on hi-tech and hospital care, continues to consume the lion's share (60 per cent) of health spending - even though only 20 per cent of the population can afford to use it.
The much-promised ANC proposal for a Social Health Insurance scheme that would draw contributions from workers in formal employment, effectively getting the poor to subsidise health care for the poorest, has yet to be put forward as policy.
Working people in need of health care face charges for treatment, unless they are covered by workplace insurance schemes. This has been an obstacle to eradicating some of the classic diseases of poverty and underdevelopment, which still take a hefty toll of lives
But so far ministers have only come up with a much more timid National Health Bill, which has been laboriously grinding its way through the parliamentary process for over seven years, and is now stuck awaiting the Presidential signature that would make it law.
Thabo Mbkei's hesitation in carrying through even this limited measure, which would regulate the private and public sector health providers, and seek to remedy inequalities in provision, stems from the bitter hostility to the measure that has been voiced by the private medical industry, and by the most prominent doctors' professional body the South African Medical Association.
They have focused their greatest venom on the provision in the legislation that would require any health facility to secure a "Certificate of Need" from the minister of
Despite the ANC's track record of favouring privatisation and of seeking collaboration with private sector providers, and despite the fact that the clause also applies to public sector hospitals, this has been read as a device to close down private hospitals in over-provided and wealthier urban areas, and to effectively compel them to move to the poorer, rural areas traditionally shunned by the private sector.
Cosatu, the trade union confederation, in its initial response to the Bill strongly urged that further measures should be brought forward to establish a system of National Health Insurance, which would ensure universal access to comprehensive health care, and allow all health services to be incorporated into the public sector.
The slow progress is perhaps most bitterly felt in the fight against AIDS, where new drugs have begun to show their potential impact.
Anti-retroviral therapy (ART) drugs A amlistered to women in labour
in Gauteng province have saved an estimated 58,000 babies from contracting AIDS in the last three years, according to researchers - restricting incidence of the virus from 33 per cent of babies to just 8 per cent.
However the progress has been far more disappointing in the wider fight against AIDS. Indeed the planned roll-out of the ART programme is running into problems, with just 3,600 patients receiving treatment so far in the 2004 financial year, way short of the target figure of 53,000. Researchers now argue that the £37 million budget for ART drugs would be enough for just 7% of South Africa's AIDS patients.
These issues were discussed at a recent conference of the Public Health Association of South Africa, whose leading members were long-standing and courageous oppospeech recalling that prior to 1994 "We thought we had only one enemy: apartheid, and only one solution: socialism. What has
"We have provided 80% coverage to prevent mother-to-child transmission of AIDS.
"But I still don't see the political commitment yet to rolling out the programme of
"We see the Director General's post is still vacant, and now we have a vacancy for the
The Health Minister herself has been quated describing the public sector provision as "in a shambles". Chronic shortages of resources in the more isolated rural areas have contributed to an exodus of doctors, dentists and other trained professionals - to the cities, to the private sector, or often overseas to work in developed countries for higher salaries - creating an atmosphere of growing crisis in public sector health care.
This has been compounded by the highprofile role of South African private sector medical firms in tendering for contracts to deliver elective health care for NHS patients in Britain. nursing staff being flown away from the health problems in Southern Africa... to deliver cataract operations to patients in Oxfordshire - one of the wealthier counties in the fourth largest economy in the take to work abroad, Britain, the US, Canada or Australia should be required to fund the training of five more," said one doctor, strug gling to maintain primary care services in a poor, rural community. hy sensible policy lies in the reluctance of the ANC government to interfere with the free workings of the market, or do anything which might in any way act to limit the inward flow of investment from the wealthi er countries which is seen as essential for economic development throughout subSaharan Africa
The general line of policy had already been established as one of collaboration with the private sector: this is in the very nature of the ANC as a cross-class liberation movement, and can be traced at least as far back as a 1991 speech by Nelson Mandela in the USA, where he declared that:
"The private sector must and will play the central and decisive role in the struggle to achieve many of these [ANC] objectives.... The rates of economic growth we seek cannot be achieved without important flows of foreign capital."
This same approach has informed the ANC government's leading role in promoting the New Partnership for Africa's Development' (NEPAD) - a continent-wide initiative launched in Abuja in 200l, aiming to resolve Africa's chronic problems of underdevelopment and dependency through encouraging additional direct investment from the main centres of capital.
EPAD is at pains to present itself as an African-owned and led initiative - but its objectives are clearly to reform and strengthen African states to encourage and facilitate a major injection of foreign direct investment.
As such, it seeks to embrace and repackage essentially the same neoliberal methods that have been urged on African countries by the IMF and World Bank for decades. Like the IME, NEPAD sees the solution to Africa's under-development and exclusion from the world's economy as "private sector-led
The founding document identifies "an annual resource gap of US$64 billion": "The bulk of the needed resources will have to be obtained from outside the continent."
The task of governments is to ensure that their countries "become attractive locations for residents to hold their wealth. Therefore there is also an urgent need to create condi tions that promote private sector investments by both domestic and foreign investors."
In other countries this has meant wholesale privatisation of state-owned corporations, big reductions in the public sector workforce, and a tax regime that leaves profits intact.
Partly because of this, the limited goals for health improvement are tied not to any commitment for long term government investment, but to appeals for a $10 billion per annum increase in external donor assistance, which -even if it were forthcoming - would leave health services dependent on the charity of the advanced economies into the indefinite future.
As an enemy, apartheid was vanquished ten years ago: but its grim legacy and another pernicious enemy, capitalism, still linger on feeding on the political weakness of the ANC leaders.
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