The constitution is a kind of backup.

Interview with Prof. Louis Reynolds

People's Health Assembly, Cape Town 

In South Africa there are currently huge changes in terms of the health care system. Can you tell us about it?

We still have a two-tier system, public and private – with both sides being in crisis. There are massive inequalities between the public and the private sector, mainly as result of the government’s adoption of a neoliberal macroeconomic policy in 1996. The private sector has thrived since then and the public sector has drowned because of privatisation and cuts in public spending. But the private sector is in a crisis because it s becoming unaffordable and inaccessible. And the public sector, except for a few excellent institutions, is largely dysfunctional because of inadequate funding, poor management, and corruption. Staff morale is low. The public system is also unevenly distributed between urban and rural areas, between provinces, and even within metropolitan areas.

When the National Health Insurance (NHI) was first announced the private sector generally opposed it. They were making statements that it was unaffordable. But they are now becoming enthusiastic about it! They see that NHI is a good pot of money.

I believe the health minister is very committed to a genuine transformation of the health system to a comprehensive and equitable one in the pursuit of Health for All. But progress seems to be blocked somewhere and is not very transparent at all. I think there is a huge battle going on in the government about the restructuring of the health system.

There are 11 pilot sites at the moment, which are health districts in the country were they are attempting to implement the NHI to identify where the problems will be. But progress is very slow. We and a group of affiliated NGOs went to one of these pilot sites two weekends ago to run workshops with the community in one of the townships and assess progress. It was striking to see how little the people knew about the NHI. There is a huge lack of communication. People gave testimonies about their experiences with the local health care system. Many of them were waiting since four am in the morning to be first in the queue. There is a gap between intention and result, despite the apparent enthusiasm about the NHI.

So the private sector is enthusiastic but the people are not?

No, I think the problem is that people on the ground don’t know much about the NHI; particularly in the poor communities. So we have this paradox: the government wants to implement it, the private sector has changed its view and become enthusiastic, and the NGOs and Civil society are in favour but are critically watching the process and are campaigning around it. Yet there is very little progress. This means that somewhere behind closed doors a struggle is going on. And in my view it’s being waged by people who have vested interests in the NHI as a means of making profits from health care. The battle really is between a comprehensive and equitable public health system and a health system that depends on Public-Private-Partnerships and the profit motive.

Other countries are also in transition. Are there certain examples you are looking at?

The model that we are looking at is Brazil, which has made huge strides in the last few years. It managed to extend its health service to remote areas and also tackled social and economic inequalities. That’s the example the government is looking at – actually all of us are.

South Africa has quite a vibrant history – also in terms of the struggle for the Right to Health. Can you tell us about it?

What we mean by the Right to Health is not only an universal accesses to essential health care, but also the social, economic and political determinants of health, which are embedded in our constitution as social and economic rights. So we really mean the whole package of social and economic rights that are essential for health and living, plus universal access to essential health interventions by the health sector. Essentially, this implies the primary health care principles as embodied in the Alma Ata Declaration.

There is been lot of progress in terms of improving access to water, sanitation and housing, but there massive inequalities that remain. In terms of income it’s the most unequal country in the world or at least right up in the top. So the social determinants of health are still a huge problem. The fact is that many people are living in conditions that make them sick. And the health care system is not really meeting the requirements either.

Under Apartheid the majority of the population were denied access to quality health services and some of them were even denied total accesses. That led to small and medium community-based projects around health in the townships and informal settlements organised by health professionals and others. Many of these came together in the National Progressive Primary Health Care Network in 1987. Together with associated organisations they were mobilising and advocating for a comprehensive primary health care, preparing the ground for the post apartheid situation.

When the transition came to democracy civil society kind of went to sleep. There was an assumption, I think, that a good democracy and a new rights-based constitution would achieve universal access to an equal society and comprehensive health care. At that time the ANC was a banned organisation mainly in exile. But within the country, South African civil society was vibrant, fiercely democratic and generally coherent under the United Democratic Front (UDF), launched in 1983 to oppose the increasingly repressive apartheid government. The UDF gave people dignity and a voice. In my view the UDF, with the Congress of South African Trade Unions (COSATU), constituted the most effective opposition to Apartheid.

When the ANC was unbanned and the dismantling of Apartheid began, the UDF was dismantled. This was one of the huge mistakes in the transition to democracy. Effectively, it removed the bottom-up, participatory democratic culture that the UDF spawned and which is so fundamental to the PHC approach. Civil society became fragmented and people’s power was surrendered to the ANC.

Then the Treatment Action Campaign emerged in response to the new government’s inadequate handling of the HIV/AIDS pandemic and its refusal to deliver antiretroviral treatment. There was, at the level of the state, a sort of denialism about HIV and the effects of Antiretrovirals. Civil society is once again becoming more active and vibrant, and there are for example women’s health projects, rural struggles, workplace struggles; these struggles ranged from grassroots levels to campaign groups. Not all of them are explicitly about health, but they are broadly looking to address the social determinants of health.

Now that ARV are available (in fact the government has been very successful in rolling this out), the focus is shifting to broader issues like food prices, access to toilets and sanitation, work, housing and struggles around the NHI scheme, which many people don’t know anything about.

The NHI process has been rather non-transparent. Interestingly we had a National Health Assembly in July, convened by the People’s Health Movement. We invited people to submit health related issues and organise workshops at the assembly. And one of them interestingly was organised by an organisation called the Benchmarks Foundation about the health impact of mining and the extractive industries. There are huge struggles around working conditions and health in the mining industry and the local and global ecological impact. These are now drawing world-wide attention in the struggles around the South African platinum mining industry.

So the struggle around health in South Africa is really very multisectoral. At the moment we are focusing on the NHI but also supporting organisation, which are working on the broader social determinants.

The Right to Health in South Africa is embodied in the constitution since 1994. Only written words or rights?

The constitution is still there, but its legitimacy is threatened by the gap between what it promises and the reality of people’s daily lives. But people are using it in litigation around the progressive implementation of social and economic rights, e.g. in many provinces there are huge problems with the education system. Our school year starts in January, but there are schools, which haven’t had textbooks delivered even today! That’s a violation of the right to education. So, one of our partner organisations called Section 27, because that’s the section in the constitution, which includes the social and economic rights, is taking the government to court. The constitution is there as a kind of backup. But really we need some experience in constitutional democracy; we need to use it more, to force the government really to do its job.


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