Perhaps the most cogent reason for introducing the NHI is that the constitution declares health care a right for all citizens, says the writer

Opinion - It is 4am, pitch dark and bitterly cold. Seventy-five-year-old Pushpa Naidoo (her real name) reluctantly gets out of bed, takes a bath and dresses warmly. 

She must embark on her monthly mission.

She gingerly goes to the kitchen and boils water for tea, which she fills in a small vacuum flask. 

She makes sandwiches from four slices of brown bread, using tinned fish chutney from the previous night. 

She packs a small faded blue insulated bag. 

After making sure she has her identity and hospital cards, she leaves home quietly, making sure to switch off all the lights and not to disturb her son, daughter-in-law and their three children, who are still asleep.

She walks past two cars parked in the yard and with the help of street lights she heads towards the bus stop 100m away from her council-built house in Bayview, Chatsworth, which her late husband had extended and modernised.

Despite the thick clothing she is wearing, Naidoo is shivering when she is joined by two other aged women and a man using crutches.

At 5am the foursome board a taxi for the RK Khan Hospital, where they will spend most of the day for their monthly medical check-up and to collect medication.

Naidoo is one of hundreds of patients who arrives at the hospital each morning for treatment; some are in their late 80s and even early 90s.

Many of these frail, elderly men and women are forced to use public transport and visit state hospitals in Chatsworth and Phoenix, although they have children who have luxury cars, hold good jobs and enjoy medical aid cover, which provides their young families with access to the best private hospitals and medical specialists.

Depending on the availability of doctors, it could be a long day for Naidoo, mostly sitting on benches. 

She sees many familiar faces and strikes up a conversation to overcome boredom. 

Many couples who are happily married must owe their wedded status to match-making that took place in the long hospital queues.

Mothers-in-law complaining about their heartless daughters-in-law; and fathers praising their successful sons, who care less about their parents' hardships, are the most common topics that make up the buzz in the hospital corridors.

It is well past 3pm when Naidoo leaves the hospital for home, carrying with her a bag of precious medicines for hypertension, diabetes and asthma. Near the taxi rank, using her meagre pension money, she buys samoosas and sweets for her grandchildren.

After preparing the evening meal in good time for her son and daughter-in-law, who return from work, Naidoo falls asleep in front of the television, too tired to catch her favourite Glow TV soapie.

I recount Naidoo’s torment when she must receive medical attention to coincide with the gazetting of the National Health Insurance (NHI), which proposes a system where there is universal, free health care for all, doing away with the two-tiered system: public and private health-care sectors.

Health Minister Aaron Motsoaledi has received bouquets as well as brickbats for the NHI plan, which is an attempt to address the inequities and scarcities of health-care resources in the country.

There is still much confusion over what will happen to medical aids when the NHI kicks in a good few years from now. Experts have warned that South Africa could lose many doctors if the NHI is implemented in its current form as the low tariffs will make them bankrupt.

The SA Society of Anaesthesiologists has warned of a mass exodus of doctors if the NHI is implemented recklessly. Did somebody say these anaesthesiologists are "unfeeling" towards the plight of the poor, who the NHI is intended to benefit the most?

The biggest criticism of the NHI is that its success is threatened by corruption, mismanagement of resources and poor quality institutions.

Most state hospitals in the country are in a deplorable condition because of ageing infrastructure, staff shortages and overcrowding of patients. 

Operating theatres and trauma units are summarily shut down because of a lack of basic supplies and patients are routinely turned away because of a lack of ventilators, beds, medicine, and even food for patients.

Critics of the NHI say that instead of building a new health system on poor foundations, existing facilities need to be urgently overhauled.

Public confidence

They say without overhauling existing state health facilities, public confidence will not be inspired and the system is doomed to fail in its goal of bringing about equitable resource allocation and improved health care.

Those who support the NHI say that universal coverage will reduce medical costs. Inflated costs for tests, hospital stays and procedures could be avoided by government monitoring. Drug prices could be negotiated as they would be purchased in greater bulk.

Not only will there be no bills, co-payments or deductibles (I will pay anything to see the smiles being wiped off the faces of smug and self-righteous medical aid company bosses) but doctors can also focus on patient care rather than waste hours dealing with medical aid companies.

In South Africa, the government spends 51.76% of the total health-care spending. Medical aids account for 82.8% of private health-care spending. 

This is in stark contrast to countries like the UK, where 83.14% of medical spending comes from the government and medical aids only make up 20.41% of private spending on health care.

The present state of our public health care is such that many people who can afford it flock to medical aid. 

This, of course, allows medical aids to charge higher rates due to the demand. However, people would be much healthier if more money in the private sector was spent on primary and preventative care.

Health-care costs would be much lower if people were treated by nurses and GPs before being sent to expensive specialists and to hospitals. 

Why, despite having medical aid cover from reputable companies, do rude and arrogant receptionists at specialists' rooms demand upfront payment of up to R1500 for the first consultation?

Only the tax man chases money more greedily than many specialists. Members must often be booked into hospitals, even if they are not seriously ill, because medical savings accounts have been exhausted to pay for the fancy German sedans in the doctors' parking lot.

Perhaps the most cogent reason for introducing the NHI is that the constitution declares health care a right for all citizens. It implores the state to ensure that this right is realised by all people, not only by those who have the financial muscle to do so. The NHI is designed to satisfy that part of the constitution.

Another convincing reason is that NHI is universal health coverage for South Africa, adopted by the UN as a sustainable development goal. Thus, this is a developmental imperative, and who in their right mind can stand against such a powerful development of the world?

No matter what technical argument the medical aid companies come up with to tarnish the NHI, the fact remains that private health care in the country is expensive and thus unaffordable to the majority.

In its present state, South Africa cannot afford a free market in health care. With people buying and selling medical services like other commodities, universal health care will never be reached. In such a system, only the rich will receive adequate coverage, and the poor and vulnerable will be excluded.

The NHI is more about making a reasonable standard of health care affordable to all people. Surely this cannot be wrong. When the NHI comes in, people such as Pushpa Naidoo need not make a torturous trip to a state hospital. They can visit the local GP for routine treatment.

However, the medical aid companies, who have the most to lose when NHI is implemented, will spend millions to fight the proposed universal health-care system. 

They have the financial muscle to engage embedded "key opinion formers" to do their bidding and rubbish the NHI in the media. They have fat reserves of moolah to take Motsoaledi to court.

In fact, one medical aid company is so rich that it offers credit cards. And this while Pushpa Naidoo munches her now-soggy tinned fish chutney sandwiches on a rickety hospital bench. Now is the time for level heads. The NHI is a vastly ambitious project that calls for public and private health services to work together to ensure that all South Africans receive the best of the most basic of treatments.

The aims of this project are not unique to South Africa, and we can learn much from other countries that have successfully implemented the NHI such as UK, Canada and US. While there is no finality on the exact funding of the NHI, it is anticipated there will be some form of pooling of revenue from the population in relation to their ability to pay.

South African citizens that can pay towards the NHI fund will have to do so regardless of whether they have a medical aid scheme or not. Payment for services from this pool would be related to need.

The NHI is based on social solidarity. We cannot continue with an unequal health-care system with half of the doctors in the country serving 16% of the population who are medical scheme members, and 80% of specialists being found in the private sector and only 20% in the public sector.

Like death and taxes, there will be no opting out clause for the NHI. There is no question about whether it will be implemented. It is just a matter of exactly when.

* Yogin Devan is a media consultant and social commentator.