no chef thank you and thank the opportunity to present on the national health insurance and its importance for us in South Africa and what we’re trying to achieve as a wider society I don’t know if we can call the presentation up the technical guys then I can actually talk to my slide you can see from the title that I see the whole process of a project problem you had a society I think maybe being created an idea of establishing a new kind of coffee service which can be in process together across the social divide is idea behind scientific move on to play in South Africa and this is the first opportunity person I before that this equation is not an external patient that it’s close the condition of the poor as mix little happy especially all the places and the position of the little gloves in society I think the debate about establishing you can offices in the idea of what kind of society do we want to live in a South Africans and not externalize the problem as something about how do we create access for poor people to health care but also talked about how we contribute as citizens or more privileged from the middle classes largely both in terms of being part of the political elite the policy leads and other sick professional sectors about what choices are we wanting to make about creating a new kind of South African society and I absolutely believe that the debate around the national health insurance proposals and houses all will be a litmus test for the kind of society we want to create in South African that will either be a more polarized fractured society based on on class and social and racial inequality or more inclusive society so I think we should lose sight of that bigger agenda and that’s why i call my title the kind of future society we want to create in South Africa sorry mrs. Cole I so so just to reflect on what we confronting in terms of looming crisis we have an unsustainable two-tiered model of healthcare provision and it’s a crisis that also confronts the middle class in terms of actual spending we find that South Africa is well within the range that the w/l recommends for for spending of a country of our size however it’s deeply and equitably split the split of funds the total GDP flows into a North k you find that four point one percent of the total funds or fifty percent of the total funds is only utilized by sixteen percent of the population and remaining fifty percent eighty-four percent of the population has to deal with and those are people who don’t have the means to afford private forms of cape so if South Africa epitomizes anything it’s an anti-social solidary stick model it’s kind of perhaps the par excellence example of an anti-social solid or a stick model where there’s a complete bifurcation between access to health care between the private and the public sector based on someone’s class position and also they played by market position so to speak but for the middle classes is also becoming increasingly unsustainable because private allocate costs have increased by under twenty percent over the last ten years and it’s a based on an unsustainable commercial model of health care provision which deflects a mismatch between services and costs okay and we have 102 medical aid schemes where the costs in terms of people accessing those medical aid schemes packages in terms of the average wages increased from seven percent in the 1980s to thirty percent by 2008 so increasingly you’re going to find it more and what is happening at the moment that more middle class people actually squeezed out of healthcare service provision they can’t afford the costs and so it’s a huge issue for the middle class about how we get a more affordable system of public health care of sufficient quality that the middle class can also buy into okay so a setting is a crucial question I don’t think the issue of a new kind of al case something that is separate from the position of the middle class in terms of their health care but the alchy needs into the future but another telling indication of the social the actual lack of social solidarity in the system is that in fact the state incentivizes the private sector health care system through the medical aid subsidies that it gives to essentially professional employees that amounts to 10 billion rand so that’s a gift of the state to the middle class okay for providing a differentiated form of alph k a level of quality that’s not seen in poorer sections of our society but in fact is the mechanism by which this anti-social solid or a stick model is reproduced it soon as medical aid this tax subsidy that I get as a professional works at Rhodes University who accesses medical aid scheme part of which is subsidized by the state which allows me to access private medical k in a place like grahamstown and if I’m probably sure

have a domestic worker that domestic worker can access their quality of care the dependent on the public system of K so there’s no cross subsidization happening and in fact it’s in the antithesis of a social solid ristic model okay and the cost it’s the extremity of the differentiation reflected in the fact that private patients 11,000 hundred and fifty and spent on private patients compared to 2700 60s in per capita on public patients and the whole human resource structure is geared towards the private sector with fifty-nine percent of doctors ninety-three percent of dentists eighty-nine percent of pharmacist all in the private sector okay so the whole system is geared around meeting the needs of the private k sector and those who have the privileged access to to to to to excess private healthcare and it’s a completely unsustainable model okay and that’s where the national health insurance proposals coming to play oh sorry oh sorry what got you gone this life I think what’s very important is the language of the national health insurance is a most nomer because in fact it’s not insurance based model what’s being proposed is a text based model it’s much more consistent with the National Health Service for example the one that we have in the UK so and I think there’s a politics about why the insurance is privileged in that idea of a national health insurance model but I think we should issue a thousand idea that what we’re talking about is an insurance based model it’s actually a national health service and as groups within civil society in the wider populous and the between people coming from professional positions we have some policy influence we should reaffirm that the objective is actually to establish a national health service okay and part of the elements of a national service is that it’s about universal health care access and that’s what the image I proposals are talking to that they want to extend universal access nervous Africa that’s incredibly a radical proposal because what it’s arguing is that everyone regardless of the social position and the financial position should have access to a basic basket of health care okay and that shouldn’t be means-tested that’s a complete and radical departure from social policies that we’ve had since 1994 which have been mainstays which have been selective and which have been exclusionary and what it allows us it allows us to talk and cook and co here around language of creating a far more inclusive society because we are we are we are attached by this idea of a universal approach to healthcare provision okay some of the nhi objectives are to improve access to quality healthcare provide financial risk prediction put of cost subsidisation and provide an essential health care package so the package the set of proposals itself is trying to break from this tradition of an anti-social solid aristocrats increasingly about the middle class working with other social groups like the poor the unemployed to pull health care resources in a way that health care can go to those who need it not on the basis of the ability to pay button the basis of need again a radical proposal for south african social policy into the future and then the principles i think are the crucial ones we I think us as the civil society groups need to go year round it’s about right to access we’re off you’ll be free at the point of delivery and that of course gives effective constitutional principle that everyone has the right of access to healthcare services and it’s the state’s responsibility to right to realize have social rights it’s also crucially crucially about social solidarity and that has not been a principle that’s been encoded in South African social policy since 94 since 94 it’s been about how we deal with the poor as an external category about how we develop policy that deals with this condition while the middle class are in luck in largely specs divorced from the problems of poverty and inequality this idea of social dollar that darity as embedded in the nhi principles completely breaks with that tradition because embedded in the agenda that’s being proposed is the idea that this can only succeed the middle class by in to a universal system of alchy provision and it will fail if we can’t get the middle class to buy into this health care provision in real terms one of the things and one of the consequences of the effect of these proposals is that the middle class needs to consider giving up the tech subsidy there’s ten billion rand that they get to access private gear and to pull those funds into a single fund so the healthy can go to those who need it and that’s a big choice that the middle classes going to have to confront and I think it comes back to the issue of the consciousness of the middle class in realizing and seeing the need to achieve that objective and it’s also based on equity crucially that those with greatest health care need are provided the timely axis and expansion of access to quality care to vulnerable groups and I think one has to contextualise is what I would argue as we store in a social policy that these proposals are absolutely an indication of a social democratic approach to healthcare provision whereas key is an entitlement of social citizenship it’s not an installation it’s an entitlement of social citizenship and it’s based on cross cross cross class solidarity for universal provision of public goods and I think that is the real radical and the pinning of this agenda I don’t think we should lose that agenda the principles

and the values that underpin healthcare provision into the future okay so i’ve talked about equity social solidarity try to access why those are important i won’t talk to the model implementation because dave will be dealing with that and i think i want to make a point about the battle of ideas because that’s what’s happening in South Africa at the moment you’ll see that a lot of government’s attention is towards the development of a developmental state however an arts frame is quite exclusion the example mr. president zuma said we are building a developmental set another welfare state and the social grants will be linked to economic activity and community development to enable short-term benefit issue to become self-supporting in the longer there’s a sort of a polarization between the idea of a developmental state and a welfare state and it comes back to this idea the wealthy state causes dependency as a kind of rehashing of kind of a new liberal language as we saw in fact I’d written in the 1970s Wade essentially there was an argument that state needs too poor to pull back the market needed to provide people social needs for people social needs and social goods however and this is where the battle of ideas coming if you actually look at ANC policy it talks to universal primary pation it talks to a national statute social insurance arrangements it talks to and of course most importantly the national health insurance proposals which are about Universal axis and the main source of revenue being an nhi fund which will be taxed based ok now these are all the key attributes of a Social Democratic policy to policies so there’s a policy schizophrenia in the ANC on the one level is talking about its developmental state and privilege economy is Amon the other level in terms of substance of social policy it’s completely about a social democratic approach which is about universalization of social provision the visualization of public goods based on cross cloth social solidarity and I think that’s where we need to locate ourselves in terms of these battle of ideas now I think what’s quite important is to also understand that that embedded in South African is in the policy is three is deeply a deeply embedded is this idea of a national health service and one that is universal and that one is which we just a provided and I think the starting point for me is to look at for example the clockman commission of 1942 to 1944 perhaps the most radical set of proposals that ever merge about health care reform in South Africa in fact I would say that he’s the most radical form of proposals that emerged it seriously Blackmon was in set in the in the 1940s it was a committee of the split of the of the smuts government of the time but was led by a radical progressive call hindi gluckman and what his vision was to establish a national health service in South Africa that would be a non-racial that we democratic and that would be based on preventive health care and in this these prognosis of the promise of South African health care was that the mere provision of mere doctoring would not provide more health so he said she was pushing for preventive health care model he talked to the problems of south africa noffke being a spectacle of divided control for coordination overlapping email distribution and gaps and a crazy patchwork of provision we know this because this is very similar to what we have currently and he also talked to the proper integration coordination of the various health service would be better achieved if the services nationally planned and directed so essentially Gutman was arguing that if you want to achieve a national service in South Africa if you want to have provision for all citizens in the country you need you to nationalize out the health care services and that would need it to be based on the surrendering of the provinces of the control of the healthcare services so the state needed to take control of our services and the delivery of the health services will be D answer lies in 220 regions and be based on 400 preventative health centers and he was very influenced by the work of Sydney we developed the Palais experiment the preventive health care k model and crucially say that would be based on essentially funded health packs and the principle is kind of epitome of a social democratic approach which you said that health care should be founded on equitable basis from each in proportion to his means instead of inequitable from each according to the gravy’s ill health and this is proposals it emerged between 42 and 44 okay and what’s crucial as well is also to indicate the historical support for these proposals you found for example the civil society groups including the trade unions the political parties the ANC the Communist Party of South Africa a fully supportive or the glassman proposals and I think it’s important to reflect on what the medical association of South Africa were willing to say about these proposals they said we are prepared on our own initiative to surrender some of our independence and to become to some extent a socialized profession so the medical associate of South Africa in the 40s was saying is we prepare to be socialized in fact we prefer to be socialized but we know that in terms of where the country is politically what we need to establish is a national nationalized healthcare service so this is the depth which there was the support for a national service in the 40s and this these proposals of course failed to be implemented course much rejected the idea that the

provinces should the control of health care should be taken away from the provinces and so the the proposals were shuffled and I think part of I historical agendas how do we reclaim the impetus of what Gluckman represented was which was the impetus towards establishing a universal national healthcare service but historically you found that the idea of a national service was also very deeply embedded in the NC for example the NC and the Coomer produces very important historical document called applicant claims which had a bill of rights and which represented I would argue the first emergence of social democratic approach to to to serve this African state you talk to the right of every child to free and compulsory education equality of treatment with regards to income maintenance and most importantly establishing will free medical and health service for sections of the population so that’s anc policy in 1943 peps the most crucial NZ document to emerge in the 40s the document called African claims it’s reflected again in the Freedom Charter under which we were truly was the head a right to the free state provided healthcare prevented an scheme scheme to be run by the state free medical and healthcare hospitalizations provided for all special people so you can see that is storica this idea of a national service and in fact I would argue a Social Democratic health care service is very deeply embedded in anc III and there’s this culture in flicks a discourse it was influenced by what was happening in Britain at the time which was at this Labour Party establishing the welfare state based on universal access of the poor and the middle class to a single form of a provision and then there was this cross filtering of ideas and I think we need no Smith must not lose sight that embedded in this idea of a national TV audience in South Africa is this very strong powerful policies 3 which is aiming to establish a national service and I would argue that what we’re trying to achieve here is the completion of this incomplete historical project which is establishing a south african national service which will be more inclusive of course after 1994 you found that this again reflected in key policy documents like the LDP base document was the idea of universal provision of social policies including preventive health care service a national scale services reflected in the antis election manifesto it’s reflected in the nineties in anc policy thinking about establishing a national service as reflecting the National Health practice African 1994 what I’m trying to argue here is that these are being a complete consistency of ideas around establishing a national service but that those ideas are displaced after the NC comes into power you found the group around the gear economic frame become a demonic and is the displacement of this Universal idea it’s about then means-tested it’s about the poor becoming external category about the middle cause being separate from an agenda of an inclusive approach to trans forming South African alpha can you saw that in the document that emerged the white paper on the RTP for example at language of affordability cost containment privatization there’s a shift from a social democratic language is an abandonment of that language okay and that’s most tellingly consolidated in the gear program an important secret social policy of gear is at revolution restraint that fiscal restraint of reducing the fiscal deficit to three percent which means it was a massive squeeze on social expenditure and that was there was the decisive break with the social democracy of Social Democratic agenda however the okay I need to wrap up I think we all want to end it is to say that what we’re finding here is that it’s absolutely in the interest of the middle class to be engaged in this debate around establishing a national service let’s call it the NH I that it is about how we create a new kind of society how we create a new kind of capitalism econ test this idea of capitalism that is not a lousy fake apple is Amit we looking for that is a most social democratic capitalism maybe that’s the roadway to a socialist possibility i hope it would be but i think that’s where the level of the contestation has to happen and that it’s about coalition building and social compact thing with the value basis around universalism and social solidarity I think the energy I proposals in Minister wat so lady gives us a profound opportunity to reclaim that V distributive agenda that’s historically embedded i think in NC policy since the 1940s and i think the political education issue it’s about the middle classes now i think it’s about the consciousness of the middle classes and getting the middle classes to increasingly buy into the idea of universal public goods like for example a national health insurance system I think that’s absolutely possible and I’d become clewd that where the foci needs to now rest is to reclaim this historical agenda by talking about establishing a national health campaign a national ad campaign that can bring together social groups across strata and bring the middle class into a coalition that can start to blue taught to talk to the establishment of a universal National Health Service in South Africa that the middle class can participate in equally with other sectors of society and I think if we can achieve that then we will create the Brighid to the possibilities of a new kind of

South African society a new kind of inclusive South African society which we all settling and still struggling to achieve since we achieve democracy in 1994 thank you