Reflections on PHASA 2019: The Right to Health 25 years into our constitutional democracy

The annual conference of the Public Health Association of South Africa (PHASA) took place in September in Athlone, Cape Town. The theme - The Right to Health: 25 years into our constitutional democracy - enabled reflections on both the gains of the past 25 years and the worrying failures and persistent issues that have not been overcome. This blog reflects on key themes in the conference discussions.

 

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A look at the gains and failures presents a sobering picture, in which health inequity and economic inequality are inextricably linked at the heart of the struggle. As various panellists pointed out, the face of poverty in South Africa is still female and black and disparities in access remain starkly divided along racial and spatial (urban vs. rural) lines. It was also clear that, with 25 years behind us, taking stock, learning from the past and mobilising experience and knowledge from across the health system will be critical – especially in the context of current reform towards National Health Insurance (NHI) and Universal Health Coverage (UHC).

Using democracy and health as a lens highlights the fundamental importance of a citizen-led health system, asking important questions about whose involvement the current system favours, whose involvement needs to be enhanced and how this can be achieved for a health system that encompasses all people. With the NHI Bill currently in parliament, the conference offered an important opportunity for the PHASA community to consolidate a shared commitment towards contributing substantively in this phase of participatory democracy.

The conference organisers developed a guiding statement for further action, the Athlone Declaration. PHASA members will also be making an official PHASA submission on the NHI Bill in parliament. Beyond these formal steps there was a general sense of energy uniting the PHASA community to participate meaningfully (and politically) in the public democratic processes that will shape our health system. Many of the conference’s discussions extended beyond the sessions themselves, spilling into tea time, lunch breaks, and the Twitter-sphere. This blog consolidates a few of these discussions.

 

Whole system change is needed
While there is broad consensus on the financial principles in the NHI Bill, many delegates felt that NHI as a financing mechanism alone will do little to bring about the change needed in our health system. Indeed, it could very likely undermine the progress made in the past 25 years, especially in the public sector. Rather than just a financing mechanism, we need people-centric, whole system change that tackles a wide range of health systems issues.

An example of this – and a recurring theme during the conference - is community health systems and community participation in health. Not only do community health systems align firmly with the principles of primary health care, they also provide valuable sites of learning for health system decentralization. Community participation thus becomes more than just a nice-to-have. It can build accountability, local responsiveness, and serve as a fundamental pillar for the further democratization and strengthening of our health systems.

 

Trust in a strengthened public sector must be rebuilt
A vital component of NHI reform will be rebuilding the trust which has been heavily eroded over the years – especially in the public sector. Trust-building processes are important and need to be “deliberate, transparent, inclusive and ready to manage inevitable disagreement”. But building trust will only be possible if we make concrete gains in strengthening public sector services. We need to recognise quality of leadership where it does exist in the public sector and “grow this good”. The risk that the upcoming phases of NHI will undercut this potential is substantial. As Di McIntyre pointed out: we cannot have NHI conditional grants earmarked to purchase vertical interventions from the private sector, thereby cutting public sector budgets and perpetuating the narrative that the private sector can do things better.

 

We need space to learn by doing
After 25 years of establishing our health system, there is a wealth of experience and knowledge to draw on. Yet much of this knowledge is messy, complex and obscured by processes of auditing, monitoring and evaluation that fail to consolidate responsive learning potential and space for reflection. One conference session focused on embedded HPSR research, looking at how to grow “learning systems” where all kinds of knowledge, including experiential and tacit knowledge, are brought into the fold of “legitimate” evidence. This session highlighted how much of this work relies upon building relationships of trust and accountability and putting people at the centre. Frontline workers and managers in particular can act as key intermediaries for successful implementation and should be supported to learn by doing.

 

Public sector and civil society must shape the NHI conversation
Social solidarity through cross-subsidisation is a major principle underpinning NHI. Yet it has largely failed in generating support for health systems change in South Africa. Instead, our fragmented and segregated society finds it immensely difficult to galvanise across race, class, generations and spatial regions – a weakness that private sector media often prey upon to produce an NHI narrative based on fearmongering and individualism, which is highly counterproductive to meaningful engagement.

While there is no need to sugar-coat the draft bill’s weaknesses, the average news headline would have us believe that the NHI is inherently doomed to fail. Currently, the dominant narrative is driven largely by the private health sector, and is primarily concerned with middle class and elite interests. There is a dire need to counter these narratives and present the pressing reasons why we desperately need this kind of reform – a complex set of reasons that need to be communicated simply and accessibly to widely variable audiences. Several conference sessions purred on this conversation.

Galvanising our society around NHI will need a cohesive social movement for health – one that builds inter-generational, cross-class solidarity around health and stresses the urgency of putting “people before profit”. We must be able to engage the general public on the complexities and nuances of NHI and UHC – and generate a sense of public ownership of and participation in our health system and its reform. As described by a conference delegate and grassroot activist, “We don’t care about all these alphabet letters – UHC, PHC, NHI whatever – what we care about is quality health care”. The People’s Health Movement have proposed a model for this with the “People’s NHI” – an idea that needs to be seeded in the public and media discourse on NHI.

We need modes of collaborating, translating and communicating across publics in the interests of a just and equitable health system. This will take awareness building, organisation and concrete action – at the grassroots level, in our homes, and across the public health care sector. A reform as major as NHI is fundamentally about politics and power. As one panellist stated, “now is time for the public health community to take back its power” and make ourselves heard. It is imperative that we convert these PHASA conversations into actions that engage the political forces currently dominating the shaping of the health system.

*** PHASA is organising a parliamentary submission on the NHI Bill. Click here if you are a PHASA member and would like to add your comments. The deadline is 2 October at 7pm ***

 

Manya van Ryneveld, researcher at the School of Public Health, University of the Western Cape

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