20 June 2007

Health and healing - private profit from public misery

Pickled Bushman reviews Michael Moore's latest documentary: Sicko (or American refugees in Cuba) showing the ravages wrought by the privatisation mania on the American health-care system, which has slipped from being among the best in the world to 32nd place, just above Slovenia.

The same thing has struck South Africa, since neoliberalism took off in the Reagan/Thatcher years.

Actually the problem is not so much privatisation as commercialisation. One of the things that caused a huge slide in South African health-care services was the nationalisation of all church hospitals in the "homelands" in 1973. This has been documented by Dr Darryl Hackland, who had been Medical Superintendent of Bethesda Hospital (Methodist) in Zululand, and after it was nationalised became a senior official in the KwaZulu Department of Health. The church hospitals were run by "private enterprise", but the difference was that they were not run for profit.

In the 1980s there was a reprivatisation of health services, but this did not take place in the poorer areas of the country, but in the rich ones. The government at the time (under PW Botha) followed the Reagan/Thatcher ideology, and encouraged the formation of commercial clinics, in which doctors owned shares. It was privatisation for profit.

Medical Aid schemes have been infected as well. They were formerly socialist bodies, owned and run by their members, as a form of mutual aid. Now many of them are owned by outside shareholders. They no longer speak of members, but "customers". They no longer provide health care, but "products". They advertise, and refer to themselves as "financial services providers". Beware of any "financial services provider" that tries to sell you a "product". Whenever anyone uses the term "product" for a service, financial or otherwise, it is a pretty sure indication that they are simply out to rip you off. They offer "rewards", like club memberships, and cards that give you discounts in stores -- but be sure of one thing, you are paying for these things, even if you don't use them, and what these frivolities mean is that you get less health care for your money, because your money is being wasted on advertising and promotion and putting money into the pockets of shareholders.

The ANC when it came to power in 1994 has basically continued the policies of the National Party under PW Botha. There have been ritual pronouncements to placate their alliance partners, like Cosatu, but basically nothing has changed.

One thing they could do, for a start, would be to set up a tax structure so that not-for-profit mutual Medical Aid schemes are not taxed, and that commercial ones, making profits for outside shareholders, and ones that run superfluous "incentive" schemes not related to their core business are also taxed. (The same should be done for mutual building societies and life assurance providers.)

Also, "faith-based" and other non-profit private health service providers should be encouraged in a similar way.

I can't speak for other faiths, but from a Christian point of view, Jesus sent out his disciples to preach and to heal, and said "Freely ye have received, freely give." Before 1973, when the provincial governments subsidised church hopspitals, they got a better service for their money than they did when the central government nationalised the services, and then later devolved them to the "homeland" governments. Why? Because Christian doctors and nurses went to work in those hospitals, not for the sake of financial gain, but because of a desire to obey the command of Jesus to "heal the sick". When the government took them over, they found it difficult to get staff willing to work in the mainly rural areas where the church hospitals were to be found, and resorted to using army conscript medical students. Secular doctors were out for money, and only wanted to work in the big cities, where they could specialise in the diseases of the rich.

Doctors in private practice did, of course, have to charge fees in order to make a living. Even healers have to eat. But when they worked on their own, or in small partnerships, they could treat the poor and needy for reduced fees, or even, in hard cases, waive the fees altogether. Where, however, they work for clinics run as for-profit companies, this is much more difficult when the fees are paid to the company, and every reduction of fees for poor patient means a reduced profit for the shareholders.

The Orthodox Church has several saints who were medical doctors, and known as "anargyri" (silverless ones), usually translated into English as "unmercentary doctors". Among them are three pairs of brothers called Cosmas and Damian, perhaps because the later ones consciously followed the example of the earlier ones.

Until now the ANC government has done little more than try to force mercenary doctors, clinics and medical aid scemes to serve the poor. But it might do better to encourage the unmercenary ones, for example by differential taxes, as suggested above.

5 comments:

The Scylding said...

Well Steve, sometimes I fear that SA exchanged one kind of fascism with another kind of fascism. Not Cmmunism, as the fear always was. But facism, where the big corporations and the state feed off the people, keeping them just happy enough to be subdued - although I gather that that is not currenly going so well?

Steve Hayes said...

No, not fascism. We still have a liberal-democratic constitution, and the government is not trying to reintroduce detention without trial (as, for example, Britain is).

The neoliberals would say that political liberalism is not possible without economic liberalism, but I disagree.

The Scylding said...

Steve,

What are your thoughts around distributivism?

Steve Hayes said...

Scylding,

I don't know enough distributivism, but I do favour forms of "guild socialism", such as the cooperative movement, and things like mutual building societies and life assurance.

dionysusstoned said...

Interesting post. In fact, the point you make about the continuity between late apartheid neoliberal experimentation and the post apartheid approaches to the delivery of services like health care and basic services, is often ignored… even by the left. The religious idiom escapes me, but I appreciate the spirit. All I would add is that the political contexts of late apartheid had placed real obstacles to restructuring the economy along neoliberal lines. And here, both sanctions and an increasingly militant black nationalist movement structured the terrain that the botha regime needed to negotiate. In many ways the political transition that began in the 90s begun working to remove these obstacles. And the ANC government has been tremendously successful in this regard. Not only has the private sector in health grown, while the public sector has needed to weather the fiscal crises created by GEAR, but private wards have been opened up in many public sector hospitals. More broadly, the growth of the private sector in health has also increased the costs of providing health care in the public sector…so, for instance, the payment scales for doctors in public sector needs the be structured so that it is competitive with their earning potential in private sector. The introduction of the cold logic of the market into the delivery of health also means that more menial tasks with little market value (like the guys who wash the sheets), either get outsourced, or are consigned to impossibly low pay scales – which, no doubt, is one of the reasons for the public sector strike. The vicious logic of these processes is that further privatisation is seen as the answer to these problems…Okay I’m getting carried away, but while I can see the benefit of the state providing support to non-profit institutions who fill gaps in the public sector, far more crucially important, for me, is for us to grow and improve the public health sector.

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