The State has a role to play in the provision of health services: We must get the balance right

South Africa has a health care system that works well for some - the quality of our private health care is among the best in the world. However, most South Africans are excluded from it. They have to rely on the public health care system, with its long queues, frequently empty medicine cupboards, and shortage of doctors and nurses.

A Monitor survey in 2004 evaluated the quality of health care across the world, and ranked South Africa's private sector fourth worldwide. Our public sector was ranked fortieth. This survey is widely used by our private sector, and rightly so, to point to its success. But it is a very clear demonstration of the gap that we have to close if we are to build a health care system for all.

How then do we bridge the divide between the private and the public health care sectors? How do we create a system which can offer a high quality of care at an affordable rate, and which all of our citizens can access?

One suggestion is to do away with the private health care sector altogether, a view put forward by Cosatu Secretary-General Zwelinzima Vavi. Speaking at a South African Medical Association Conference late last month, Vavi argued that: "There is a need to radically shift the way society funds its health care - by incorporating all health care resources in the public sector".

Like most populist solutions, this proposal overlooks the long term consequences in favour of short term expediency. Nationalising health care would be disastrous because it would shift the burden of providing quality health care entirely onto the state. Experience has shown that the state is incapable of providing quality health care for all. The inevitable result of nationalisation would be the rapid collapse of the system as a whole, the flight of medical personnel, and the further stripping of skills from both the private and public sectors.

Another approach, adopted in the National Health Amendment Bill, would give the Minister of Health the power to determine private sector hospital fees. This too, would lead to a further loss of skills. It would also force some private health care providers to close their doors, thus shrinking the private sector and placing an even greater burden on an already incapacitated public health care sector.

It is clear that we need to fix what is not working without destroying what does. This must be at the heart of any approach to reforming the health care system.

The DA believes that the state has a key role to play in achieving a more equitable and efficient health care system. The challenge is to carve out an enabling, rather than a prescriptive role for the state - a lesson we can draw from the top three health care systems (according to the 2004 Monitor Survey) in the world - Canada , Singapore and Taiwan . In all three of these countries, the state is involved in the financing of health care, but it takes a back seat in the actual delivery of services, allowing market forces to ensure efficiency and to keep down costs.

When evaluating best practice in other countries, we need to bear in mind that no two countries are the same; there is no panacea for an effective health care system. Every country is grappling with a different set of circumstances and political pressures. Some are developing and some are developed. Some have a strong tradition of public health; others tend to be more laissez-faire in their orientation. Some have a strong revenue base and others do not.

Nevertheless, there are some important lessons to be drawn from the Monitor survey.

Firstly, in all three of the top-ranked countries, the state is heavily involved in the financing of health care, but takes a back seat in terms of the actual delivery of services.

• Canadian hospitals are controlled by private boards or regional health authorities, rather than being part of government.
• About a third of Taiwanese health care is provided by municipal or public hospitals, while two thirds is provided by the private sector.
• In Singapore , private practitioners provide the overwhelming majority of primary health care services, while publicly run hospitals provide most secondary and tertiary care.

Secondly, the state has a key role to play with regards to funding. It must fund some services itself, where funds would not otherwise be available, but it must also ensure that all citizens who can make some contribution to their own health care do so.

Thirdly, expensive health systems are not necessarily good, and the best health systems are not necessarily the most expensive ones. The primary focus must be on the effectiveness of expenditure, not the amount of money we spend. South Africa already spends far more on health care than many other developing countries, but there is a tendency in government circles to believe that more money must equate to a better system. We need to make the money that we do spend work better. And we need to ask ourselves how best we can do this.

Fourthly, the best health systems around the world are those where the private sector and the state co-operate to provide health care. In South Africa we need to integrate the private sector into the public sector, in such a way that access to the private sector can be expanded without compromising the quality of the system overall.

This last point is crucial. At the moment in South Africa , we have a public sector and a private sector that operate largely independently of each other. A quality health care system depends on integrating the private system into the public system, and working out a solution that allows private providers to earn a living while the state is still able to meet its obligations to its people.

Clearly, there are many different ways in which this can be done. Different countries have used many different models, with varying degrees of success. But it cannot be achieved at all if we start from the premise that the private sector is the enemy.

Any plan for a health care system that provides a high quality of service to all our people must involve a partnership between the public and the private sectors. There is no such partnership at the moment.

Where there is any relationship at all, it is defined by mistrust and suspicion - hardly the grounds for a healthy relationship. We need to change this, and this involves talking in much more detail about how the different components of our health care system could be harnessed to work better. I hope that discussions today will contribute towards this process.

This is an extract from a speech by Helen Zille, Leader of the Democratic Alliance, delivered at the DA's New Vision for Health Care Conference, in Johannesburg, September 9 2008