High court ruling on free healthcare is a humanitarian triumph but politically dangerous

It’s a humanitarian triumph but politically dangerous. It’s a policy based on good intentions but it may kneecap an already buckling public healthcare system and stoke already explosive levels of xenophobic populism.

The High Court in Johannesburg this week ruled that provincial health departments must provide free healthcare to pregnant and lactating women and children under the age of six, irrespective of nationality or documentation.

Section 27’s Mbali Baduza hailed the order as a blow to the “health xenophobia [that] has been on the rise in certain provinces”.

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Sharon Ekambaram of Kopanang Africa Against Xenophobia said the matter was “but one component of a broader crisis of institutionalised xenophobia”.

The order invalidates the care guidelines of the Gauteng health department. These guidelines, followed by a number of provinces, were an honest attempt to respect the constitutionally enshrined right to health with the reality of trying to balance virtually infinite demand against decidedly limited budgets.

At a primary level, there has always been unrestricted access. However, at secondary and tertiary facilities, there was a throttle. Because of cost and scarcity considerations, advanced medical interventions demanding sophisticated equipment and highly trained doctors and nurses, services were provided free only to SA citizens with no medical aids, and to documented refugees and asylum seekers. Everyone else paid a means-tested fee.

The new order changes this. From now, it will be illegal for any health facility or health practitioner not only to deny free treatment to any pregnant and nursing mothers and their young children, but makes it illegal even to attempt to classify them with the view of assessing whether they should make any contribution to the costs of their care.

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The only exceptions are that these services will not be provided if these people belong to a medical aid or have come to SA “for the specific purpose of obtaining healthcare”.

And herein lies the rub. How can one possibly determine medical aid status or whether they’ve come to SA in search of better medical care, when no classification and fee determination process is allowed?

In effect, the order means that SA’s public health facilities, already struggling to cope, can no longer turn away the many thousands from elsewhere in Africa who understandably seek an alternative to the collapsed medical systems of their home countries.

Former health minister Dr Aaron Motsoaledi said a few years ago at a nursing conference that “the weight that foreign nationals are bringing to the country has nothing to do with xenophobia”, but with reality.

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Last year – as home affairs minister – he reiterated the foreign patient problem, saying over 70% of births in Gauteng, Limpopo and Mpumalanga were to Zimbabwean and Mozambican women.

Last year, Health Minister Dr Joe Phaahla mooted billing countries of origin of foreign patients. In the light of this week’s court order, this now seems unlikely.

We shouldn’t be too noble. Virtually every country restricts foreign access to their precious health care. In Botswana, Namibia and Mozambique, non-nationals pay for all medical services except emergency care. Botswana and Zimbabwe deny undocumented migrants any medical care, at all.

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Health activists, most of whom have medical aid and access to SA’s top-class private hospitals, should be circumspect with their pejorative label. Neither financial prudence by government officials, nor justifiable resentment by the public, necessarily equates to “health xenophobia”.