wiseMusings

Hey fam,

I’ve taken it upon myself to learn about health policy – in public. That means reading lots of literature, doing lots of research, and compiling it all into a (hopefully) semi-coherent article that puts everything into perspective.

This is the first of a series of articles about health policy – what it is, how to identify problems with it, how to engage with it, and how to make our world a healthier place.

It bears noting that the ideological positions outlined here are simply part of a theoretical model, and do not necessarily exist in their ideal form in the “real world”. Either way, knowing theory is important because it’s a conversation starter. And there are many conversations we haven’t even started to have yet.

This is meant to be a learning space, so if you think I got something wrong, shoot me a comment & I’ll look into it. This is also meant to inspire others – if a topic interests you, do further research on it. I’ll name my sources at the end of every article to better facilitate this.

I’ll also add questions for deliberation for myself & you, the reader, to potentially mull over.

Let’s get to it!.

– Wiseman Zondi

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We live with other people – a definition of health systems

There seem to be as many definitions of “health systems” as there are people writing about health systems. However, the definition that most resonated with me was the one used by the World Health Organisation (WHO) in their World Health Report 2000. They name health systems as

“includ[ing] all the activities whose primary purpose is to promote, restore or maintain health”.

World Health Organisation, 2000

This widens the scope of the typical understanding of the health system. We think of clinics and hospitals, along with the people who work in them, as constituting the health system. They do, but it’s not just them.

That traditional healer that gives patients umuthi to cure their erectile dysfunction? Part of the health system.

Those folks that figure out the kilojoules in a McDonald’s burger? Part of the health system.

Those folks on the road that wave flags to let cars know when to stop & when to go when there’s maintenance being done? Part of the health system.

Rule of thumb: if their job is to keep you safe from harm or make you feel better from sickness, they are part of the health system. It’s broad, yes, but it does a good job in pinpointing the collective nature of how we get (and stay) healthy. Many people contribute to our continued well-being, and those contributions should be made explicit. Minimising those contributions is how we end up with a public health crisis when dozens of people are getting sick, and a government is unwilling to change it.

If we think of health as an individual issue (I get sick, I see the doctor, I get better), we lose so much of what constitutes social reality. Rich and poor people do not experience the health system in the same way. If our health systems do not account for this, then health inequalities will continue to be an issue. Health will remain inaccessible to so many people, and as we all know, issues of health are often life or death issues.

While I am hesitant to look at human beings as resources to be utilised by an amoral market, we lose so much by perceiving ourselves as atoms working in isolation from one another. We get a child in Michael Komape falling and dying in a pit latrine, because a flushing toilet is seen as a luxury rather than a necessity.

Michael Komape could’ve very well been the future president of South Africa. He could’ve been an adored entertainer. He could’ve had a decent life doing decent work. We’ll never know the potential that Michael Komape could’ve had. And it’s all due to people who don’t give a shit (pun very sadly intended) about the health of people beyond themselves.

This is partly why the study of health policy is important:

– it allows us to look at health as a holistic concept that doesn’t solely depend on ill-health or disability;
– it lets us examine the causes, consequences and implications of health systems not working optimally;
– and it puts us in a position to….. maybe, perhaps, conceivably, for all we know….. change things.

The above-mentioned definition of health systems is the best one I’ve found that encapsulates all this. It recognises that we, in fact, live with other people & that we need them well and alive, so that we all flourish. Call me idealistic, but that’s my framing, and I’m sticking to it.

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“Resources were still constrained” – identifying key debates in health systems


Based on this framing, there is no way for me to act neutral regarding the debates in health systems. Bridging the gap in health (when it comes to class, race, gender and so on) is crucial if we want to live in a world that values fairness and equity. This might take the form of universal health coverage. Conversely, it might take other forms of healthcare reform. Either way, equity without sacrificing quality is the gold standard for me.


To this end, it seems as if the debates in health care systems boil down to a tussle between the public and private sector, or the tussle between National Health Service and private systems. These differences are not unimportant.

In fact, they underscore all of the debates that occur in all of social policy. There are some who believe that health systems should be self-occurring systems enabled by the market, and others believing that governments have an active role in facilitating the welfare of all citizens. This is no less different when it comes to health.

To be clear, this isn’t an insignificant issue as public & private sectors prioritise completely different values. The public sector often prioritises equality and fairness, and are more likely to call for universal health coverage to facilitate this. Conversely, the private sector is more likely to prioritise efficiency and profit-making, often through private healthcare systems.

Of course, this is not a black-and-white theory, as actors in the private sector might form partnerships with the public sector, and actors in the public sector – particularly the New Labour government in Britain – might want health systems to be more efficient. Donors who donate large sums of money to political parties also make an appearance here, as they are not above influencing healthcare policies for their own ends.


The one sentence that most caught my attention during my research was the sentence, “resources were still constrained.” This is what must be fundamentally understood from the health debate – governments can’t do everything. They can only pick one set of choices (with the necessary confidence and evidence necessary), and hope for the best.

The New Labour government made the choice to empower patients by reducing waiting times for them. This was part of an overall change in the way health services were seen – as a system that can be managed to achieve peak efficiency. Even the policy success of the wait-list reduction was seen in that light: targets were created, pressure was placed to achieve them, there were negative consequences for those who could not achieve them, money was given to incentivise those who could achieve them, and then, success!

The problem was that healthcare providers were not happy about this. This was seen in the undignified way they treated most of their patients. This is indicative of the shift in perspective that they were told to make: hit your targets, hit your targets, hit your targets!

This has the side effect of patients being treated as products. It’s not about treating John Doe’s cancer, it’s about making sure John Doe sees a specialist in a matter of weeks rather than months, so that the hospital doesn’t get a rating of “zero”. This might make healthcare an impersonal act rather than something that has an element of care in it. It’s in the word, after all.

But here’s the thing – it worked!

Some folks would say they’d rather receive quality treatment from a rude doctor than sunny-dispositioned doctors being unable to treat them because of bureaucratic reasons. That’s fair.

But what happens if the doctors and nurses, as important actors in the health system, decide to down tools because of dissatisfaction?

Negotiation between competing groups who want the same thing but on different terms, that’s what.

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Health systems aren’t apolitical – healthcare versus health


Another consideration is how countries may either prioritise healthcare or health, the former being the functioning of clinics and hospitals for citizens to attend, and the latter being preventive tools to ensure citizens do not get sick in the first place. There seems to be a global shift from healthcare to health, the world over. The coronavirus (also known as COVID-19) pandemic forced most countries to prioritise public health interventions instead of merely using the treat-when-sick method. This is because COVID-19 was transmitted through air droplets that spread easily in public places.

Because of this, there was no way to combat the COVID-19 pandemic without dealing with the very public way in which the virus is spread. Notably, the same interventions were not standardised for HIV, a disease which mainly spread through sexual intercourse. Depending on one’s perspective, one may either see this as the evolution of our understanding of disease as being a collective problem or as a problem so big that private corporations couldn’t ignore.

However, this highlights an important aspect of health systems: they can’t do everything at the same time. They must prioritise. They must pick and choose what policies are appropriate for a specific time, place, and demography.

For instance, a country with an ageing population is more likely to prioritise healthcare, as old age leads to more illnesses in the body, while a country with a younger population might pick the exact opposite. This is why policymakers should know the country in which they work in, and why blanket solutions (conjured up by management consultants) will only work up to a point.

These two debates – public versus private as well as healthcare versus health – aren’t even that separate from each other. The commonality between these two debates on health systems is the influence of politics.

In a country that names universal health coverage as “socialised healthcare“, we are more likely to see a privatised health system that is at the mercy of the market. It is also more likely to want to minimise the role of the state, and to fix health problems as & when they happen. So in such a system, individuals take care of their own health. If they get sick, they go to hospitals and pay their own way.

Compare that with a country that preaches equality as one of its core tenets. Such a country is likely to advocate for more – and not less – state involvement in health debates. It is also more likely to spend the money and resources necessary to prevent people from getting sick in the first place. With these two examples, one can see that health systems aren’t apolitical – in fact, the difference between life and death could hinge on the politics of the country that they live in.


In that vein, as David J. Hunter noted, we cannot separate health systems from their political context. There is a reason why the individualistic (to the extent that it is) United States and the collectivist (to the extent that it is) South Africa have different health system trajectories. There is a reason why conservatives do not like Obamacare, and why progressives should love the NHI but don’t.

It’s because politics gets in everything, and we would be remiss to examine health systems without investigating the political context they are formed under. History matters. And so do political institutions. Before making prescriptions on a country’s health system, understanding the rest of its political history – right down to who really holds the levers of power – will be more illuminating than anything else.

This is tied to trust. If citizens trust the political leaders in charge, then they are more likely to “buy-in” to the health system being used or proposed. This is at the heart of why the NHI system in South Africa leaves many progressives uneasy, despite the NHI aligning with their politics.

The point that undercuts health system trajectories, even more than the sometimes uninvited appearance by politics, is the inevitability of it all. All countries have health systems, whether they are minimalist or maximist. All countries (especially after the COVID-19 pandemic) ought to have some sort of understanding that health outcomes aren’t individual, they’re global. This understanding might still be used to propel the market as the fix-all, or it might strengthen the case for greater state intervention. Either way, it’s there.


Questions for Further deliberation

1. What is the most convincing case for the privatisation of health care? Is it at all convincing?
2. Is it at all possible to pursue market outcomes in health while prioritising equity? Or is it always a case of “one or the other”?
3. Is the National Health Service model indeed outdated for the 21st century?

Resources to read on the topic

1. The Health Debate (2nd edition) by David J. Hunter
2. World Health Organisation. World Health Report 2000
3. Social Science Perspectives on Health Care by Julia Morgan
4. Problems Arising in Health and Social Policy by Christian Aspalter
5. “How New Labour succeeded with NHS policy” by Nicholas Timmins, Financial Times
6. Health Policy Analysis: Framework and Tools for Success by John W. Seavey, Semra A. Aytur, and Robert J. McGrath
7. “The law and the horror of the death of Michael Komape” by Franny Rabkin, Mail & Guardian