NOTHING makes the achievement of a better society less likely than a government's failure even to try. Without ambitious public policy goals, and programmes that stretch the capabilities of public servants and citizens, no society can make major developmental advances.
Political leaders, however, can be prone to breezy optimism. They assemble wish lists that have no prospect of realisation, and assume that the capacity to implement complex programmes can be created overnight.
The result is the adoption of symbolic policies that placate organised interests but do society no good at all - and often do a lot of harm.
Italian political philosopher Antonio Gramsci got the appropriate balance broadly right when he wrote that "I am a pessimist because of intelligence, but an optimist because of will".
President Jacob Zuma's state of the nation address last week was interpreted by some analysts as heavy on optimism of the will, most particularly in its hopes for a national health insurance (NHI) system. SA's constitution, of course, embodies a right to healthcare, which the state must take reasonable steps progressively to realise. NHI, however, strikes many critics as ideological and impractical.
Knocking Zuma on these grounds is probably unfair. NHI in fact reflects a global shift in thinking about how healthcare should be financed. In the "Washington consensus" decades, the emphasis of international institutions was on stimulating the growth of private healthcare insurance and encouraging citizens to support public systems with higher user charges. Practical and theoretical understandings of the limitations of dominant private insurance markets, however, have led to a new international consensus in favour of prepayment financing through mandatory NHI.
First, voluntary insurance markets are subject to "adverse selection" because those least likely to fall ill opt out until cover becomes unaffordable for those who need it most.
Second, information asymmetry in the health sector leads to "overtreatment", a pathology that partly explains spiralling healthcare costs and so premiums.
Third, private schemes provide limited population coverage. Even in the US, where almost inconceivable resources are devoted to healthcare, tens of millions are excluded. In SA, the number of private medical scheme beneficiaries remains at 7-million, more or less where it was 15 years ago, despite such schemes eating up about 60% of financial resources.
Fourth, there is burdensomely high total expenditure, but resources are not efficiently or equitably allocated - and so outcomes are poor. The state shoulders the cost of training health sector workers but these scarce human resources disproportionately service private scheme members. A private sector general practitioner (GP) has 600 patients (or 250 in a medical aid scheme) whereas a public sector GP serves 4 000. There is one specialist doctor for each 470 private patients but only one per 10 000 in the public hospitals.
For these reasons, there are grounds for an overhaul of the national health system that reconfigures the relationship between private and public sectors. The fact that private health markets are imperfect, however, does not help policy makers to know what is possible or desirable in SA. All manner of combinations of revenue-collecting mechanisms, funding pools, purchasing instruments, and mixed private and public provision methods are possible.
Building new institutions will be expensive and difficult and SA's shambolic state cannot be burdened with complex tasks. The revenue service and private medical schemes must be used as instruments of implementation. Scarce human resources must not be chased away and lost as a national resource.
The public hospital system, moreover, needs to function much better if NHI is not to represent another tax on the formal economy. Despite some symbolic gestures, there is no sign that the new African National Congress leadership will pay frontline health workers adequately, empower hospital managers, or address the mismanagement and corruption at provincial health administrations.
Critics have found it hard to enthuse about the reported role of Human Sciences Research Council head Olive Shisana in what has been a needlessly secretive policy development process.
Zuma pledged to introduce the NHI in "a phased and incremental manner" and after the "urgent rehabilitation of public hospitals", which means there is still time for the process to be shaped by a wider public and specialist debate. While there is plenty of optimism of the will on show, however, so far there has been too little pessimism of the intellect.
Butler teaches public policy at UCT
Anthony Butler: Business Day, 8 June 2009