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Health care reform, as Barack Obama is currently learning, is one of the hardest things in politics. The sums involved are huge, the interests involved are many and powerful, and health is something that voters really care about. 

If, however, Obama may be heading for defeat or a bloody draw, this is as nothing to the colossal train smash which awaits South Africa's ruling ANC as it attempts to force through its National Health Insurance (NHI) scheme. The scheme is very much the pet project of the South African Communist Party (SACP) and its trade union allies in Cosatu (the Congress of South African Trade Unions), who dominated the ANC committee which has come up with the scheme. The NHI committee knew only one statistic, which was that R56 billion a year (£4.1bn) was spent on the eight million people covered by private medical insurance while the state spent the same sum on the remaining 41 million of the population. This is a pretty average situation for a middle-income developing country like South Africa. But the ANC has already shown that it aspires to Scandinavian standards of welfare: it has created Africa's only welfare state, in which 27 per cent of the population receive welfare grants and only 11 per cent pay income tax. Accordingly the committee recommends that the whole population should be able to use public or private facilities quite indifferently, that anyone earning less than £4,000 a year should make no contribution and that the rich should pay for everybody — a sum equivalent to an extra R100 billion (£7.5bn) in tax. The SACP leader, Blade Nzimande, has been promising large crowds of the unemployed that they will soon be receiving care in private hospitals and that the Party will "wage war" on anyone who resists NHI.

Alex van der Heever, the only public finance specialist on the committee, was horrified, believing the scheme to be wholly unaffordable and "without any rational connection to South Africa". But anyone who raised doubts was immediately vilified as an "imperialist" or "anti-transformation". "The proposals that were discussed were ludicrous," he says. "There were so many things that were technically wrong that it was difficult to know whether to walk away or try to engage them." He walked away in disgust. The medical aid societies have all said they would be happy to help devise the scheme, but this is simply a way of getting themselves involved in the discussion process so that they can raise such key points as what terms the private sector will be offered in order to get them to contract in to an NHI. For doctors have a constitutional right to practise their profession and those in private practice will not contract in unless the terms are right-which could well increase health spending to 15-20 per cent of GDP.

The biggest problem is the collapsing state of the public-health sector. The ANC has made many of its political cronies hospital managers, with disastrous results. Doctors and nurses have fled the public sector, many hospitals are in chaos and mortality rates have soared. The reason why 8 million people are willing to pay top dollar for private health, paying taxes to sustain the public health sector, is that many are frankly scared of going to a public hospital. The public hospitals are, inevitably, flooded with Aids victims, at least 1,000 of whom die every week. 

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