Class divisions and the struggle for honest conversations about the NHI

Class divisions in South Africa, particularly the perspectives held by the so-called middle class, have long posed significant barriers to honest conversations about the struggles of poor and working-class people, even struggles about themselves. 

This issue is acutely evident in recent discussions surrounding the National Health Insurance (NHI). The middle classes, entrenched in their own experiences and prejudices, often engage in in-group derogation, which obstructs meaningful dialogue and understanding of the real challenges faced by marginalised working-class people. 

In this opinion, I will attempt to discuss this in-group derogation, which refers to the phenomenon where members of a particular social class adopt a dismissive and often harmful stance towards others within the same broad category, often to distance themselves from the perceived negative traits associated with that group. 

For the middle class, this manifests in attitudes that devalue and stigmatise poor working-class communities, creating a chasm that impedes empathetic and constructive discourse. I argue that the middle class, in its failure to interrogate its positionality and disillusioned privilege, perpetuates a systemic silencing of the true needs and realities of marginalised people. 

Moreover, the discussions on corruption and the governance of the NHI, although seemingly well-meaning, often misdirect anger and anxiety, obfuscating larger systemic issues.

In May, President Cyril Ramaphosa signed the NHI Bill into law. The NHI is a health financing system that aims to provide universal health coverage to all South Africans, ensuring everyone has access to quality health services based on their needs, irrespective of their socio-economic status. 

The NHI Bill was first introduced to parliament in 2019. This was also the year I did an internship with the Rural Health Advocacy Project. 

I conducted research on the effect the NHI would have on rural health perspectives and witnessed the multi-layered and systemic disparities in healthcare access. Going through the Bill and the conversations with civil society organisations, it became clear just how profound were the inequalities that rural and marginalised communities face in accessing quality healthcare, starkly contrasting with the relative comfort of urban middle-class experiences. 

The disparities I observed were not merely about resource allocation but were rooted in historical, socio-economic and racial inequalities. 

The middle-class discourse around the NHI often fails to capture these nuances, instead focusing on abstract principles of efficiency and corruption without addressing the lived realities of those most in need of healthcare reform. The disparities I witnessed were far more complex than a mere legislative framework could address, but it was a start.

I recall the conversations with my peers, even back then, often revolved around the inefficiencies and corruption within the healthcare system, a perspective predominantly voiced by the urban middle class. They would argue passionately about the need for systemic reform, citing abstract principles of fairness and efficiency. 

These conversations were intellectually stimulating, yet they left me grappling with an internal conflict that I couldn’t initially articulate. 

The crux of my dissonance lay in my lived experiences. I had been one of those teenage mothers, seeking help at a clinic and being turned away due to resource shortages. I had seen my grandmother, blind from old age, being asked to pay R1 000 for spectacles, which she could not afford. 

I had family members among the many chronically ill who went through insuperable difficulties, often taking years of prolonged consultations to access essential medication. 

These were not just stories; they were fragments of my life and the NHI, for me, was not just a policy decision, it was a much-needed revolution. Yet, in all these discussions about healthcare reform, I found it difficult to see myself in the people we were advocating for. 

I thought there was no room for my experiences — all these narrations and discussions about healthcare disparities were being recounted by other people, detached and impersonal. 

The dissonance emerged from the clash between my personal reality and the clinical, often detached, narratives of healthcare inequality. Why couldn’t I see myself in the eyes of the poor? Was my intuitive understanding of what the NHI could achieve less valid because I was somehow part of this middle-class lifestyle?

As I spent more time in rural clinics and community health centres, the layers of my cognitive dissonance began to unravel. The systematic disparities in healthcare were, and are still, entrenched in historical, socio-economic and racial inequalities. These were not just issues of resource allocation but were rooted in a long history of marginalisation and neglect. 

The middle-class discourse around the NHI often fails to capture just how intractably linked these nuances are, instead focusing on abstract principles without addressing the lived realities of those most in need. 

The turning point came during a visit to a remote clinic in the Eastern Cape, where I come from. There, I met a young mother who mirrored my younger self. She was desperately seeking help for her sick child, only to be told the clinic had run out of medication. Her story shattered the last remnants of my detachment. 

This confrontation with reality remains both painful and liberating. Nonetheless, it is an exercise I engaged in to reconcile the self with the broader systemic issues I was advocating for. I began to understand my dissonance stemmed from a reluctance to fully acknowledge the depth of my own trauma within the larger narrative of healthcare inequality. 

Maybe this is where the differences among us lie. Perhaps our memories need to be jogged, to remind us where we come from and how easily we could find ourselves in those very marginalised positions again. Because, after all, all people of middle-class status today were once, or are descended from, someone of working-class status. Most middle class people know just how fragile and precarious this lifestyle is. 

Economic stability can be a fleeting thing, subject to the whims of the market, changes in employment, or unexpected expenses.

In Marxist terms, class is defined objectively by one’s relationship to the means of production. The bourgeoisie owns the means of production, while the proletariat sells their labour. This clear-cut division has blurred in modern society, where a sizable middle class has emerged, characterised not by ownership of means of production but by marginal access, and social and cultural capital. 

This shift complicates class analysis, as middle-class folk often see themselves as separate from both the bourgeoisie and the proletariat, leading to a distorted understanding of their role in systemic inequality. The middle class’s failure to ask the right questions and introspect on its position stems from this lack of clarity. 

We do not fully grasp what it means to be “middle class” in a capitalist global order that largely ignores us. Instead, we focus on preserving our precarious status. This misalignment often perpetuates a discourse that is out of touch with the realities of those most affected by systemic inequalities and healthcare disparities.

The thing about middle-class sensibilities and our struggle to maintain empathy is that it’s often hidden in plain sight. On social media, you can see the depth of our challenges amid the current economic climate. We’ve become a dysfunctional group, resorting to alcohol and drugs to cope. The soaring cost of living, including the cost of healthcare, has made normal functioning nearly impossible. We’re suffocating under the weight of middle-class expectations, yet paradoxically, we perpetuate these norms, to the detriment of ourselves and others. 

Our adherence to middle-class ideals of meritocracy and self-reliance creates barriers for poor working-class individuals at every level. 

These norms dominate universities and prestigious workplaces, deterring poor working-class people from applying, being selected or staying in such positions. The disparities in identity, cognition, emotions and political behaviour of the middle class often prevent poor working-class individuals from accessing educational and job opportunities that could enhance their material well-being. 

Are we truly that different because we clawed our way out of the trenches? Are we so exceptionally gifted that we can’t spare a backward glance to see where we came from? 

The NHI did not come without political controversy. By the time the Bill was announced as law, it was strategically beneficial for the ANC, which was facing losing a significant portion of its voter base due to public discontent over allegations of corruption and mismanagement of funds — particularly in the public health sector, which was, and still is, in a state of decline.

This discontent is genuine and must be addressed. I am not saying that people should not question why there has been a systemic failure in our government to administer and manage the roll-out of public services. 

However, I argue precisely at a point where public services are being rolled out to support and ease the burdens on poor working-class communities, we seem to be shaping a narrative around what corruption is and what it looks like. 

If we are sincere in our efforts to seek truth and accountability about corruption, our pursuit of truth and accountability should radicalise us to align with the needs of society, alongside what the majority of society desperately needs.

Abongile Nkamisa is a lawyer at Open Secrets. This is an edited version of the winning essay in the Canon Collins Troubling Power Essay Competition.