Rush job on NHI?
Inequities in the health system, which has resulted in the private sector monopolising resources disproportionately, need to be addressed. However, this must be done in a manner that does not destroy the functioning private sector and cause more skilled health professionals to leave the country.
It is widely accepted that former health minister Barbara Hogan’s insistence that the current NHI proposal be subjected to proper processes and public scrutiny led to pressure from the unions that she be removed from the health portfolio.
Insiders have confirmed that the task team is dominated by unionists led by Teboho Phadu, who believe that the goal is a scheme that would ultimately get rid of medical aids and force all citizens into public health. Those wealthy enough could pay cash for expensive healthcare from a much reduced private sector.
While pooling the country’s scarce health resources is essential to improve the health services of the majority, there is a fierce battle about how this should be done and funded. Those on the left are arguing for the effective nationalisation of private health while medical aid schemes are keen to remain part of the health system and administer parts of the NHI.
A confidential NHI draft distributed in February proposes universal coverage that is free at the point of service and covers all ‘medically necessary’ interventions. It states that NHI should be a state administered, single-health insurance system, and that funding for NHI should be sourced from general taxes and compulsory contributions by all employers and employees.
Interestingly, the draft was funded by the Gates Foundation, although the foundation says it does not fund political parties.
“The Gates Foundation funded the Human Sciences Research Council (of which Shisana is CEO) to conduct research for the purpose of developing recommendations and policy options regarding health priorities, including health insurance. The foundation does not fund political parties,’ said Gates spokesperson Deborah Lacy.
According to the current draft tax rebates for medical aid contributions will fall away, increasing cost pressures on employers and employees, making medical scheme cover unaffordable for most, particularly those at the low income end.
The NHI was a key ANC election promise and the party promised to implement it within five years despite the current economic downturn that has brought massive job losses. It is understood that the February draft has since been further developed and will be presented to a high level ANC meeting in the first weekend of June.
Economist and Dean of Research and at the University of the Western Cape Professor Renfrew Christie questioned whether economists or actuarial scientists had run the numbers and shown NHI was feasible.
‘It is a rich country solution. Sweden has a tiny population, superb civil servants and was totally healthy when they did it. The UK was used to war time draconian measures and had a superb civil service and buy-in across most classes in 1947 after the war and was a richer country without pandemics.
‘If you want to tax the rich more, do that, and then spend it directly on health through the ordinary treasury budget honestly.
‘This is the crux. If you want health, fix the health service you have got,’ said Christie.
During the ANC’s 15-year reign, it has consistently underfunded health services and shifted resources away from hospitals at precisely the time when the HIV/AIDS epidemic has increased exponentially. Real per person spending by government (after inflation) on public sector health services declined from 1996 and only returned to the 1996 levels in 2005. This translated into fewer resources per person than in 1996 all the way through to 2005.
Health economist and University of Cape Town’s Professor Di McIntyre said that South Africa fundamentally needed an NHI. ‘It is possible and affordable, but what we have to do first is invest heavily in public hospitals, the backbone of any NHI.
‘We need to turn it from the current crisis situation into service providers that the public feel confident in and want to utilise. It could be a phenomenal service if we get the hospitals right.’
McIntyre cautioned that there was very little public discussion about NHI and that the public did not have the information available explaining to them what NHI would mean.
Adila Hassim, head of litigation at the AIDS Law Project agreed there was widespread support for some form of NHI, and welcomed the renewed commitment to equity and accessibility of health care services. But she said that the process on how it is formulated and introduced was critical.
‘It needs to be an open and transparent process led by government, it can also not be rushed through parliament which means we have to see a white paper and meaningful public participation.
‘A policy of such significant public importance requires consultation that will ensure buy-in from all sectors and at the same time isolate vested interests that depend upon current health inequities for profit,’ said Hassim.
Health economist Alex van den Heever described as ‘dangerous’ the current process of formulating complex policy behind closed doors. ‘The lowest quality policy emerges from processes where you insulate yourself from any critique,’ said Van den Heever.
Sources confirmed that there was widespread concern among stakeholders that the whole process was being built around Shisana, who they felt was positioning herself to head the NHI Authority, which according to the draft document would be a powerful financing structure set up parallel to the national health department.
Shisana has been driving the process and has already tasked Debbie Pearmain, legal representative at the Board of Healthcare Funders, to formulate draft legislation. Shisana wants to get the proposal implemented this year with herself in the powerful position of CEO of the NHI authority where she will ‘brief’ the national health minister and not report to him. Shisana was not available for interviews until early June.
Van den Heever said the task team appeared to be looking in the wrong place to solve the health system’s woes. ‘Institutional reform is certainly needed across both the public and private sectors. This should include the use of national insurance modalities. However the proposals advanced do not relate to the systemic challenges and are more likely to exacerbate than solve them. There is also an irrational bias against people having access to medical schemes, which are an essential component of the health system,’ said Van den Heever.
‘We need to keep building up the funds dedicated to the public sector, consider the establishment of a national emergency insurance fund which will see everyone in trauma and emergency situations treated at the nearest health facility irrespective of whether it is public or private sector. The public sector requires a considerable re-assessment of its systems of funding and accountability,’ said Van den Heever.
Nonkosi Khumalo, chairperson of the Treatment Action Campaign said there was recognition that the resolution of the crisis in public health care is one of a number of key steps integral to laying the groundwork for the introduction of NHI.
However, she added that universal access to health care ‘ a defining feature of NHI ‘ cannot be achieved without appropriate regulation of the private sector.
Dr Jonathan Broomberg, head of strategy and risk management at Discovery Health said that private sector stakeholders were not in general opposed to the objectives of NHI, but had significant concerns regarding some aspects of the proposed mechanisms used to achieve it.
‘South Africa has a world class private healthcare system. We must guard against any proposals that will damage this system, and focus on how the private sector can assist in achieving the objective of improving health outcomes for all South Africans,’ said Broomberg. ‘ Health-e News Service
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