Health Funding Health Management Human Resources National Health Insurance (NHI) Policy and Legislation Public Health & Health Systems

Fix state hospitals before introducing NHI

Health-e will for the next few weeks publish opinion pieces from various stakeholders and experts on National Health Insurance. Anso Thom sets the scene with the first contribution with Dr Jonathan Broomberg, Discovery Health’s head of strategy and risk management.

Hardly a day goes by without South Africa’€™s beleaguered health services hitting the headlines. Many of the stories speak of neglect and poor health care.

Only recently a Johannesburg newspaper reported that state clinics and hospitals misdiagnosed a boy with suspected meningitis on four occasions. Neo Alberts (16) was brought to a Johannesburg clinic twice in two weeks after complaining of severe headache, vomiting and a stiff neck ‘€“ classic symptoms of suspected meningitis.

He was sent home with nose drops, penicillin and a sick note. When he was taken to Chris Hani Baragwanath Hospital, paramedics and a doctor reportedly accused him of taking drugs. It was only when it was too late that the doctor told his parents he had “severe meningitis” and was put on a drip. Neo died shortly afterwards.

Closer to home asthma sufferer Bevan Gaffley was reportedly refused proper treatment at the Delft Day Hospital. According to his family they begged staff for hours to assist him, but to no avail. His mother later found him slumped in a chair, his eyes rolled back in his head, allegedly still waiting to see a doctor. The young man is now on life support in Somerset Hospital’s intensive care unit.

And on Friday thousands of doctors took to the streets to voice their unhappiness with the state of our health care system. They are not only protesting the very low salaries afforded to young doctors who have to attend to an inhumane number of patients every day, but also among others the poor state of affairs at the institutions where they work where equipment is often dysfunctional and basic supplies out of stock.

While all this if going on, a team of people tasked by the ANC to come up with a National Health Insurance (NHI) plan have been meeting behind closed doors drafting a proposal that they believe will ultimately pump more money into the buckling health system. And this weekend leader of this ANC task team and CEO of the Human Sciences Research Council Dr Olive Shisana will present the grand plan to a high level ANC meeting.

The NHI was a key ANC election promise and the party promised to implement it within five years despite the current economic downturn. Top ANC brass have recently been promising that it will be in place within a year.

While pooling the country’€™s scarce health resources is essential to improve the health services for 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 schemes are keen to remain part of the health system and administer parts of the NHI.

Insiders have confirmed that the task team is dominated by unionists who believe that the goal is a scheme that would ultimately get rid of medical schemes.  This would mean that those wealthy enough could pay cash for expensive healthcare from a much reduced private sector.

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.

Tax rebates for medical aid contributions will fall away, making medical scheme contributions unaffordable for those who wish such cover over and above that provided by the NHI, particularly those at the low income end.

There is widespread agreement that 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 firmness 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. It will be one of newly installed health minister Aaron Motsoaledi’€™s first big tests to see whether he will be resolute that the ANC proposal is subjected to same processes Hogan insisted on.

While some in the ANC are keen to see an NHI plan in place by September, health economists and other experts have cautioned against moving too fast. Many respected experts in their field who were initially part of the task team have left after they realised that their voices were not being heard and it is important for these people to be drawn back into the process.

Right now it is important for the ANC and those involved to make the proposed plan public and allow the experts to scrutinize the contents and be given an opportunity to give feedback. There has also been almost no public discussion about NHI. The public do not have the information needed to help them understand what NHI really means. It is therefore extremely important for civil society to be given an opportunity to understand the key issues and for their preferences to be taken into consideration.

As with the Civil Union Bill, the NHI plan should be taken around the country and there needs to be consultation with a wide range of communities and stakeholders.

By doing this the ANC will allow key stakeholders including medical schemes and private sector service providers to identify the role they can plan in an NHI.

Fundamentally South Africa needs an NHI of some form. Those in the know have pointed out that it is possible and affordable, but that is critical that the country first invest in our public hospitals, the backbone of any NHI plan.

We need to keep building up the funds dedicated to the public sector and 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.  

Our public hospitals are struggling to cope. The HIV/AIDS epidemic is flooding wards, we have a critical shortage of nurses and underfunding is seeing a cut in beds, malfunctioning equipment and a constant shortage of drugs and other supplies.

The funding of systems and solutions to uplift the hospitals is critical as it will move the institutions from the current crisis mode where the public have very little faith in their ability to cope to service providers that the public feel confident in and want to utilize.

South Africa’€™s health sector has much going for it and has the potential for it to be a phenomenal service, but hastily adding an NHI plan to the system which would only add to the burden is not the solution. Once the hospitals are able to offer an excellent service it would make sense to move to some form of NHI at a rapid pace.

However, the process being used to implement NHI and the pace at which it is being done, could remove any hope of getting it right.

Others have added their shopping lists of matters to be addressed before NHI can begin to be introduced. These include:

  • Addressing the human resources problems
  • Addressing infrastructure problems, especially in terms of hospitals
  • Establishing an effective procurement and supply chain
  • Implementing a proper IT system
  • Putting proper monitoring and evaluation systems in place in order to understand the disease burden
  • Finding an effective system through which to collect revenue
  • Addressing issues of budgeting
  • Ensuring that the proposed system meets Constitutional obligations
  • Address issues of accessibility to NHI, especially for people who do not have identity documents or who are not permanent residents

Countries such as Norway, Singapore, Ireland and Canada that have achieved full NHI systems share several key characteristics ‘€“ high per capita expenditures on healthcare, high employment levels and low levels of income inequality and an adequate supply of human and physical health care resources. South Africa does not meet most of these criteria at present.

The private sector argues that South Africa must follow a path to NHI through gradual expansion of employment based health insurance coverage. They point out those countries that have successfully implemented full NHI systems following this path included Austria, Costa Rica, Germany and Japan. It took Germany over 100 years to complete universal coverage, Japan took almost 40 years, Austria almost 80 years and Costa Rica 20 years.  

However, others point to the failure of many countries, particularly in Latin America, to achieve universal coverage through this approach.   Experience in Mexico, Chile and many other countries has shown that developing a two-tiered Social Health Insurance (covering only the employed) has heightened health system inequities and proved an obstacle to moving to universal coverage.   A growing number of countries, such as Ghana, are implementing universal NHI from the outset, with government paying the contributions out of tax funds for those unable to pay.

The elimination of medical schemes will not accelerate the implementation of NHI. Medical scheme premiums are private money and eliminating them will not shift that money to the NHI system. Elimination will also not automatically shift doctors and nurses back to the public health system ‘€“ some believe that private doctors will either exit the system of work for cash. Migration to the public sector will only occur in large numbers if remuneration and working conditions are improved.

Ultimately politicians and those tasked with devising an NHI plan can fiddle around the fringes – ignoring the elephant in the room – but until Government properly finances the public health system which has been systematically underfunded for years NHI remains a potentially good idea on paper.

Health-e will for the next few weeks be running opinion pieces from various stakeholders and experts on NHI.

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