Trust in health system key to NHI success

There are certainly critical problems. For those on the lowest incomes, use of health services is often demeaning and too often, simply does not lead to better health. Even the small cost of catching a taxi to reach the local hospital, added to other household costs, can threaten a family’€™s ability to buy food, or get them into greater debt. And the rich are also feeling the pressure of rising medical aid costs combined with more and more limits on what services are covered by the monthly premium.

To live in a society that fears using health care for any reason is clearly to live in an unjust society; it is a mark of shame.

Something has to be done. But is a National Health Insurance (NHI) system the answer?

In broad terms, an NHI promises a health care system in which everyone, regardless of income level, can access decent health services at a cost that is affordable to them and to the country as a whole. That is a goal that many, like me, can support.

But there are various paths to this goal and much debate about which set of proposals is more ‘€˜correct’€™. Less discussed but just as important in reaching that goal, are the approaches used to move us down any path ‘€“ processes which can themselves help or hinder us in reaching our goal. For example, it will be necessary to manage the power battles that have begun to rage between the different interest groups or stakeholders in the current health care system. If these battles are not managed, the fall out is likely to be a worse health system for all.

Even more important are efforts to think through how to ensure that everyone, and particularly citizens and public health workers, as opposed only to interest groups, have a stake in the new system. In other words, to think through how to re-build trust in the South African health system. A health system simply cannot function effectively without trust. It is the fundamental basis of an effective provider-patient relationship; it is an essential component of the contract between health worker and employer; and it sustains cooperation between the different elements of every health system, including public and private actors, that must work together to ensure effective service delivery. And we need to trust our health system to trust that the government is working in our, the public’€™s, interest.

Three key challenges will face the government as it seeks to re-build trust in the health system, even whilst moving towards an NHI system.

The first is that the discussions about NHI have largely been a technical affair, happening behind closed doors. Even when ‘€˜the public’€™ is presented with a set of proposals for discussion, there is a danger that too little time will be given to allow people, rather than only interest groups, to get to grips with them.    

Yet debate about what sort of a health system and so what sort of a society we want is the first step through which trust could be re-built. Open debate gives people a chance to express their own views and to hear the views of others. It gives them opportunities to build a stake in the system being developed and so, to re-build their trust in it. It can be achieved by taking the proposals on the road, to communities across the country – to the public at large, not just the technicians or the stakeholders in the current system. And face to face engagements matter, not just media and internet debate. Taking the time to do this will itself demonstrate respect for the wider public, and it can also build the broad support base required to sustain the long-term implementation of such large-scale change in the health system.   Political power is often not enough for this task. In Thailand, a country that has recently successfully implemented its own health insurance reforms, it was grass-roots support’€“ including people marching in the streets ‘€“ that was key to securing real change, not just an electoral victory.

The second challenge is that NHI is not going to be written on a blank piece of paper. Instead it has to be built on a health system that is already saturated with changes from the last 15 years. Whatever the intentions, many public health workers have experienced these changes as simply making their work and lives more difficult. And as an anonymous South African nurse said about her employers: ‘€˜They fail to deliver on promises which they make. They expect us to deliver and yet they are not delivering… I don’€™t trust them.’€™

Any set of NHI proposals are by themselves unlikely to address this challenge. They will inevitably focus on re-structuring the hardware of the health system ‘€“ the funding mechanisms, and the organisational and regulatory frameworks of the system. Yet it is the software of the system, the human and social elements, that play out in the daily experiences of patients, health workers and their managers, and that influences levels of trust. Paying attention to this software requires a central focus on actions that re-build health workers’€™ own trust in their employer ‘€“ partly through salary increases, but also through fair dealing with them on a daily basis and in future salary negotiations. Decentralising decision-making authority to managers at local level, in hospitals and in districts, is important  ‘€“ so that they can take action to support their staff, tackle local problems and engage with their communities. And managers with greater decision-making authority must be required and supported to take on leadership roles within the system. It is they who represent the face of the health system to the public and who must lead their staff every day.  As Mark Moore, a leading American thinker on public management has said, ‘€˜Public managers are explorers who, with others, seek to discover, define and produce public value; they are strategists, not technicians’€™.

Any moves towards NHI must, therefore, be accompanied by wide-ranging and coordinated action to strengthen the software of the health system.   Equally importantly, such moves must be taken with sensitivity to the current frustrations and disillusionment of staff and patients alike so that steps towards NHI do not make the current bad situation worse.

Indeed, the third challenge is that implementing an NHI simply cannot be a ‘€˜stroke of the pen’€™ exercise. Many elements have to be developed to work together, including re-building the software that underpins a well functioning health system. International experience shows, for example, that it is important to sequence the steps of policy implementation’€“  so that initial actions build the basis for success in subsequent actions. For NHI the necessary first step is clearly to strengthen the public health system and, as many have noted this will require increased investment despite the economic downturn.

Also important is to think through how to build a new insurance authority that will itself be trusted. It is likely that the NHI proposals will include establishment of a new organisation to manage the collection of insurance contributions from citizens and the reimbursement of providers, for example. Such an organisation has to be trusted by citizens to use their contributions for the purposes intended and to secure for them good quality care that meets their needs. Perhaps lessons can be taken from the South African Revenue Services about how to build a trustworthy organisation. Good communication with the public, responsiveness to clients, taking fair but hard action on defaulters when necessary are all important. They are, in turn, based on strong organisational leadership ‘€“ fair dealing with employees, creative managerial practices, good information systems. An NHI authority will also have to think through its relationships with other parts of the health system ‘€“ where the borders of responsibility and authority lie between it and the national Department of Health, for example. And it will be important to think about what legislation might be necessary to secure the funding base of the authority, and so of the system as a whole, despite changing political mandates. The public will want to know and understand the decisions made about these issues ‘€“ and these decisions will affect their trust in it.

But whatever happens about NHI, we will still need a decent health system for all people. So we need debate now about the principles on which such a system should be based, and we need to work with public health system leaders and health workers to translate these steps into real improvements. Our power as citizens must be married with political and managerial power to ensure effective change, to build a health system we can all trust.

  • Lucy Gilson is a Professor of Health Policy and Systems at the University of Cape Town,



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