National Health Insurance (NHI)

Unity is our best shot at a healthy future for all

Public-private partnerships are key to national health insurance, writes Mamphela Ramphele.

The public and private sectors have been invited to walk together to arrive at a national health insurance (NHI) system.

They should seize this opportunity, as it is the best chance we have of developing a workable and affordable system that will help provide access to healthcare for all South Africans.

The invitation has been extended by the new Minister of Health, Aaron Motsoaledi, a man of considerable ability who is earning increasing respect.

He may turn out to be one of the best health ministers this country has had.

Motsoaledi, a medical doctor, has appointed a 25-person ministerial advisory committee. This committee is tasked to listen, consult and then advise him on aspects of NHI policy and an implementation plan for the national health system.

The committee comprises medical experts, health insurance and funding experts, academics and representatives of the public and private sectors.

They have a huge task and deserve as much support as possible to ensure that South Africa gets a well-designed and implemented national health insurance system.

Why am I so strongly in favour of national health insurance? There is no way we can have a healthy society in which 90% of the population does not have the requisite quality of health services – and here I am referring not to hospitals, but to the promotion of well-being, prevention of ill health and the provision of healthcare for those who become ill.

The walking together starts well before we get to the premises of the health system. Health insurance is like any other insurance – it is a safety net to catch you when things go wrong. A substantial part of the challenge facing our health services is that our overburdened hospitals and clinics – with multiple attendant problems, including funding, staffing and equipment – have to treat people with illnesses and diseases that could have been prevented or treated locally by qualified health workers.

So the first task is to reduce to the minimum the number of people needing the insurance safety net. We have a health system that is dealing with socioeconomic problems that should be dealt with in collaboration with other departments.

We need an approach to development that affirms people’s dignity and self-respect, thereby enabling them to help themselves and not become dependent on state hand-outs. We need high-quality education to enable all to rise to their potential, know more about their bodies, be better able to look after themselves and contribute more to society. We need to ensure that there is enough water for basic sanitation and food preparation, to prevent illnesses. People who are cold, wet and hungry also become vulnerable to illness.

NHI is not a panacea for our complex problems. We must go beyond that and make sure our people have the infrastructure to provide the basics that support wellbeing. We must invest in people so that their dignity and sense of self-worth motivate them to take care of themselves and sustain their own well-being.

Much can be accomplished with inexpensive basic healthcare. When I was banished to Lenyenye township in Tzaneen in Limpopo during the apartheid years, I was able to work with people there to reduce preventable child deaths and improve people’s wellbeing through simple interventions.

The key success factor is recognising people’s local knowledge, thus affirming them and enabling them to change harmful practices without feeling disrespected. Grandmothers were quick to adopt oral rehydration using a simple mixture of boiled water, sugar and salt. The community also banished pellagra (vitamin deficiency) and promoted vegetable gardens and better cooking methods to preserve nutrients.

We need efficient referral systems, from community health workers to clinics, provincial and tertiary hospitals. We must make better use of technology – cellphones can send photographs to help in the diagnosis of a rural patient or to monitor whether a patient is taking antiretroviral drugs.

When we set about designing our NHI, we must make haste slowly. There must be a level of haste, because it is an urgent matter. But we must ensure that we create a framework that will address the concerns and needs of all of us in an affordable manner. If we start by cutting corners, we will have a very long and difficult journey ahead of us.

We need a framework that will get the public sector to think differently about health, and give the private sector the opportunity to adapt so that the two can walk together.

We must also learn the lessons of our past, particularly our recent past.

The past 15 years have shown how quickly a reasonably well-functioning health infrastructure can be run down and how expensive it is to build up again.

The system of political deployment put untrained, inexperienced people in charge of hospitals with disastrous consequences. We need experienced, trained and professional managers in charge of our healthcare facilities.

Respect for expertise must be the touchstone of our system.

We must learn from the experience of other countries. We can study what has worked and what has not in the many NHI systems that have been implemented around the world. However, we must also be careful not to have preconceived ideas that what has worked somewhere else can necessarily be transplanted unchanged into South Africa.

Management training has been identified as a serious need in our healthcare system, particularly in the public sector. I hope this will be discussed as a matter of urgency by the ministerial advisory committee.

The minister has called for public-private partnerships to help restore our public health system. Management is one area where the private sector has a comparative advantage – it knows how to run hospitals efficiently and cost-effectively.

We need to strengthen human resources for our healthcare system. We need thousands more nurses and, therefore, a rapid increase in training facilities. Reopening nursing training colleges is essential. Here, too, the private sector can help because of its well-developed nursing training programmes. Private hospitals must also become part of an expanded training platform for medical specialists.

In the UK and some other countries, universities offer an MBA in health care. We don’t have that business degree here to help prepare senior managers at public and private hospitals. It is something that our academic institutions could investigate. We should also be looking at one-year and part-time courses for lower-level managers.

Walking together needs to be embedded in all training courses, from nurses and doctors to top managers. We have become a nation where caring for the sick and vulnerable is not underpinned by respect.

One of the most urgent priorities is to revamp our infrastructure, particularly large public hospitals, which are training grounds for doctors, nurses and specialists. They used to be centres of excellence, but some are run down and in a state of disrepair.

Creative and sustainable public-private partnerships are essential to the viability of national health insurance, given the tight fiscal space.

Consideration should be given to ask each of the private hospital groups to restore and manage one or more of the rundown public-sector tertiary hospitals to the standards we should expect of these facilities.

The private hospital groups may not have the money for all of this, but they know how to raise and manage capital. This would involve the creation of well-planned facilities and management contracts for five years or more, including a commitment to train and develop public-sector staff.

Fast-tracking infrastructure improvements at our public hospitals could start now, before the advisory committee has completed its deliberations.

Finally, we must realise our limitations. South Africa cannot afford a super-duper national health insurance model. We will have to develop an affordable system. So I hope that the ministerial advisory committee will look at a number of models – the high road, the medium road and the low road

– and see which will work best for us. We need to find a model that will give top-quality healthcare to as many people as possible at a price the country can afford.

Strengthening our healthcare system and setting up national health insurance is going to be challenging. We need to walk together, not walk away. We cannot afford not to afford a well-designed and carefully implemented NHI.

Ramphele is the Chairman of Circle Capital and convener of Dinokeng Scenarios

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