DA ‘ State intervention not what the doc ordered
OPINION: No country in the world has a perfect health system. But some countries have got it more right than others, and where countries have got it right, it is through the state being involved to some degree in regulating the system. by Mike Waters, MP.
But this does not mean, as the ANC appears to believe, that the more state intervention the better for health care. The ANC’s NHI proposal ‘ contained, in its latest draft, in a document released last month – is based on the assumption that intensifying and extending the government’s reach over health care, through the creation of more government bureaucracies, and reducing the role of the private sector, will lead to better health care.
Everything that has emerged from the ANC on this subject appears designed to justify this greater role for the state rather to really get to grips with the problems of the South African health system. The facts and figures that the ruling party produces are all aimed at validating its pre-determined position rather than engaging with the real picture.
The unfortunate truth is that the ANC’s instinctive response to any problem is to create a new bureaucracy, and now it is doing the same thing with health care. All South Africans should be very worried about the consequences for their health.
The ANC’s record on managing bureaucracies is poor. But even if we make the assumption that the new bureaucracy will be well managed, we also need to ask whether it is in fact the system that South Africa needs.
We currently have a system that works well for some. Our private health care system is one of the best in the world. But the reality for most people is not this; it is rather the long queues, empty medicine cupboards and in particular the catastrophic shortage of doctors and nurses in our public hospitals.
The DA believes that the state does have a vital role to play in providing health care. But it must get this role right.
So then we need to ask: what works?
A Monitor survey in 2004 evaluating the quality of health care across the world helps to show us what works well in the rest of the world.
The three countries who were rated top in the world rankings in terms of quality were Canada, Singapore and Taiwan, in that order.
It is notable that in all of these countries, there is a high degree of involvement by the state in both paying for health care and in ensuring that those citizens who can afford to contribute towards their own health care, do so.
In Canada, publicly funded insurance schemes cover all medically necessary hospital and physician care. In Singapore, although the state only directly provides about a third of the total funding for healthcare, it is heavily involved in ensuring that its citizens do contribute directly towards their health care. The state also plays a strong role in regulating the supply and prices of healthcare services in the country to keep costs in check.
Taiwan inaugurated its National Health Insurance program in 1995. Before then the three major social health insurance programs left 40 percent of the population uncovered. Now, almost all Taiwanese are covered by a compulsory, most premium-based insurance system. The private providers who previously delivered health services to a small part of the population have become part of the new system, and there are no waiting lists and a high level of satisfaction.
The Canadian government also involves itself in other ways through, for example, a centralised system for buying drugs which allows for bulk buying and strong negotiating power in price discussions. This keeps medicines prices on average between 35 and 35% lower there than in the United States, where the law specifically prohibits the state from becoming involved in negotiating medicine prices.
Looking at the top three countries’ health systems, the state is heavily involved in the financing of health care, but it is notable that it takes a small role in terms of actual delivery of services ‘ very much not what the ANC is proposing.
Canadian hospitals are controlled by private boards or regional health authorities, rather than being part of government. About a third of Taiwanese health care is provided by municipal or public hospitals, while two thirds is provided by the private sector. In Singapore, private practitioners provide the overwhelming majority of primary health care services, while publicly run hospitals provide most secondary and tertiary care.
So what lessons can we learn from this?
Firstly, it is clear that, while good health care costs money, it is not a case of the more money, the better your health system. The richest of the four top countries in terms of GDP per capita, as rated by the Monitor survey, is the United States, yet its health system was rated only number four. Many countries whose populations are extremely wealthy have health systems which do not rank highly at all.
It is also clear that the cost of delivering a good system varies enormously. Taiwan’s health system is rated as better than that of the United States, but costs less than half as much per capita as the US system.
So we need to be clear, when it comes to our own system, that the primary focus must be on the effectiveness of expenditure, not the amount of money we spend. South Africa already spends far more on health care than many other developing countries. But the ANC’s proposals do not have this focus. The emphasis is very much on raising more money, not on making the money we do spend worker better.
How do we make our health care money work better?
Another lesson from the ranking exercise by Monitor is how necessary it is to implement policies that allow the private sector to co-operate with the public sector, in a way that the usage of the private sector can be expanded without compromising on the quality of the system overall.
At the moment in South Africa, we have a public sector and a private sector that operate largely independently of each other. The message increasingly being given to the private sector, through the various documents coming from the ANC, is that it is an unnecessary appendage that should be made to wither away and die.
The message from the world’s best health care providers is exactly the opposite. We see from these countries that, in fact, a quality health system depends critically on integrating the private system into the public system, and working out a solution that allows private providers to earn a living while the state is still able to meet its obligations to its people.
There is no such partnership in South Africa at the moment. Where there is any relationship at all, it is defined by mistrust and suspicion. The ANC is not inclined to recognise the limitations of its role in society, but the evidence shows that in health care, it is important that it do this.