While it remains unclear how much money will be required to finance the proposed National Health Insurance (NHI) nor where the funds will come from, a public health medicine specialist recommends that the government increase taxes to raise funds.

Prof Susan Goldstein, Deputy Director and COO at the SAMRC Centre for Health Economics and Decision Science-PRICELESS SA, believes taxes on alcohol, sugary beverages, and tobacco must be targeted.

NHI status

The NHI is a health financing system designed to pool funds to provide access to quality, affordable personal health services for all South Africans based on their health needs, irrespective of their socio-economic status. But the proposed bill is still being deliberated in the National Assembly, and no information has been shared on how the proposed legislation will be funded.

According to the National Department of Health spokesperson, Foster Mohale, the Health Portfolio Committee has voted in favour of its desirability and is now considering the contents line by line, which will resume next month.

NHI is going to cost a fortune

But Goldstein warns that for NHI to be correctly implemented, it will cost the South African government a fortune and that not all health services will be available.

“The NHI will cost the government a lot of money, and not all health services will be available, so there will have to be careful prioritising. It is not only money that needs to be considered but equity, and other values and ethical issues,” stated Goldstein.

Impact of non-communicable diseases in SA

Goldstein believes that for the government to increase its income, which will also benefit the implementation of NHI, it should consider raising taxes on products which are the main driving factors behind the burden of non-communicable diseases in South Africa.

“All these things [alcohol, sugary beverages and tobacco] cause non-communicable diseases and create a huge burden on the health system and families and individuals,” said Goldstein.

According to Statistics South Africa’s Mortality and causes of death in South Africa 2018 report, the top ten leading underlying natural causes of death were; tuberculosis, diabetes mellitus, cerebrovascular diseases, other forms of heart disease, HIV and hypertensive diseases, among others.

Goldstein also said: “I don’t know how much is needed as the packages haven’t been worked out yet. I believe universal health coverage of good quality health services will benefit all South Africans. Still, I would suggest that there should be a simultaneous focus on promoting health and looking at the major causes of ill health.”

The World Health Organisation (WHO) states that, currently, at least half of the people in the world do not receive the health services they need. Further, 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health.

Poor quality of health care

According to Goldstein, poor quality of care remains a significant challenge facing the healthcare fraternity in the country.

“What is important in the NHI is not so much coverage as SA has pretty good coverage – and much is free at the point of service (for pregnant women and children under 6). Our biggest problem is quality of care, which is closely related to governance and management. Funding decisions must be transparent. Several issues not directly in the health budget are important for improved quality of care. They include infrastructure – roads, water, electricity, buildings, and maintenance,” said Goldstein.

Public health infrastructures are not ready.

During the NHI public hearings, the issue of poor general health infrastructures was raised and whether it will be possible to roll out universal health coverage in old, dilapidated buildings. But according to Mohale, some public health infrastructures are not ready for the rollout.

“Some are, and others are not, but that is, in any case, premature since the phasing in the NHI will take several years, and there is no entity established yet to purchase benefits anyway. This gives time for public and private establishments to comply with the required standards and align with accreditation requirements,” said Mohale.

But according to Goldstein, several determinants of health need to be also addressed to improve the health outcomes of South Africans.

“These are inadequate housing, alcohol, tobacco, poor diet that includes highly processed foods and sugary beverages. If these things could be controlled, the nation’s health would improve hugely. Additionally, addressing the causes of violence and traffic crashes would decrease the burden of ill health. Thailand introduced a National Health Promotion Foundation when it introduced their national health insurance scheme for exactly this reason,” said Goldstein.

The impact of the COVID-19 pandemic

Goldstein further stated that the COVID-19 pandemic was also a setback for the provision of healthcare services in the country.

“Well, it had a positive and negative effect. With all services directed to COVID-19 many services suffered – such as childhood immunisation and the diagnosis of tuberculosis. However, the positive was the intense illustration of the relationship between alcohol and trauma in our country,” said Goldstein.

“Another positive change was the massive swivel to prepacked medications for those with chronic illnesses. This had been happening for HIV patients but increased dramatically during COVID – saving people a lot of time and money. The impact of this on people with chronic illnesses’ health is still to be determined,” added Goldstein.

When is the ideal time?

The National Assembly Chairperson of the Portfolio Committee on Health, Dr Kenneth Jacobs, stated that there is never a perfect time to roll out NHI in the country.

“People need a better health outcome which will be shared by having access to quality, affordable healthcare. So, the question is, when the good time is to roll out the bill? Or was it a good time five years ago? Or will it be a good time five years from now? So, unless we start with the rollout of the NHI, we will never know if the country is ready or not,” said Jacobs.

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According to him, Parliament is resuming work on the 17th of August. They will then restart work on the clause-by-clause deliberations on the NHI bill a week later.

“The process is that we must complete the clause-by-clause deliberations before we can do anything else. When the bill becomes a reality, it must be rolled out in phases. It will be a phase implementation. We are the custodian of the bill because it has been forwarded to us by the national department. When we complete our work on it, it will be returned,” he said. – Health-e News