'Fix health system first'
The ANC’s discussion document on a national health insurance (NHI), unveiled at the party’s national general council last week, contains few details on how to fix the embattled public health system and little in the way of innovation, experts complained last week.
But they said it did suggest that the ANC’s position on an NHI was evolving.
Alex van den Heever, a health and policy analyst, said the discussion paper did not materially change what currently existed in public healthcare.
“There is very little in the way of innovation where it matters throughout the body of the health system, such as governance and accountability, and not much clarity on how new money is to be spent,” he said.
Van den Heever said providing a “shopping list” of changes the ANC wanted to make to the health system was not helpful, especially when many of the key points listed had been raised in government policy papers going back as far as 1994.
Issues such as drug shortages, hospital capacity and the uneven distribution of healthcare workers between public and private facilities and in urban and rural areas had been raised in the past and remain unresolved.
“If history is anything to go by, confidence[in the 2012 implementation date proposed in the discussion document] is low,” he said.
Jane Goudge, the director of the Centre for Health Policy at Wits University, welcomed the document’s recognition that an efficient public health system was a precondition for an NHI. “There’s an acknowledgement that there are two sides to the equation—both funding and access need to be considered in reform,” she said.
To ensure that an NHI brought better access to healthcare, there would need to be a concurrent improvement in the reach and quality of healthcare services and an increase in the number of facilities and staff in the sector.
In addition, she said, reports compiled by the integrated support team set up during Barbara Hogan’s stint as health minister highlighted the severity of problems with management, accountability and financial planning that had led to inefficiencies and skyrocketing debt in provincial health departments. As of April 2009, provincial health departments were more than R7,5-billion in debt.
The state would need to improve these areas if it was to build public confidence in the public-health system, Goudge said.
“If people are expected to make a ‘solidarity sacrifice’, they need to be reassured that there’s not an enormous black hole into which funds are disappearing,” she said.
Mark Heywood, the executive director of health advocacy group Section27, said it would be difficult to comment on any proposals relating to an NHI until the government produced a green paper.
“To see how it will work, we need to look beyond broad, sweeping statements to a level of detail that is not yet there,” Heywood said. “The [health] department must urgently publish a green paper on an NHI to allow proper, informed discussion with all stakeholders.”
Some commentators felt the ANC document blurred the line between state and party, and questioned the party’s motives for putting out the discussion paper.
Norman Mabasa, the South African Medical Association chairperson, warned that the ANC’s discussion document should not be seen as a government announcement. “It’s an announcement that came from the ANC, but its tone implies that it’s a done deal,” he said.
But a ministerial advisory committee, put together by the health minister, Aaron Motsoaledi, has been working on a national health insurance proposal for almost a year and has yet to release a report.
Mabasa said a 2012 deadline for implementation was optimistic, given that any policy would still have to be drawn up, presented to the Cabinet and treasury and then referred to the public for comment.
“It would be optimistic to think that the process would be so smooth as to conclude by 2012.”
He said it was important that the process should be conducted cautiously so that public support for the system could be built up.
Insurance an unbearable burden on middle class, say economists
The ANC has shed some light on how the NHI scheme would be funded, but economists and health industry analysts were still largely in the dark when the Mail & Guardian spoke to them last week.
Some went so far as to describe the ANC’s discussion document as “vague” and “opaque”, arguing that there was not enough detail to assess the proposal properly.
The document suggests that the roll-out of the NHI could begin as soon as 2012, with the initial year’s funding requirements amounting to R128-billion.
The ANC projects that this will rise to R267-billion by 2020 and R376-billion by 2025.
The health budget for the current financial year is R101-billion, with R117-billion provisionally budgeted for the 2012-13 financial year—suggesting that the additional amount required for the roll-out would be just R11-billion in the first year.
But the private health sector has priced the NHI at R200-billion over and above the government’s current health spend.
The document proposes a number of ways in which the NHI could be funded, including an increase in VAT, a surcharge on taxable income, a payroll tax for employees and/or employers and the abolition of tax exemption for medical costs.
Efficient Group’s chief economist Dawie Roodt said a 1% increase in VAT could collect well in excess of R10-billion, whereas abolishing tax exemptions could collect between R4-billion and R5-billion.
But Roodt questioned why these measures were being proposed if the government needed to collect only an additional R11-billion, a relatively small amount.
He said: “This is just going to squeeze the middle class even further. It is already saving almost nothing.”
Economist Mike Schussler said the NHI was “not affordable” and was “to a large extent wishful thinking”.
The country had at most five million people who pay income tax.
“You can’t have less than 10% of the population paying for everything,” said Schussler. “We get so little back for our taxes as it is.”
If the NHI is pushed through as proposed, there would probably be a tax revolt.
Health economist Alex van der Heever pointed to the huge fiscal hole in public health budgets, estimating that, on an accrual basis, it could amount to R12-billion.
The proposal to improve health facilities in rural areas was an admirable one, he said. But the district health system was not functioning properly and getting that right would be vital to the success of the NHI.—Lloyd Gedye