A new health scheme favoured by the government is likely to prove hugely popular. Pat Sidley reports
THE government is actively investigating a national health insurance plan which would, if implemented, revolutionise the country’s health system and provide the funds for basic health care to all citizens.
Three options are under consideration. The Weekly Mail & Guardian has been given a copy of a summary of the option most favoured by the Department of National Health, which is the most contentious of the three.
This plan, if implemented, is likely to be hugely popular with the majority of South Africans; resisted by those already paying large amounts of income tax; alienate many doctors; and, at the very least, set off widespread debate about its merits.
It would, if implemented:
* Be funded by a payroll tax of three percent of annual income to be shared equally by the employer and employee. Self-employed people would pay two percent of their income. This tax, which would be levied in addition to normal taxes, would raise about R5-billion a year, to which the state would add a further R1-billion.
* Provide basic care at the level of general practioner (and nurse) throughout the country, with no exceptions. Included would be certain basic medicines identified on a drug list.
* Private practices, clinics or community health centres would be accredited as national health practices and would be funded upfront with a global payment to run the practice. General practitioners could not charge on a “fee for service” basis, as they do now.
* Patients would not necessarily be treated by doctors. At least half to a third of complaints would be attended to by a nurse or other health professional.
* All primary or general practice care would be removed from existing medical aid and insurance packages. These institutions would accordingly lower the premiums they charge their members.
* It is envisaged that most of the basic care and medicines would be offered free of charge, although there is the possibility of a nominal charge for visits. Some procedures, such as immunisations, would attract a small charge; the plan suggests R10. However, pregnant women and children under six would continue to receive free health care.
The department is in the process of setting up an “implementation committee” to review all three options and is unlikely to have a plan in place until the 1996/97 budget. The introduction of any such major change is likely to undergo a great deal of debate, including a separate debate in parliament.
The plan the department currently favours was put forward by Australian health economist Dr Jonathan Deeble, who has visited the country on two occasions. In 1992 he came at the request of the ANC health support group, bringing with him the experience of Australia’s own relatively recent introduction of a national health system. He returned this year, spending two weeks investigating options for the introduction locally of a national health insurance scheme.
According to a summary of Deeble’s proposals in the hands of the WM&G, patients would be covered for three visits a year to primary care centres — a substantial drop in the coverage they are getting from medical aids. The number of visits is currently an area of widespread abuse by both doctors and patients.
Deeble recognises in his summary that it would be “unrealistic” to expect medical aid members to “reduce their GP use immediately”.
Some people whose salaries are low and who are either not on medical aids, or who pay very little into their medical aid schemes, would probably have to pay more for their health care through the insurance scheme than they pay now.
Indigent citizens would still be able to get most of their basic health care needs met through state facilities.
Somebody earning R50 000 a year (around R4000 a month) would pay about R1500 a year on the proposed national health insurance scheme. People receiving higher salaries would also effectively pay more than they have been paying for general practice care. This would have the effect, according to Deeble’s paper, of redistributing wealth for health care.
After his 1992 visit, he produced a report which compared the South African and Australian systems, from which it emerged that South African doctors charge fees similar to those charged by their Australian counterparts. However, he noted that the care costs South Africans relatively more, because their incomes, even among whites, are much lower than Australia’s average income.
He remarked in 1992: “The problem is not just one of affordability, however. Insurance-supported fees now yield private doctors in South Africa, particularly GPs, relative incomes very much greater than their Australian counterparts, which makes their incorporation into any financially viable public system very difficult indeed.”
The proposals by Deeble form one of the three options which have been offered as alternatives. Among the points of departure are the nature of payment to doctors, whether they should be paid on a fee-for-service basis or by “capitation” (whereby they would be paid upfront to run the practice).
Other options include providing primary care through state facilities only — leaving private doctors out of that system.