/ 2 June 2009

‘Rich-country’ solutions –

An ANC task team headed by former director general of health Olive Shisana is trying to convince the ANC and government to implement a national health insurance (NHI) swiftly, but many believe this could be the kiss of death for an already buckling public health system.

There is wide speculation that former health minister Barbara Hogan’s insistence that the NHI proposal should be subjected to proper processes and public scrutiny led to trade union pressure for her to be removed from the health portfolio.

Stakeholders last week confirmed they are worried that the process is being built around Shisana, whom they believe is positioning herself to head the NHI authority.

According to the draft document, which the Mail & Guardian has seen, the authority would be a powerful financing structure set parallel to the national health department.

Shisana has been driving the process and has already told Debbie Pearmain, legal representative on the board of Healthcare Funders, to formulate the draft legislation. Shisana is said to want the proposal implemented this year with herself in the powerful position of chief executive of the NHI authority, from which she would ”brief” the national health minister, rather than report to him.

Approached last week for comment, Shisana said she would be available for interviews only next month.

Insiders say the task team is dominated by unionists, led by Nehawu’s policy head, Teboho Phadu, who see the ultimate goal as the disappearance of private medical aid schemes and railroading all citizens into the public health system.

The idea is that those who can afford private healthcare would subsidise state healthcare.

A confidential NHI draft distributed in February proposes universal coverage that is free at the point of service and covers all ”medically necessary” interventions.

It states the NHI should be a state-administered, single health insurance system and that funding for it would be sourced from general taxes and compulsory contributions by all employers and employees.

According to the draft, tax rebates for medical aid contributions will fall away, increasing cost pressures on both employers and employees and making medical scheme cover unaffordable for most people, particularly those with low incomes.

In its election manifesto the ANC pledged to implement a national health scheme within five years, despite the economic downturn and massive job losses. Sources said the February draft has been further developed and will be presented to a high-level ANC meeting on the first weekend of June.

The dean of research at the University of the Western Cape, Renfrew Christie, questioned whether economists or actuarial scientists had crunched the numbers to show that an NHI in South Africa is feasible.

”It is a rich-country solution,” Christie said. ”Sweden has a tiny population, superb civil servants and was totally healthy when they did it. The United Kingdom also had a superb civil service and it was accustomed to draconian wartime measures. There was buy-in across most classes in 1947. It was also a richer country without epidemics.

”If you want to tax the rich more, do that, and then spend it directly on health through the ordinary treasury budget.”

The ANC has consistently underfunded health services and has shifted resources from hospitals as the Aids epidemic has grown. Government spending for each person on public health services declined after 1996, returning to 1996 levels only in 2005.

Health economist Alex van den Heever said the formulation of complex policy behind closed doors was dangerous. ”The lowest-quality policy emerges from processes in which you insulate yourself from any critique,” he said.

The task team appeared to be looking in the wrong place to solve the health system’s woes. ”Institutional reform is certainly needed across both the public and private sectors, including the use of national insurance modalities,” he said. ”But the proposals do not relate to the systemic challenges and are more likely to exacerbate than solve them.

”There is also an irrational bias against people having access to medical schemes, which are an essential component of the healthcare system.”

Health economist at the University of Cape Town Di McIntyre said South Africa needed an NHI, which was possible and affordable. ”But first we have to invest heavily in public hospitals, the backbone of any NHI.

”We need to turn it into a service provider the public feels confident in and wants to use. It could be a phenomenal service if we get the hospitals right.”

Adila Hassim, head of litigation at the Aids Law Project, said there was widespread support for some form of NHI, but that the way it was formulated and introduced was critical.

Jonathan Broomberg, head of strategy and risk management at Discovery Health, said private sector stakeholders were not in general opposed to the objectives of an NHI, but had significant concerns about aspects of the mechanisms proposed for achieving it. ”South Africa has a world-class private healthcare system. We must guard against proposals that will damage this system and focus on how the private sector can assist in achieving the objective of improving health outcomes for all South Africans,” said Broomberg.