Follies the NHI should avoid

The frenzy of public debate, suspicion and negativity across the social, economic and ideological divides that has torn South Africans apart with regard to the National Health Insurance (NHI) will surely be calmed down by the publication last week of the government’s green paper.

Although the paper gives no final details about how the NHI will be funded, it does commit the government to improving the quality of health services, especially in the public sector.

In our interview with Aaron Motsoaledi, the health minister explains why the NHI is the only logical solution to healthcare in SA, and why our current model is unsustainable.
The publication of the green paper is the culmination of a long march towards the transformation of the South African population in general and is therefore a landmark development in healthcare.

It recognises article 25 of the 1948 Universal Declaration of Human Rights, which states that “everyone has a right to a standard of living adequate for the health and wellbeing of himself and his family”. This is the only laudable justification for universal coverage; the many other reasons advanced are peripheral and sometimes bear no relevance to the overarching reason.

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The green paper fails to eliminate an erroneous preoccupation with trying to find justification for public health system failures in its private counterpart. Reference to private hospital costs having increased by 121% and specialist cover by 120% over 10 years deliberately fails to inform South Africans that the corresponding figure in the public health system is 277% (budgetary allocations 2001 to 2011) for the same period of acknowledged quality deterioration. Let it also be known that the figures for salary and food inflation for the same period are 111% (21st Century) and 113% (Stanlib), respectively.

Of greater concern should be the source of funding for the NHI. The small taxpayer base of 5.9-million in a population of 50-million is what caused the minister of finance to caution against increasing tax and instead confirming that conditional grant funding would be used to top up the scheme. Whatever that means, government revenue comes from taxes, so we should not be under any illusion that taxpayers will not be squeezed some more, one way or another.

It should be clear to all of us that the best way to increase this pool without “pain to our economy” is to deal with poverty. We need to remove all barriers to an improved economy by investing more in education and skills development, stopping irrational and ideologically failed economic policy pronouncements and dealing comprehensively and ruthlessly with corruption. It is a fact that wealthier nations are healthier nations.

The green paper informs us that the precise combination of funding sources is the subject of continuing technical work that will be clarified in the next six months, parallel with public consultation. But the public consultation period, according to Government Gazette No 657 of August 12, is two months, which effectively excludes the public from giving input on the most important aspect of the policy.

The administration of the NHI will be done through a national health insurance fund to be established as a government-owned entity that is publicly administered. South African healthcare providers historically do not have positive experiences with government-owned entities, such as the Road Accident Fund, in terms of reimbursement efficiency. It is therefore justified that there is nervousness about the mooted reimbursement system.

The role of the NHI fund should ideally be that of monitoring policy provision, making sure the system achieves what it is intended to do. The document says that a multipayer system in an NHI will be explored as an alternative to the preferred single-funder, single-purchaser publicly administered fund. This should not be an area of experimentation, because we have overwhelming evidence (as acknowledged in the document) that expertise does exist in the private sector in the administration and management of insurance funds. Outsourcing the collection of revenue to the South African Revenue Service is realistic and laudable and so would be the distribution of those funds for reimbursement purposes through established and experienced health fund administrators. Allow for competition between administrators and that will lead to improved efficiencies.

The re-engineering of the primary healthcare system is paramount in achieving improved health outcomes because it symbolises a paradigm shift from medicine to health, cure to prevention and promotion, biological to social causes and centralised care for a few to decentralised services for many. It must be lauded and supported by all.

Director general of health Malebona Matsoso has been quoted as saying there are two things that will make or break the NHI—the management of the institutions and the human resources the country will be able to train and make available. It is known that, in the past 10 to 15 years, the number of healthcare human resources—doctors, nurses, pharmacists, medical technologists, medical engineers and so forth—has declined. We almost need to declare a Marshall Plan that will combine all available resources, private and public, to remedy the situation.

In conclusion, before the green paper hardens, there is still a lot that those in power should do to allow South Africans to contribute to their healthy future. Ideally, we should therefore request more time for consultation—six months, perhaps.

Dr Nkaki Matlala is the chair of the Hospital Association of South Africa. The views expressed in this article are his own

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