Making healthcare equitable

The Constitution of South Africa gives all citizens the right to access healthcare. Since 1994 the government has tried to ensure that everyone in this country has equitable access to necessary healthcare services, but with very little success.

There are communities in rural and disadvantaged areas that cannot easily access or use healthcare and residents of highly populated areas who have to rely on overcrowded public facilities with too few health professionals and poor equipment. Almost 20 years after the onset of the democratic era, the bulk of the country’s doctors, dentists and specialists still serve a minority of the population, those who can afford private healthcare.

National Health Insurance: A dummy’s guide



The amount spent on the healthcare of each person with medical scheme cover is four times the amount that is spent on each person who relies entirely on public healthcare facilities.
This funding disparity translates into a major gap in the quality of healthcare services available to the rich and the poor respectively. This disparity is clearly illustrated in key health indicators, such as maternal and child mortality and the declining life expectancy for the national population. The private healthcare sector in its current form is unsustainable and is likely to collapse as tariffs increase uncontrollably.

The status quo cannot remain as it is. There is a clear and urgent need for the government to provide decisive stewardship on how the health system can be overhauled to ensure that all South Africans enjoy a long and healthy life. This intervention is in the form of the National Health Insurance (NHI).

The NHI is intended to ensure that all South Africans have an equitable and timely opportunity to access required health services when needed. No individual, irrespective of his or her socioeconomic status, should face avoidable barriers to accessing health services. Household and individual income should not be a precursor to one’s ability to access and make use of quality healthcare.

Further, the lack of financial means must not be a factor that limits the poor from accessing health services. This particular barrier—and the need for the government to ensure that all South Africans have access to sustainable, quality healthcare—is at the foundation of the NHI. All contributions to the NHI will be based on the ability to pay, with appropriate exemptions for people who fall below a stipulated threshold. The exact detail of the proportion of income contribution that individuals will have to make towards the NHI is still being worked out between the treasury and the department of health.

A guiding principle, however, should be that the level of contribution should be relatively lower than what households currently contribute towards their private health insurance cover. Affordability of the projected contributions is another key factor that will be taken into account prior to determination of the exact contribution rates.

Under the NHI, South Africans will have access to a comprehensive package of quality healthcare services, including primary healthcare, access to specialised secondary care and highly specialised tertiary levels of care. The state is committed to offering as wide a range of services as possible, within available resources. Nonetheless, the NHI will not provide anything and everything.

The focus of the healthcare package is to offer services that will reduce the levels of mortality and morbidity most effectively and thus address the population’s health needs more holistically. This package of healthcare will be distinct from the current benefit options as offered by medical schemes where there are a defined number of consultations, limited diagnostic tests and little or no cover for primary healthcare services.

To ensure the successful implementation of the NHI, the government recognises the need to improve the quality of healthcare provided at public health facilities. The improvement of quality in the public health system is non-negotiable. Moreover, the pricing of services in the private health sector must be radically changed to introduce more rational, transparent and balanced tariff-setting systems. This will go a long way towards ensuring sustainability of the entire healthcare system.

The preliminary cost estimates included in the green paper on the NHI are inclusive of current public sector spending, as well as requirements needed to enhance the quality of care and infrastructure in the public health sector. The R103-billion reflected for 2011 is the current total government expenditure on healthcare in the public sector. The estimated R125-billion for the 2012 financial year is inclusive of the R110-billion that the treasury will allocate to the department of health as indicated in the budget framework, which is in the public domain.

The difference is the financial resources required to undertake the re-engineering of the primary healthcare system, the roll-out of quality improvement plans, the establishment of the Office of Health Standards Compliance, the training and recruitment of health professionals and the enhanced revitalisation of the health facility infrastructure.

The NHI will be implemented in a phased approach with an initial focus on overhauling the public healthcare system and piloting key aspects related to administrative components and the service packages. These pilot projects will be conducted in 10 districts. The NHI fund will be created in the latter part of the initial phase once the relevant legislative provisions have been put in place.

It is an opportune time for the government to transform the healthcare system decisively into a more equitable one. It is not an attempt to stifle the private healthcare sector, rather an opportunity for the health system to be transformed into one that offers better value for money and ensures that all South Africans can live a long, healthy and productive life.

Dr Anban Pillay is the chief director of health economics in the department of health and Dr Aquina Thulare is a ministerial adviser to the health minister

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