Owning the NHI system

In 2008 the South African Medical Association unanimously adopted a resolution in favour of supporting the principle of universal access to healthcare. This position has not changed—it has merely been reaffirmed. The association anticipated that the likely vehicle to achieve this policy would be a National Health Insurance (NHI) system.

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 association has always remained willing to hold meetings with all NHI stakeholders and welcomes the release of the government’s green paper on the proposed insurance. Through its health policy structures, the association has already started the process of comprehensively reviewing all aspects of an NHI system and will now incorporate the document into this process. Doctors and other healthcare professionals are significant stakeholders in the proposed NHI system and the association looks forward to robustly contributing towards shaping it.

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Although several issues are dealt with or alluded to in the NHI green paper, there are a few matters that warrant special mention. The association believes that an NHI system will not be able to be implemented if these issues are not addressed.

The first is the poor state of the public healthcare system and, more specifically, its institutions. The system has to be addressed and overhauled urgently—it needs resources, staff, management, infrastructure, equipment and efficiency.

We acknowledge that such action forms part of the government’s 10-point plan and that, for example, issues such as managers are being discussed. But this should occur independently of the NHI ­discussion and at no time should the temptation arise to use the introduction of a national health insurance system as the conduit through which it happens.

The second issue is that the green paper has helped to settle the fears of our private-sector colleagues who, justifiably, have felt a degree of threat to their continued existence while this document was in progress. The NHI will coexist and collaborate with the private sector. Medical aids will seemingly not be abolished, contrary to speculative reports, but one would need to acknowledge that the way they function and the benefits and options they offer will likely change in the future.

That is not new—several funds have continually adapted to the changing environment over many years. But what is clear is that the disproportionate staffing ratios between the public and private systems in our healthcare paradigm will be addressed only to a limited extent by incorporating private sector practitioners into the NHI. It can never be the only mechanism used to address the skewed distribution of human resources between the two systems, although it will help to provide wider access to quality doctors in the short term.

The long-term solution must be a vastly increased output by training institutions of a range of healthcare professionals, including doctors and specialists. Although there is the sense that a willingness prevails among many private sector doctors to contribute to an NHI, it is proper that appropriate remuneration is offered for their services.

It is promising that specific remuneration details are not listed in the document—we regard it as a unique opportunity to present the position of general practitioners and specialists on what they see as reasonable professional tariffs for their services. It is a critical aspect of the NHI and the association will encourage its members to express themselves in this regard, just as it will implore the government to listen to their voices and hear their concerns.

The green paper has scant information about the sources of funding for the NHI. Clearly, funding is probably the single biggest challenge facing the system and it may seem naive to omit details about it, but this lack suggests that, as yet, minds have not been made up in this regard. The situation creates an opportunity again for the public—and experts—to provide ideas about the best way to fund an NHI system without further burdening the taxpayer or harming the country’s developing economy.

The association will contribute to and put suggestions forward on the accreditation of facilities, contracting general practitioners, designing appropriate benefit packages and reimbursement models for contracted providers, proper referral systems, the role of private specialists, utilisation trends and many more. It is clear that proper information technology systems will have to be in place for the registration of the population, payment of service providers, record-keeping and all related areas.

In essence the green paper lacks detail in several areas, but the association views this as an advantage because it provides an opportunity to propose and put forward its positions and points of view.

In the coming weeks the association will encourage all its members in both the public and private sectors to identify the areas that are relevant to them and make appropriate contributions.

We trust that the lack of detail in the NHI green paper is deliberate so that all positions and comments can be accommodated in a spirit of co-operation. The ultimate ownership of this critical and far-reaching policy will belong to the public—as the primary recipients of the system—but also to healthcare professionals, such as doctors, who will be the resource that delivers the care.

Dr Norman Mabasa is the chair of the South African Medical Association and Dr Mark Sonderup is its vice-chair

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