/ 19 April 2013

Comment: Take care over the next hill

New life: Will the NHI bring a glimmer of hope for rural patients?
New life: Will the NHI bring a glimmer of hope for rural patients?

Perched on a hill overlooking the N2 on the outskirts of East London is a new private hospital managed by one of South Africa's largest private healthcare groups.

The hospital offers what it describes as "world-class healthcare that is achieved through a combination of unparalleled quality and clinical excellence". In many ways, its position on this hill marks the gradual expansion of middle-class suburbia into former resort towns of the Eastern Cape; it is a ­conspicuous symbol of "progress" and "development". 

As you pass this facility driving towards Mthatha, about 230km away, you start to notice a distinct shift in the landscape from a mix of industry and urban life to the strikingly beautiful open spaces of the rural Eastern Cape. This beauty, however, belies the many hard realities rural communities in this part of the country face every day when trying to access healthcare services of any kind. Here there are few "world-class" facilities.

You need only to look at media reports on the long-standing health crisis in the province to understand that the public health system is wholly under-resourced, understaffed and perpetually on the verge of collapse. To say that rural communities have particularly poor access to healthcare would be an understatement. 

The proposed National Health Insurance (NHI) plan, as opaque as it still is, provides the first real opportunity to reform the South African health system. Reform will hopefully start to close the gap in the quality of services middle-class families living in East London can expect to receive and the quality of services a family eking out a living from subsistence farming in the Eastern Cape can expect.

Infrastructure-inequality gap
To achieve this ideal, some serious work needs to be done to overcome what is referred to as the "infrastructure-inequality gap". In the current order, regions with greater capacity to spend, in terms of facilities and personnel, receive greater resources to further develop capacity to deliver services. This is always to the detriment of regions with greater need, which receive less because they have less capacity to spend. If we do not act purposefully to break this cycle, inequality inevitably grows. 

For the Rural Health Advocacy Project, this is where the real challenge for the NHI plan and rural health lies. A crumbling public health system and the absence of any significant private sector means that, unless we overtly prioritise the development of capacity in rural areas to spend and deliver services, NHI funds will "naturally" flow disproportionately into urban settings.

In a world where the public sector provides good-quality services efficiently, there would be no need to discuss the role of the private sector in the NHI plan and the case could be made for no private profit in public healthcare. The hard truth is that the weakness in the public sector and the urgency of reform demand that we be more pragmatic on the role of the private sector in the NHI plan.

We would argue that there are a number of prerequisites for this to happen. The first is that the issue of private sector regulation needs to be addressed. We need to establish what the main cost drivers in this sector are, and how instability and profiteering can be controlled. Understanding that the private sector is for profit, reimbursement of private providers should be based on the number of patients they see, the kinds of cases they treat and the outcomes they achieve. Profit should only be achieved through efficiency and good management. Finally, private sector involvement must be to the benefit of the nearly 40% of our population who access services in rural settings, not to their detriment.

Drawing private providers into the rural setting is difficult, but not impossible. If accreditation of new health facilities is more closely based on geographic spread and need, then underserved settings will receive greater attention. 

There are also opportunities to pull human capacity and skills into these areas. The health department has already started to make some headway in the contracting of GPs to provide services in the public sector.

This has the potential to boost services in rural areas where GPs are arguably the most readily available private providers. The details of how they will be contracted must still be resolved, though. Health Minister Aaron Motsoaledi is keen on GPs contracting in, which means they see patients at public facilities such as clinics and hospitals, thereby strengthening the capacity within the public system. The private sector seems to want contracting out to be the preferred method because it allows GPs to work from – and sustain – their practices, while providing an opportunity for some public patients to see a doctor closer to their homes.

Merits and pitfalls
Both options have their merits and pitfalls. There may be an argument for flexibility with the chosen method based on the needs of a particular district and the availability of GPs. As with any good idea, though, implementation really depends on how well you plan for unintended consequences. We know that one of the challenges with the current system of private doctors being contracted and being paid for sessional work in public facilities is that some of these doctors don't actually do any work in a public facility. Effective oversight of contracted GPs and the assessment of their effectiveness is something that is very tricky to achieve but is nonetheless essential.

Another potential public-private relationship that could improve access to services is being implemented in the Western Cape, where the provincial government has a contract with Clicks to make use of their pharmacy and clinic services for its immunisation programme. For a relatively small fee, caregivers can take children to Clicks to receive their jabs. 

Evidence that this improves access is sketchy, but, in principle, access is improved if the savings in money and time travelling to and waiting at clinics offsets the fee paid by patients. This may have significant benefits for patients in underserved towns where rural clinics are overburdened and there is space for privately run pharmacies with day clinics.

The real trick of the NHI plan will be how it balances public and private interests. We cannot deny that the private sector has the capacity to offer the skills and resources necessary to turn things around. But we also cannot deny that health is not a commodity like any other; those who can least afford it need it the most.

The NHI scheme is not going to result in the construction of many private hospitals in the rolling hills of the rural Eastern Cape. That is not its purpose, and it shouldn't be. What it will hopefully achieve, and what we are going to continue fighting for, is the provision of world-class healthcare services for all, regardless of their ability to pay. For rural communities across the country, this is long overdue. 

Daygan Eagar works for the Rural Health Advocacy Project as its rural proofing programme manager. The project is a partnership between the Wits Centre for Rural Health, the Rural Doctors Association of South Africa and Section27.