/ 8 August 2013

NHI a tonic for extreme inequality

National Health Insurance (NHI) is seen by some as a gift from the middle class to the country's poorest. But experts argue that everyone is hurt by the stark divisions in South ­Africa's health sector.

As a result of unequal access to quality healthcare and the skyrocketing costs in the private sector, South Africa spends a lot on health, but, according to David Sanders, the emeritus professor at the University of the Western Cape's School of Public Health, the country "has a similar low life expectancy and the same under-five mortality rate when compared with countries that are much poorer and spend much less on health such as Rwanda."

According to the World Bank, South Africa spent 8.5% of its gross domestic product on health in 2011, above the World Health Organisation's recommended 5%. But life expectancy in the country is 59.6 years, according to a 2013 mid-term estimate by Statistics South Africa, nearly 10 years less than the average 68.81 years for less-developed countries, according to the United Nations World Population Prospects 2012 report.

While health outcomes differ greatly between race and income groups in the country, depressed health indicators are not confined to the poor: even the richest are doing worse than similarly wealthy counterparts living elsewhere.

According to Sanders, the infant mortality rate among the country's white population – the wealth­iest  group – is 15 deaths per 1000 live births, higher than developed countries such as Norway. "Even for the best-off in our country, infant mortality is [higher than] what it should be compared to the same income groups in other countries," he said.

Experts say inequality is partly to blame for poor outcomes.

"Inequality is a source of major stress in society," said Louis Reynolds, the associate professor of paediatrics at the University of Cape Town. "It's stressful to the poor, because they're worried about their position, and it's stressful for the rich because they have to throw themselves behind security gates."

Inequality breeds ­violence: 15940 people were murdered in South Africa in 2010, according to the South African Police Service, and injury and violence is a key factor in the country's high mortality rate. And inequality is rife: half of the country's total health spending goes to only 16% of the population, with the other 84% – primarily the 35-million people reliant on the public sector – left to pick up the scraps.

Sanders said that the effect of disparate spending was seen in health outcomes: infant mortality among the country's poorest 80% is four times that of the country's wealthiest 20%. Some experts say the NHI scheme is necessary to transform South Africa, currently one of the most unequal societies in the world. "A decent [health] system can promote equality," said Reynolds.

The NHI could also help to stem costs for everyone, as regulation of healthcare costs in both the private and public sector is envisioned in the plan. Private-sector healthcare costs are not regulated, save for those of medicines, and costs have increased 120% in the past decade, according to Robert van Niekerk, the director and professor of social policy at the Institute of Social and Economic Research at Rhodes University.

SOme experts believe that South Africa should look to countries that have been successful in bettering health outcomes with simple interventions as a model for the NHI.

In a matter of years, Rwanda has turned its indicators around by focusing on strengthening primary healthcare and utilising a large cadre of community healthcare workers. "In 1994, Rwanda had an under-five mortality rate of 270 per 1000," said Reynolds. "Now it's the same as South Africa [40 deaths per 1000 live births, according to the 2011 department of health data]."

Despite being a least-developed country, Rwanda actually performs better than South Africa in some categories. For example, Rwanda's immunisation coverage for DPT – a combination vaccine which protects against diptheria, pertussis, and tetanus – is now above the regional average, whereas South Africa's is still far below it. (DPT coverage rates are considered a good indicator of the strength of a country's immunisation programme.)

"Rwanda has already reached its millennium development goal of decreasing under-five mortality," said Sanders. "South Africa won't reach it."

Experts say that strong public participation, government transparency and a renewed focus on training health professionals is needed to make the NHI successful. "This is an historic opportunity. It happens once in a lifetime," said Reynolds. "The consequence of getting it wrong is another 30 to 40 years of inequality."