How could everyday South Africans hold as big a scheme as the National Health Insurance (NHI) accountable for the quality of its care?
The scheme, for which membership will be compulsory, is a state financing system that will buy healthcare services from public and private providers for the entire nation, regardless of their income. According to the current version of the NHI Bill, for which public submissions closed last week, the NHI will be fully operational by 2026.
The Bill was published in August.
Once it’s active, the NHI will have to account for the quality and compassion of its care, explains Leslie London, the head of the University of Cape Town’s Public Health Medicine division at its School of Public Health and Family Medicine.
But public health experts warn that health workers and patients, the two groups that could play a crucial role in holding the scheme answerable for its standard of services, are being left behind.
For a start, researchers argue, patients could be given more influential roles in technical meetings where the big decisions are made about, for example, which benefits the scheme covers.
The health officials were speaking at the South African Medical Research Council (SAMRC) and the health department’s November universal health coverage dialogue in Kempton Park.
Some role players say patients will have more influence if life is blown back into the country’s health committees or citizens are given basic legal training to empower them.
In countries such as Guatemala, India and Uganda, people were given paralegal training to give them the tools to hold clinicians and the health system accountable. A 2017 study published in the journal World Development found that this kind of intervention could help to slash bottlenecks in service delivery and improve trust between communities and clinics.
In India, for instance, community paralegals helped to tackle high rates of child mortality in the country’s north-eastern state of Assam. They tracked failures of maternal healthcare services in the area by using a text-based reporting system that led to a court case against the state.
Even technical decisions about details such as which benefits the scheme will cover are not neutral, Sasha Stevenson from the public interest law organisation Section27 says. These choices should be made in consultation with the people who will be using the scheme — the people queuing at clinics for care.
South Africa’s Constitution protects citizens’ right to government policies that are rolled out in a way that reflects their needs. But civil society has long complained that consultations on the NHI are insufficient.
Although Parliament’s portfolio committee on health has run public hearings on the NHI Bill over the past few weeks, a Section 27 community mobiliser, Sfiso Nkala, argues the meetings are “no more than lip service” and that people’s testimonies are unlikely to translate into any real changes in the way the scheme is run.
Nkala says the hearings have been dominated by trade unions and political parties and that ordinary people testifying in the two KwaZulu-Natal hearings he attended did not have the detailed knowledge “they needed to make contributions that will lead to policy change”.
But Stevenson told Bhekisisa in September that even written public submissions from activists and
academics on the previous iteration of the Bill have not had much impact. Section27 sent detailed concerns to the department on both the green and white papers to no avail — the issues raised remained unchanged.
As it stands, Stevenson says, there is only one proposed NHI body in the Bill that involves health workers and civil society: the stakeholder advisory committee.
She warns: “It’s the only committee that doesn’t have any real power to make recommendations.”
Russell Rensburg of the Rural Health Advocacy Project says people in policy meetings often make the wrong assumptions about what people on the ground need.
For example, he argues, universal health coverage as defined by the World Health Organisation aims to provide healthcare — that doesn’t cause financial hardship — to all people.
But without citizens in the room, important details of people’s everyday experience of the health system could be lost.
Rensburg explains: “For South Africans, financial hardship does not stop at the cost of getting the care they need. It also costs money to get to the clinic in the first place.”
According to London (the head of UCT’s Public Health Medicine division), refreshing the country’s health committees could be one way to get communities to participate in their health system in a meaningful, structured and ongoing way.
These committees are statutory bodies that, according to the National Health Act, should include local government councillors, members of the community and the heads of clinics or health centres.
But the Act leaves the work of deciding what exactly health committees can do, and how much power they have, up to provincial health departments — and those rules have remained largely unwritten. The Eastern Cape, according to London, is the only province that specifies how health committees should be elected.
And in practice, the committees often have no place to work from or face disrespect from the communities they serve, London says.
But there is evidence that health committees can shape the way in which health services are provided, if they have the right support.
In 2018, London and his colleagues trained 24 health workers and clinic managers in Cape Town on the roles of health committees. In surveys completed after the training, the participants described the training as “empowering” and “an eye-opener”, and even had suggestions for how the committees could be improved by, for instance, liaising with social workers, security guards and schools to help health workers stay informed.
The training also helped to build trust between committee members and other health workers where there had been discord about who was responsible for what.
Participants also revealed that a functional health committee cannot operate without money. A lack of money for petrol and airtime were among the reasons some committees could not fulfill their role well, the study found. The research was published in the journal Frontiers in Sociology in April.
“The government has been spoon -feeding the community for a very long time,” one participant wrote. “It is now time that the society takes the responsibility or ownership of their health. Health committees would bring a tremendous improvement in our society because they do not feel left out.”