It is hard to imagine a more confusing debate for South Africans than the National Health Insurance (NHI). In the face of warnings by the health ombudsman that the health system is on the “verge of collapse”, an apparent response has been to expedite into implementation of the long talked about, or threatened, NHI.
The public would be right to question whether this is a real reform or just political posturing ahead of next year’s elections. If the NHI is a diversion from the reforms needed to heal the health system, then expect continued deterioration of all aspects of the health system, in both the public and private sectors.
In a nutshell, the NHI is a proposal to expand the coverage of the public sector to include all medical scheme members. This differs from universal health coverage strategies of other countries, where the objective is to include vulnerable and excluded groups, rather than a covered group, into a system of coverage. South Africa, however, already covers the national population either through a subsidised public system or through regulated access to medical schemes for those able to afford their own coverage.
Our public health sector resembles a poorly governed version of the National Health Service (NHS) in Britain, while the system of medical schemes resembles an incomplete version (from a regulatory perspective) of the system in the Netherlands or Germany.
In both South Africa’s systems, good performance is hindered by state governance arrangements. The public system failure is owing to systematic inefficiency, corruption and poor health outcomes. In the private sector, the result is cost increases and a deterioration of the quality of coverage over time.
The recently published NHI Bill is puzzling, as its focus is purely on establishing a national fund – the NHI Fund (NHIF) – at the national level of government, with the primary task of procuring health services. These services are to be procured from provincial and local government, as well as the private sector – provided they are accredited by a quality assurance regulator.
The bill, however, proposes no changes to the governance arrangements or how to fix the systematic collapse of the integrity of the public health system. Yet governance failures plainly derive from the ability of political structures to appoint staff and interfere in procurement systems. The NHI Bill proposes to replicate this error, as the “independent” board is to be appointed by the health minister together with the fund’s chief executive.
The same model applies to the accreditation authority, which is to be trusted (as proposed) with the procurement of all health services. Such a model is plainly vulnerable to capture in the same manner as provincial structures and other state-owned enterprises.
When seen together with the unchanged provincial model, South Africa will have merely introduced an additional source of patronage without altering existing patronage arrangements operating within the provinces. Not only is this proposal therefore incapable of enhancing universal coverage in South Africa, it is excellently positioned to achieve the opposite – a reversal of coverage.
On close scrutiny of the bill, as with the various vague policy papers on the NHI, it is long on objectives, but short on substance. Interestingly, no specific proposals are made for what the NHIF must achieve by the rather distant 2026.
An extraordinary proposal, plainly envisaged at some date well into the future, is that whatever services are covered by the NHIF cannot be covered by medical schemes. This would imply that if hip replacements or oncology services are covered by the NHIF, medical schemes cannot cover them.
While this has little possibility of surviving a legal challenge, it goes some way to revealing the quality of thinking going into the policy framework.
No coherent public purpose could justify any such contraction of the rights of South Africans. It is, however, conceivable that some deeper rationale may underpin such a proposal. While no such rationale has been communicated in the public domain to date, a clear responsibility lies with the minister to make plain the public purpose.
Another unusual proposal made in the bill involves transferring the function of academic hospitals away from the provinces to the national level of government.
Although arguably a poisoned chalice, this shift is likely to complicate provincial service planning as these hospitals largely contain provincial-level services.
As things stand, the health system faces further deterioration unless a credible set of measures is introduced to reverse the rot in the public sector and to stabilise costs in the private sector. Although the most concerning aspects of this bill are unlikely to achieve more than the establishment of another questionable national agency, all South Africans will remain victims of an unaccountable health system that is drifting further and further away from universal coverage.
There are a large number of dedicated people who remain committed to the continued improvement of the health system, it is sad to see their growing despondency. This needs to change, but it will not change unless society makes the current state of affairs politically unacceptable.
- Professor Van den Heever is chair of social security at Wits University