The current healthcare rhetoric in South Africa is very concerning for anyone delving deeper into the problems facing the South African healthcare system. The Lancet commission report which was published a few months ago recognised various shortcomings in the public health system, based on extensive research. The key problems identified in the report were:
- Gaps in ethical leadership;
- Management and governance contribute to poor quality of care;
- Poor quality of care costs lives;
- Malpractice cases and medical litigation;
- The human resources for health (HRH) crisis;
- Health information system gaps constraining the country’s ability to measure or monitor quality, and
- Fragmentation and limited impact of quality of care initiatives.
The document does not identify inequity in funding as one of the six main problems. Despite this, the first three pages of the Presidential Health Compact are dedicated to funding inequalities in the South African environment, which is used to advocate for a single funder system. It is not referred to as National Health Insurance (NHI), but that is implied. Why would government requisition a report on the problems of healthcare in South Africa, and then add their own problems which are not based on the evidence provided in the report?
The simple answer is that this is driven by an ideological decision, and not by any evidence. As early as 2010, there was no concrete evidence provided for why South Africa needs a single payer model such as the NHI. Recent revelations at the Zondo Commission on State Capture probably provide better evidence for the reasoning behind wanting to create a massive state-owned entity with access to twice the funding of Eskom, than any of the reasons put forth by the Department of Health.
If Eskom is too big to manage, and needs to be broken in three parts, why was the decision made to have a single payer NHI fund as a new State-owned Entity? NHI by itself will not fix the South African Healthcare system. 95% of public sector facilities won’t even qualify to contract with the NHI fund at present. So why continue with an NHI model if the state won’t be able to form part of it. The flawed assumption is currently that the Presidential Health Compact will fix the public sector. It is assumed that because we signed it, it will work. Ten SAA turnaround plans in the last decade were also signed off by stakeholders and did not succeed in turning around SAA. A strategy is only as successful as its implementation. South Africa has a shortage of skilled implementers of policy.
Many of the proposals of the Presidential Health Compact revolve around implementation of existing legislation and regulations and doing work that is already supposed to have been happening. The same managers in the public system who have been failing for the past 15 years, are now expected to suddenly start doing their work because a document was signed. This is unlikely to be the panacea that South Africa requires. The radical overhaul of the South African health system requires is an overhaul of the Senior Management in National and Provincial Departments of Health and almost every service rendering facility. When politically deployed incompetents are removed from the system, it might have a chance of starting to work.
If the only aim of NHI was to provide “free quality healthcare for all, to be paid for by those that can afford it”, that can be done in the confines of the current system. The patient fee system has already been scrapped for those earning under R350 000 annually. The required addition is that those earning above R350 000 should be legally compelled to belong to a medical scheme. Forced scheme membership will reduce the costs of private healthcare by reducing the under-writing costs for scheme members by about 20%. If government can impose a minimum wage, they can impose scheme membership. This will create an environment where those who cannot afford to pay have free access to healthcare and those who can afford to pay will do so. The “free healthcare” is funded by taxes in any case, as it would be under NHI.
With a management overhaul in the public sector, quality will start improving. Innovative ways of getting private providers involved in reducing surgical backlogs and waiting lists will provide access to private sector services for state patients. Additional thought must be given on how to involve private GP practices in primary healthcare provision for state patients. Most private healthcare providers will almost certainly be willing to provide an hour a day pro bono towards seeing state patients, especially if the government offers them a tax incentive to do so. It does not require a central fund.
The aim in South Africa should shift away from wanting NHI, to wanting Universal Health Coverage (UHC), which is not the same thing. The NHI is only a funding model, it is not going to fix the health system. It is a political ideology with no concrete, practical way of ever being implementable. Recent reports on the abysmal failure of the NHI Pilot projects has done absolutely nothing to bring any sanity to those in power on how poorly conceived an idea the NHI is. Concerned efforts towards provision of UHC is what is required, not the current concerned efforts towards establishing a centralised fund.
Dr Serfontein is a Healthcare Consultant to SAPPF, a member of the Free Market Foundation Health Policy Unit, and a published novelist under the pseudonym Jean Cerfontaine.