National Health Insurance – A model for building equitable healthcare?

Preamble

Proposals by the African National Congress (ANC) for a comprehensive reform of South Africa’s health financing system envisage shifting private healthcare to the public sector by employing a single-fund approach. This would mean replacing existing arrangements with a new centralized Government controlled institution as conceived in the National Health Insurance (NHI) Bill. While this has been under discussion for many years, progress has been slow.

Background Information

Against this backdrop and in the context of the parliamentary Portfolio Committee on Health having concluded deliberations on the National Health Insurance (NHI) Bill, it is not surprising that there’s been many outspoken comments and views published by various sources. This coincided with the second Presidential Health Summit that was recently held.

The excerpts summarized in this brief represents a collection of notable thoughts and opinions from differing interest groups hoping to shape developments in the health-related sector. This article intends to give an abridged perspective of the dynamics at play.

National health insurance: Portfolio Committee on Health

• Medical Brief recorded that most opposition parties have opposed the Bill.
• The probability of tender corruption and looting, as well as the unconstitutionality of the document, were cited with only the ANC and IFP voicing their support for the Bill.
• The Cape Argus reports that at a meeting at which the Committee Chairperson, Dr Kenneth Jacobs (ANC), gave members a chance to deliberate on the legal opinion presented by the state law advisers and parliamentary legal services, DA health spokesperson Michele Clarke said her party rejected the Bill. She said it presented numerous issues which would be assessed in the Constitutional Court if it is passed using the ANC’s parliamentary majority.
• Within this frame of reference, Medical Brief reported that the DA has compiled fifty reasons why the NHI will not be feasible among which the following few examples are noted:

• South Africa is physically and financially not able to finance the NHI in its current model.
• The NHI would give the Minister far too many powers and duties.
• Public healthcare standards are already abysmal and the NHI will abuse patients’ rights to quality healthcare.
• The pooling of funds will make the NHI vulnerable to theft and corruption and the amplification of lack of consequence management.

• Philip van Staden (Freedom Front Plus) said his party would not support the Bill, and because it excludes asylum seekers and undocumented foreigners from healthcare service coverage, could lead to a constitutional challenge.
• The EFF’s Naledi Chirwa said the Bill maintained the current two-tier system, which did not reflect the EFF’s aspirations of a socialist country.

National Health Insurance (NHI): Presidential Health Summit 

• As delegates met for the second Presidential Health Summit, longstanding, unresolved challenges were back on the agenda, but adding to the woes were several new hurdles, not least load shedding and funding for NHI, notes Medical Brief.
• The summit set out ten key target areas for intervention to meet the government’s objective of advancing the introduction of NHI, but also touched on some unresolved challenges, like corruption, critical staff shortages and the need to boost nurse training through private-public partnerships.
• Some long-standing health sector challenges include failing infrastructure and maintenance of hospitals and clinics, staffing shortages at crisis levels, widespread corruption that goes unpunished, political interference and poor governance, mounting medico-legal claims and costs arising from sub-standard treatment and care, and patient experience of clinics and hospitals marked by high levels of dissatisfaction and distrust.
• Compounding problems was the major issue of power outages, and the impact of the government not having in place a stronger strategy to end the rolling blackouts that have worsened to higher stages of load shedding at greater frequencies each year.

A proposed course of action

Andrew Donaldson’s (economist and Senior Research Associate at UCT) contribution to the book Better Choices affirms that this is a complex policy area in which public and private institutions have both complementary and competing roles.

He goes on to state that whereas current reform plans envisage entirely new institutions to replace existing arrangements, more rapid progress might be achieved by building on and enhancing existing public and private sector capacity. The administrative competence of medical schemes provides an existing foundation through which a standardized benefit and regulatory reforms to achieve more effective delivery and alternatives to fee-for-service purchasing should be pursued.

Conclusion

Persistent delays in resolving issues are highlighted by the comments voiced by delegates at the Presidential Health Summit which, moreover, has been exacerbated by home-grown weaknesses including load shedding and a stuttering economy hinting at a government being in a state of limbo.

Although there is no argument with the moral imperative of universal healthcare, the critics argue that the plan reveals a set of aspirations largely divorced from the realities of public sector infrastructural problems and endemic capacity constraints brought about by poor governance as well as a lack of constructive engagement, competent management, and leadership.

Ultimately, we support a pragmatic approach as recommended by Andrew Donaldson and believe that the following factors will determine the success or failure of the NHI: a balanced funding model, collaboration between the private and public sectors, the availability of skilled management and a capable workforce, in addition to seriously addressing corruption.

Better Choices Ensuring South Africa’s Future: contribution by Andrew Donaldson