The recent high profile signing of the National Health Insurance Act set me thinking about the public perceptions of healthcare in South Africa. In a South African context one hears much about problems experienced in the public health sector but less about those in the private health sector. In the public health sector issues relate to the poor quality of healthcare while in the private sector the issue most frequently is the high cost of services.
I have had the advantage of having worked for forty years in the South African public health sector and subsequent to my retirement being part of, or having undertaken, various investigations into public health services as well as engagements with the private health sector in this country. In addition, I and my family members have experienced at first hand care in the private health sector in recent years.
The public health services in South Africa are largely in a state of turmoil, not solely caused by inadequate funding but to a significant degree due to ineffective and at times corrupt management. In any assessment of the public sector in South Africa it must be borne in mind that this service, which is the last resort for the majority of South Africans when in need of healthcare, must deal with very large numbers of patients from communities with a high burden of disease. Despite this, there are undoubtedly areas of excellence that exist with the public sector and the following are some random examples that I have encountered in the last seven years as a consultant. I met a lone obstetrician providing exemplary care to women at a KwaZulu-Natal hospital under difficult circumstances. Despite the fact that his unit was chronically understaffed and overworked he had spurned a higher income to work in the public service. I encountered a pharmacist in a regional pharmacy of another province who despite stock-outs elsewhere in that province had, without additional funding, reorganised both the pharmacy and the distribution network to ensure that products were effectively distributed reducing stock-outs to a minimum. I discussed the “patient journey” in a large provincial hospital with a surgeon, working both in the public and private sector, who emphasised the fact that in his view a multidisciplinary team all of whom were on the staff establishment of the public service hospital and were responsible for all aspects of patient care greatly benefited his patients. I encountered many health professionals and support staff who with a “can do” philosophy despite the challenges they faced provided the best care possible to their patients
But I also came across public health facilities in a shockingly poor state of repair where even the most basic issues were left unattended. In one hospital I visited numerous seagulls nested on a leaking roof of the top floor ward below which lay patients in a surgical ward. The bathroom walls of the same ward were black with mould. In another hospital lifesaving diagnostic equipment that had the ability to save lives had been unserviceable for months while a life-saving haemolytic drug required for the early treatment of heart attacks was unavailable in another. The latter in a facility serving a population where heart disease is prevalent leading in the opinion of doctors at the hospital to unnecessary deaths. In a rural district hospital, I came across an elderly man with his fractured leg in rudimentary traction who had been awaiting referral to a regional hospital for several weeks. In a private hospital this person could have been operated on within days for the same condition. In various provinces I encountered patients waiting prolonged periods for life-saving cancer treatment or procedures such as joint replacements. Despite the reports of various provincial and national task teams, of which I was a member, identifying the problems and making recommendations to address them, these appear to have been largely gone unheeded.
It is insightful that the President at the signing of the NHI Act referred to the fact that a future NHI would bring about a “Rolls-Royce health service” for South Africans. In the minds of many in the general public this means a health service which equates to what they perceive is currently provided in the South African private health sector. For this reason it is necessary to look in more detail at the current advantages and disadvantages of the private health sector. In large measure the quality of, and access to, private healthcare is at the very least adequate and in many ways on par with the best in the world. However, what is provided comes at a cost which in many instances is not fully covered by the various medical schemes despite the implementation of a legislated system of what are termed “prescribed minimum benefits” (PMB)1 to which all medical scheme members are entitled whatever scheme option they chose. Many private health professionals but more especially doctors are what is termed “contracted out” and charge fees that exceed that guaranteed by the medical scheme. In fact, in some instances an “out-of pocket” prepayment will be required before hospital admission or for a particular procedure. This has necessitated the need for what is termed “gap cover” in addition to membership of a medical scheme to provide insurance against amounts not covered by the medical scheme. It must be borne in mind that the cost of membership of medical schemes and out-of pocket payments come from after tax income although there is currently some tax relief related to these payments.
Cost notwithstanding there are other drawbacks to private health. Not all are aware that doctors and health professionals registered under the Health Professions Act and liable to Health Professions Council of South Africa (HPCSA) rules, which excludes nursing staff, may not be employed by private hospitals. This rule is intended to ensure that perverse incentives in terms of hospital usage do not occur. Thus all act as individual service providers operating independently within a hospital environment operated by a private hospital group or in an independent practice. The consequence of this is that patients admitted to a private hospital are under the care of a particular doctor but if additional care is required various additional health professionals will be consulted. This has the potential to result in a fragmented approach to the “patient journey” to which I referred earlier.
Another fragmentation which I have personally experienced in a private hospital is the fact that the various support services, such as catering and cleaning are contracted individually to provide services in a hospital but at ward level function independently. An example is when catering services deliver food to a patient but place that out of reach. This may seem outrageous but I personally experienced this while hospitalised after major surgery and my wife had a similar experience very recently. In both cases family was obliged to assist. A professional nurse when confronted in the latter instance responded pertinently that this was not a nursing responsibility but that of the catering services! Clearly as with criticism of the public health service the issue would appear to be a lack of adequate coordination and management at operational level but this gives lie to the impression that healthcare in the private sector is necessarily without a blemish.
The Health Market Inquiry2 provides valuable insight into the challenges facing the South African private health sector that the Inquiry identified during its extensive investigation. The Inquiry identified “inadequate stewardship of the private sector” utilising existing legislation and as a consequence “the private sector is neither efficient not competitive.” This single finding is damning and reflects in particular on the failed role of the National Department of Health in this regard and that of the various entities that fall under its jurisdiction. It was the view of the Commission that “a more competitive private health market would translate into lower costs and prices resulting in greater value for money for consumers.”
With respect to medical practitioners the Inquiry found that the private sector is “characterised by stand-alone single practices or single speciality group-practices” and, as I identified in my discussion with the surgeon referenced above, that “multi-disciplinary teams are not a feature of the market.” The Report, referenced below, makes detailed recommendations that I will not attempt to outline here but suffice it to note that many of the issues raised in terms of cost, anti competitive behaviour and the role of medical practitioners addressed in the extensive and indeed complex recommendations have been allowed to gather dust on a virtual shelf in the National Department of Health.
I have written extensively on the challenges faced by the South African public service and what in my opinion could be the solutions to these challenges. I have written less on South African private health care but as I have outlined above there is much that needs to be addressed in this sector as well.
These examples indicate that neither the South African public or private health sectors are without fault. The underlying philosophy of the NHI Act is to address the current inequitable distribution of resources that exists in the two tier South African healthcare system. However, inequity is mirrored at all levels of South African society, more especially economic inequality (Gini coefficient 0.67), and it would seem over ambitious to think that without addressing the broader aspects of inequality in this country that equity can be achieved in one sector through legislation. The solution for healthcare as envisaged by NHI places the responsibility for the entire health system in the hands of a national structure under the stewardship of the National Minister of Health. With the failure of the stewardship of the National Department to date both in public and private healthcare, it seems wishful thinking that this will solve the problems faced by healthcare in the South Africa of today. It is my contention that while healthcare in South Africa requires decisive leadership to address the shortcomings in both sectors that centralisation in the manner that is intended by NHI, given the realities that exist in the South Africa of today, is unrealistic. In fact it has the potential to damage, possibly irrevocably, both. Rather there are existing powers and remedies to meaningfully change the current realities in both public and private South African healthcare. In both sectors it would be better to build on what is good and address that which is not without the potential of destroying both.
