A recent media report in TimesLIVE (8th April 2021) quotes the National Health Minister, Dr. Zweli Mkhize, as saying that “one of the glaring lessons highlighted by the COVID-19 pandemic is the urgent need for universal health coverage (UHC) to ensure no-one is left behind”. Further “the implementation of National Health Insurance (NHI) is seen as a critical intervention that will assist in restructuring the core components of the health system”. In his opinion central structures such as the Coronavirus Command Council and the Ministerial Advisory Committees created during the pandemic to support governance were able to foster confidence in the interventions proposed and implemented especially those that required a great deal of social and financial science by sectors and individuals. The Minister then elaborates on the various actions taken by government during the pandemic which in his view “lay a strong foundation for the NHI fund providers accreditation and contracting environment.”
There have been numerous opinion pieces and media reports about the proposed National Health Insurance (NHI) system envisaged for South Africa since its release in July 2019 both before and during the COVID-19 pandemic. The parliamentary process has begun and Parliament was flooded with comments on the draft legislation indicating the high level of interest in the future of the healthcare in this country.
The National Minister of Health has previously reacted strongly in the media to criticism of the NHI Bill. The battle lines have been drawn with those in favour seemingly unwilling to accept that criticism of any aspects of the NHI Bill are justified. The fact that only a minority of South Africans are able to afford private health care which provides care perceived by many to be of a standard much higher, albeit at a higher cost, than that provided to the majority in State health facilities is used to point to an unacceptably inequitable and discriminatory situation in the healthcare sector, a fact repeated by the Minister in the most recent media report. In contrast, those against the NHI Bill refer to the collapse of the health system and the destruction of the private health sector with dire consequences if the government proceeds with its intention to implement a National Health Insurance system. There have been surveys that indicate that many health practitioners currently in the private sector would consider immigration if NHI is implemented.
As a health professional having spent around 20 years in clinical practice as a paediatrician employed in the State health sector and a similar period heading two provincial health departments in South Africa subsequent to that, I have reflected deeply on the fundamental changes to the South African health sector proposed in the NHI Bill. The Bill aims “to achieve universal access to quality health care services in the Republic in accordance with Section 27 of the Constitution” and in the Preamble to the Bill states that the legislation is necessary “to achieve progressive realization of the right of access to quality personal health care services and make progress towards achieving Universal Health Coverage.” These are without doubt noble goals.
The challenge increasingly facing all healthcare systems across the world, and South Africa is no exception, is that the need for healthcare is infinite but that the resources available to provide that healthcare are finite. In addition, the advances in medicine over the last century while they have increased the lifespan and quality of life of many people, have at the same time exponentially increased the cost of healthcare.
Against this the World Health Organization (WHO) constitution of 1948 declares health as a fundamental human right and determines that all member states should strive to provide Universal Health Coverage to their citizens. Universal Health Coverage indicates that “all citizens and communities can use the promotive, preventive, curative and palliative health services they need, of sufficient quality to be effective, while ensuring that the use of these services does not expose the user to financial hardship”.
The South African Constitution in the Bill of Rights states in 27(1)(a) that, “Everyone has the right to have access to health care services, including reproductive health care” and further in 27(1)(c) that “no-one maybe refused emergency medical treatment.” In 27(2) it is indicated that, “the State must take reasonable legislative and other measures within its available resources, to achieve the progressive realization of each of these rights.”
Assuming the imperative to meet the requirements to provide access to health care services for all the citizens of South Africa outlined both in the WHO declaration and the Constitution is a necessity, the intent stated in the Bill cannot be questioned. However, the manner in which to achieve this is surely an aspect of the legislation that can and should be meaningfully debated.
A plethora of media reports over the last decade have highlighted deficiencies in the public health sector indicating a lack of appropriate equipment and essential drugs in some facilities as well as the exodus of highly trained health professionals leaving state patients without access to the health services they require. Further the failure to adequately maintain existing facilities and ensure that contracts for essential support services are in place have resulted in patients and staff being exposed to unsafe conditions in State hospitals with the potential to result in harm to both patients and staff in these facilities. The COVID-19 pandemic, despite the view of the Minister that “the government lead health response was successful and for the first time brought together the public and private sector”, in the eyes of many it left much to be desired. Certainly the rampant fraud and corruption that occurred with the procurement of personal protective equipment (PPE) does not foster confidence in the Minister’s view of the “strong foundation for the NHI fund providers accreditation and contracting environment” laid by the experiences during the COVID-19 pandemic.
On the other hand, the private health sector in South Africa, which provides healthcare perceived by most to be of a high quality and standard in conditions that are generally safer and more acceptable, is attacked as profligate and unaffordable for the majority. It is certainly a commodity for which those able to afford private healthcare pay dearly and for which many would welcome savings. This was the driving motivation for the Competition Commission market enquiry into private healthcare.
South Africa currently spends an estimated almost 9% of the GDP on healthcare which is slightly below the average of 9.3% of the OECD countries. However, in South Africa the public share of 48% differs from the comparable OECD figure of 72% and is comparable with countries such as Chile, Mexico and the United States. Indeed, it is essential that every “health rand” be it in the private or public sector is appropriately and effectively utilised. However, a pertinent question remains and this is whether the not inconsiderable amount of funding currently allocated to the public sector provides the value for money that it should and if not, what is the reason?
The current public sector health budget provides health care for predominantly the approximately 40 million uninsured population of South Africa but this compares poorly, around three and a half fold less, with those contributing to one or other form of medical insurance or making out of pocket payments. While the stark difference between the per capita expenditure on health is an easy answer to the criticism of the differences between the public and private health service delivery, it can be questioned whether a more equitable distribution of the resources currently expended on healthcare in South Africa is the answer to the problems experienced? Would a simple redistribution of the total national expenditure on healthcare in this country as envisaged in the NHI Bill result in safe and quality healthcare in the South African public sector? Certainly, this difference has an impact on the level, quality and safety of services that are provided in the public sector compared with that provided by the private sector but there are other factors that impact on the challenges faced by the South African public health sector.
The report of a Ministerial Task Team investigation into service delivery at selected hospitals tabled in Parliament by the then Minister of Health in 2017 revealed the sad decline of the quality of health care provision in most of the hospitals evaluated. This situation has been echoed by various other subsequent investigations and while in general, health professionals are adequately trained and, in the majority, hard-working, honest and dedicated, the major deficiency in the public health system is the lack of managerial capacity and administrative capacity and systems to ensure the efficient functioning of hospitals and on a wider front of provincial health departments. The result is that without adequate management, administration and systems health professionals do not have the facilities, drugs, disposables and equipment that they require to provide quality health care. While funds are limited by the financial realities and further reduced by fraud wastage and corruption, I feel strongly as I have stated many times previously that if competent people were appointed supported by effective administrative systems and management, much more could be achieved with what is and should be available.
It seems unnecessary to state that whatever the resources available for healthcare, an essential factor that will ensure the most cost-effective utilisation of every scarce health rand is how the available resources are distributed and managed. South Africa and indeed many other countries are challenged by a lack of management and administrative capacity in many sectors and if this is not addressed an increased allocation of funding will not necessarily impact positively on the safety and quality of healthcare experienced by the average citizen in their countries. Certainly, the appropriate and effective utilisation of technology will increase the benefit that is derived from the resources that are available, but healthcare is about people and the skills and commitment that they possess. The Minister in his most recent communication refers to the lessons learnt during the pandemic in the field of data management, integration, sharing and reporting but it is uncertain if the same is true for the everyone tasked with implementation of government policy.
South Africa as a result of its unique history inherited a health system, that following the democratic transition in 1994 apart from an inequitable distribution of health care services lacked not only the number of health professionals required to deliver healthcare in the public sector but, in addition, lacked the managerial capacity and expertise required to transform and manage the health service. Restructuring plans developed for health in the lead-up to the democratic transition of 1994 envisaged by the African National Congress as outlined in, “A National Health Plan for South Africa” much of which was captured in the White Paper released in 1997 “Towards a National Health System” and to an extent is now reflected in the NHI Bill were both ambitious and far-sighted. However, these plans and policies under-estimated the management capacity and skills needed to implement them. In the years that followed despite an enabling legislative framework as set out in the National Health Act and other legislation and the best intentions of many committed individuals the outcome has fallen short of the optimistic expectations of the early years of South Africa’s fledgling democracy.
Against the background that I have sketched, the implementation of a National Health Insurance system is proposed as the solution to the challenges that healthcare in South Africa has faced from 1994 and before. I will not deal with every aspect of the NHI Bill but rather focus on what in my opinion are some of the essential features of this system that are promoted as the solutions.
A key step will be the establishment of a National Health Insurance Fund as Schedule 3A autonomous public entity. All citizens will make mandatory “prepayments” or contributions which the Bill envisages will “achieve sustainable and affordable universal access to quality health care services”. The NHI Fund will be the single and only purchaser and payer of health care services in South Africa. It is envisaged that the “pooling” of all the funds currently available within the health sector will result in “equity and efficiency” through strategic purchasing from accredited and contracted health care service providers. The net result is that all the funds currently utilized for health care in the public and private sectors with, in addition, funding that will apparently become available from the removal of tax deductions currently available to citizens utilizing the private health sector, will be controlled and managed by the NHI Fund. This Fund, in consultation with the National Minister of Health, will purchase health care services, as determined by a (Health) Benefits Advisory Committee, largely on behalf of South African citizens. The Fund will be governed by a Board of eleven persons faced by weighty responsibilities, appointed by and accountable to, the National Health Minister.
The central nature of this step appears to contradict the notion of decentralization and to an extent impact on the current powers and functions of provincial health departments although whether it is not in line with the Constitution remains moot. Without doubt, the NHI Bill if implemented would give the National Health Minister immense power and influence over the health sector in South Africa for good or bad. The centralization of all funding into a Schedule 3A public entity will in the minds of many increase the risk of fraud and corruption on a grand scale with dire consequences for the health care system in this country. The shocking revelations related to State capture and most recently with the procurement of PPE’s during the COVID-19 pandemic have not increased the public confidence in many State entities.
The central role of the Benefits Advisory Committee in determining what healthcare is provided to the South African population seems to have escaped the attention of many. In essence this committee with a membership of wide-ranging expertise, not dissimilar to the Ministerial Advisory Committees (MAC) of the COVID-19 pandemic will determine at all levels of care, what health care South Africans will receive and what healthcare they will not. This implies that the current situation where healthcare provided in the public sector and the private sector may differ according to affordability will no longer be the case, which in itself is not negative. While it is understood that, as stated earlier, the need for healthcare is infinite but the resources available to provide that healthcare are finite, it does need to be clearly understood that this committee could potentially ration healthcare and the principles by which it does so require careful scrutiny. I have noted that there is a perception that with the coming of NHI, all citizens will receive healthcare similar to the “best” currently provided in the private health sector, which cannot be the case based solely on affordability. By stating this I am not implying that what is currently provided by the private sector should be seen as the gold standard. Far from it, but a clear understanding of how healthcare will look in the future is necessary for an informed decision on what that future should look like.
The Health Care Benefits Committee, which to an extent already exists in other form, will have an increased scope and will recommend the prices of health service benefits. While this appears seemingly simple, it needs to be accepted that this is a complex and sensitive task that if wrongly managed has the potential to cripple health care providers and force providers and manufacturers out of the market. Current disputes requiring to be settled in the High Court between the public utility, ESKOM and the National Energy Regulator (NERSA) are instructive in this regard. There is potential danger in a doctrinaire and ideological approach to the pricing of health benefits located in a committee appointed by a political functionary.
The Bill sees strategic purchasing as a solution to many of the challenges facing the South African health sector and while without doubt there will be a significant benefit from this approach, the capacity within the country to undertake this initiative given its scale and critical nature should not be under estimated. Again the recent experiences with regard to the timeous acquisition of COVID-19 vaccine for South Africa brings the wisdom of this approach into question. As with the centralisation of funding, the magnitude of the contracts involved will provide tempting targets for those with nefarious intent. This weighty responsibility falls to the envisaged Office of Health Products Procurement that is tasked with determining the health-related products to be procured, developing a national health products list, coordinating supply chain management and negotiating prices. A seemingly simple set of responsibilities but critical to the functioning of the health system, which will be entirely dependent on this Office for the supply and logistics of the entire national health system. My experience while heading the Western Cape Department of Health was that central “transversal” contracts handled by either the National Treasury or the National Department of Health were at times problematic. I would recommend that serious consideration be given to revisiting this aspect of the NHI Bill.
I am reminded of the adage, “Don’t put all your eggs in one basket!” As I have said before, while the intentions may be noble, I am concerned that with the current state of public sector health care, governance and managerial capacity what is envisaged in the NHI Bill may just be “a bridge too far”. Approached differently with a more nuanced strategy many of the principles and concepts set out in the National Health Insurance Bill are praiseworthy. However, I would respectfully differ from the National Health Minister, that rather than the COVID-19 pandemic highlighting the need to proceed more rapidly toward an NHI as envisaged in the Bill, that an honest appraisal of what the COVID-19 pandemic has revealed without the need to remain wedded to what is currently set out within the NHI Bill would, even if politically challenging, be a better way forward.
