I have written on several occasions about the proposed National Health Insurance Bill (NHI) that is currently before the South African parliament. I have proposed a rational debate and have raised my concerns about what is proposed in the draft legislation. I was thus interested in an interview with Dr Nicholas Crisp, the deputy director-general tasked with National Health Insurance in the National Department of Health published in the Sunday Times on 3rd April 2023. Dr Crisp, who is one of the most senior officials in the National Department of Health, was posed a series of questions by Chris Barron and his responses, if he was correctly quoted, I found enlightening as to what government is saying about NHI.
When challenged on the limited South African tax base, his response was, “Lots of countries have been on these journeys. They take 15,20, 25 years, but plenty have done it. If you look as Mexico, Thailand …” When asked whether these countries have unemployment rates approaching 50%, his response was, “That’s this year. But what are we going to have in 15 years time. Do we believe that we’re just going to sustain this disaster?” When pressed on whether he regarded the South African health system as is in a mess, his candid response, for which I must applaud him for his honesty, was that he was “talking about the country that’s in a mess.” not necessarily the healthcare system. He indicated that is his view it cannot “stay in a mess forever and that we have to pull it out of that mess and do whatever we need to do with our health reforms”.
Chris Barron followed up questioning whether rather than the budget it was the health system that was terribly managed which was accepted by Dr Crisp adding that it does need to be improved. In response to a comment that instead of NHI shouldn’t the focus of government be effectively using the current health budget, Dr Crisp with, if correctly quoted, responded with an apparent non sequitur referring to the fact that 67% of medical specialists in the country are in the private sector and asked how their skills could be accessed, indicating that the answer was to “have a system that works more closely together and shares its resources more effectively”.
Then with a response that I found very insightful he responded to the need for a more conducive working environment to attract medical specialists that it could not be done with the budget sitting at its current levels, that is without more money. Pressed on the fact that the current resources are mismanaged and have been wasted and stolen, Dr Crisp retorted that as a proportion of spending, the losses in the public sector that are mismanaged, wasted or stolen do not differ much from that in the private sector which he estimated at R11 billion annually apparently conceding that that in the public sector it was impossible to quantify.
Finally when confronted with the perception that the national (health) department mired in corruption cannot be trusted, Dr Crisp conceded that it was “a hill to climb” and agreed that government is not perceived as trustworthy at present. He elaborated that despite these challenges he is not planning for 2022 but rather for 2025 to 2035 indicating that one has to start somewhere by creating the framework and further that the National Prosecuting Authority, “Special Investigating Unit, police and everyone must do something about it …”
I have known Nicholas Crisp, a medical doctor and public health specialist, for several decades and in fact we both headed provincial health departments during the first five years after the 1994 transition, I in the Free State and Nicholas in Limpopo. While I remained in the public service to head both the Free State and Western Cape Departments of Health until my retirement in 2015, Nicholas due to political infighting was forced out of the Limpopo province and spent many years as a successful consultant both here and elsewhere in Africa. Most recently he was appointed as the senior bureaucrat in the National Department of Health responsible for the implementation of National Health Insurance. Dr Crisp has a wide experience in health matters and is a person of impeccable integrity and commitment whom I greatly respect so I am interested in what he sees and what I may not see about the way forward for healthcare in South Africa.
It appears that we agree on many of the challenges facing government and in particular the public health sector in South Africa. Certainly we agree on the need to strive for universal health coverage for the population of this country. We agree on the fact that any change to the status quo must occur over time, that currently public healthcare is badly managed and that there is mistrust of government and in particular the department of health. We also agree that when public healthcare is able to provide a more conducive environment for the employment of health professionals that the current disparity between the public and private sectors could be reduced. While I would agree that corruption and theft is a major challenge in the public sector, I am less convinced that a similar situation prevails in the private sector. Let me make it very clear that I hold no brief for the private health sector in South Africa and agree that the sector has many deficiencies that require attention.
Although the Competition Commission Healthcare Market Inquiry1 highlighted many issues requiring attention in the private health sector I would be interested in the source of the R11 billion “mismanaged, wasted or stolen” as quoted by Dr Crisp. The Inquiry found that in the private sector there was a general absence of value-based purchasing and that practitioners are subject to little regulation and that there is failure of accountability at many levels. The Commission found the private health sector as “neither efficient not competitive”. I am not sure if this is the basis for Dr Crisp’s assertion. I would argue that while inefficiencies in the private health sector must be addressed and that although the Commission found that there had been “inadequate stewardship of the private sector with failures that include the Department of Health not using existing legislated powers to manage the private healthcare market” the circumstances that prevail in the public health sector are not comparable.
Notwithstanding the fact that there are many issues in the private health sector that require attention, I am concerned that if the solution to the failures of the public sector is seen as redirecting the resources currently utilised in the private sector to what will be an essentially public sector NHI model, it will fail. In a previous post, I had raised my concerns about the creation of yet another public entity in the form of the NHI Fund appointed by and accountable to the National Minister of Health. Dr Crisp acknowledges the perception that the department and indeed government cannot be trusted but counters that he is forward looking and that something must be done about it. I am afraid that I view that response as a somewhat naive sentiment on which to base the future of such a critical component of South African society.
In my analysis, I proposed that the funding for healthcare should remain located within the National Treasury as a designated budget line accountable to parliament rather than located with a public entity accountable to the National Minister of Health. The National Treasury, often the butt of criticism of health activists for the application of neoliberal fiscal policies to the detriment of health, has over the past decades been one department that has largely, although not entirely, resisted the ravages of State Capture, fraud and corruption. The same cannot be said for many public entities, the National and many Provincial Departments of Health. To put it simply I would not put all my eggs in that one basket!
Another concern not raised by either Chris Barron of the Sunday Times or Dr Crisp is the centralisation of power to a single entity that both decides what healthcare will be provided but more concerning attempts to manage the healthcare system from a central point. NHI in its current form will remove provincial departments of health from any meaningful role in the delivery of healthcare. While I am aware of the failings of many such departments, I do not believe the situation will be improved by centralising these functions. The centralisation of functions even at provincial level that I have experienced over the last decade has not been positive. Again I would argue that from the point of view of sound management principles this is a mistake and again it appears to put all the eggs in one basket further increasing the risk of failure.
I would argue that while it is important to plan for the future, to embark on legislated change to the status quo of health care in South Africa of the magnitude envisaged in the NHI Bill is an endeavour that is fraught with risk, a risk that in my view is just too high. The examples quoted of Mexico, Thailand and others provide me with little comfort. The initial step must be to stabilise and correct the multiple deficiencies in the public health sector which are not alone resource based. In my work over the last six year since my retirement I have documented the issues faced by public healthcare services at the coalface and recommended solutions based on my managerial experience, which sadly in many cases have been ignored. If these have not been addressed, simply redistributing the current resources utilised by the public and private healthcare sectors (the 8.5% of GDP) is not the solution. Without doubt public sector healthcare in South Africa needs additional resources but the challenge that should be addressed first by Dr Crisp and his colleagues is to ensure that every health rand currently allocated to the public healthcare sector is effectively and efficiently utilised. This is not the case at present and requires skilled accountable management without political interference and the consequence management of those who do not meet these requirements. Attempts to address these shortcomings through so-called NHI pilots over the last few years have proved unsuccessful.
In conclusion, I would appeal again for a rational debate on the challenges that face the healthcare system in South Africa and possible solutions rather than the defence of fixed positions. Government should be prepared to accept that there are valid and serious concerns about what is proposed. Both from the responses of Dr Crisp as a senior bureaucrat and representatives of the ruling party in parliamentary standing committees it is my concern that hard ideological lines have been drawn that preclude the rational debate that I am advocating. My contention is supported by a review of the various policy documents from the initial NHI Green Paper, the NHI White Paper and now the NHI Bill that is currently before parliament, which reveals that despite numerous submissions, hearings and discussion that in essence what was proposed in the Green Paper remains unchanged in the NHI Bill. It appears that the door has remained closed to alternative views which often have been labeled as reactionary. My hope is that at even the last hurdle that the door will open and meaningful discussion will occur. I fear that if this does not happen that the healthcare of all South Africans is at risk in the future.
