Pali Lehohla, former Statistics South Africa head. Photo: Thobile Mathonsi/African News Agency (ANA)
Pali Lehohla, former Statistics South Africa head. Photo: Thobile Mathonsi/African News Agency (ANA)

OPINION: NHI elicits a heated debate

By Pali Lehohla Time of article published Aug 19, 2019

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JOHANNESBURG - Health  is a matter of life and death.  It is hardly surprising therefore that the National Health Insurance (NHI) has elicited such a heated debate around the world. 

The UN Sustainable Development Goal on health and nutrition also attracted polarised debates because of the role the private sector had in Universal Health Coverage (UHC) and the growing privatisation of health services. 

From 2014 to 2018 I had the privilege of serving on a nine member team of the United Nations Secretary General’s Independent Accountability Panel (IAP) for the Health of Mothers, Children and Adolescents.  In that period we produced three reports.  

The first report discussed accountability as transparency and remedy, the second focused on the 1.2 billion strong adolescents globally who are hardly visible while the third asked whether the private sector could be held accountable for protecting women’s, children’s and adolescents’ health.  

The debates in South Africa seem to concentrate not so much on whether UHC is necessary but on whether the rickety system can meet the demand if opened up to all.  Some feel that the private sector should be left as is whilst public sector medical services get fixed and readied for the implementation.  

The extreme view is that we should allow the private sector to deliver medical care under the current medical aid scheme regime for those who can afford it.  Former health minister Aaron Motswaledi was at pains to point out that the model of privatisation and commercialisation of health was fundamentally flawed and thus not sustainable.

He went further to demonstrate that he actually accesses medical care in public hospitals and he has confidence in the system.  

The Gupta’s Mediosa mobile health services in the North West best demonstrate how abusive the private sector can be especially when private interests are not regulated.   
I once had a long discussion with Motsoaledi on the deterioration of health care globally as commercialisation and privatisation abetted by medical aid schemes firmly take root.  
In fact the proliferation of private hospitals has had a net negative effect of nurses and doctors moonlighting whilst keeping positions in the public sector. 

The existence of private health facilities does not lead to better outcomes to the general public.

Instead it leads to the cannibalisation of public health and constrained the possibility of deploying the health workforce with focus on primary health care.

Is the current discourse in South Africa of fixing the public health first and leaving the private sector as wells of excellence before implementing the NHI not a false dichotomy aimed at perpetuating health enclaves? Is this model of health delivery sustainable? 

Experience elsewhere shows that health provision can be sustainable. High income countries such as Germany, France and the Scandinavian countries and those that are middle income like Georgia, Cuba and Thailand have deployed an NHI equivalent to achieve UHC as a sustainable model.  

In the US, where health care has proven unsustainable, the implementation of Obama Care demonstrated that sustainable health is possible under conditions of an NHI equivalent.  South Africa’s malfeasance is its Achilles heel.

However, malfeasance is curable and should not be a red herring in the march to better health outcomes. Health Minister Zweli Mkhize has to take off where Motswaledi left.

Dr Pali Lehohla is the former Statistician-General of South Africa and former head of Statistics South Africa.


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