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Horrifying news reports over the past year reinforce growing public anxiety about dangerous deficiencies in public healthcare in South Africa – raising questions about the government’s determination to introduce National Health Insurance (NHI).

More than 100 media reports on negligence, corruption, and mismanagement in our public health sector between April 2017 and August 2018 were collated in the recent report by the Institute of Race Relations (IRR), ‘South Africa’s National “Death” Insurance Scheme’.

There have been more media reports since. The latest report, published on 19 October by Spotlight (a print and online publication ‘monitoring South Africa's response to TB and HIV, the state of our health systems and the people that use it and keep it going’), provides a harrowing account of doctors battling to avoid the ‘abyss of deepening crisis’ at the troubled Mahikeng Provincial Hospital in the North West province.

The report was republished by Daily Maverick under the headline ‘Broken babies, dying patients as North West hospital crisis deepens’.

It tells of North West state doctors who spoke to Spotlight describing ‘their reality’ as ‘finding coping mechanisms to process the noticeable spike in brain-damaged babies who are arriving in the paediatric wards. Doctors trace it back to when the Mahikeng Hospital theatre services were interrupted last year and limped along to a complete halt for two months in August and September this year’.

The IRR argues that while many dedicated people are working to make public health care work, the problems run deep and come at a high cost to South Africans, and that it is clear the public sector will not be able to cope with the greater numbers envisaged under NHI. Despite this, the government seems determined to push ahead.

NHI’s goal of providing free, quality health care to all South Africans is a noble one, but it is unlikely to be realised. Instead of strengthening the country’s health system it will likely weaken it. Here are five reasons why NHI is likely to fail:

1. NHI is going to cost South Africa – a lot

NHI is going to be expensive – very. Initial figures from the government say that it will cost about R250 billion by 2025 (in 2010 rands) but we at the Institute of Race Relations (IRR) estimate that it will be even higher. We estimate that the final cost of NHI will be about R1 trillion. But the fact is, the minister of health, Dr Aaron Motsoaledi, does not even know how much it will cost. When answering questions around a new bill which would see NHI be implemented, he said it was impossible to determine how much NHI would cost. It is baffling nobody knows what the budget of this massive project will be. 

2. Nobody knows how it will be paid for

The NHI is probably one of the biggest projects (if not the biggest) that any post-apartheid government is undertaking, and despite its huge cost, nobody knows how it will be paid for. When asked about where the money for NHI would come from, Dr Motsoaledi said that the National Treasury would have to determine this. The Davis Tax Committee said that without economic growth NHI will be unsustainable. At the moment it seems that NHI is likely to go ahead while economic growth will remain low. This means that the burden is likely to fall onto ordinary taxpayers, many of whom are already stretched thin.

3. NHI is basically a giant government-administered medical aid

Dr Motsoaledi has explained that NHI will effectively be a giant state-run medical aid. Everyone who can afford to, will pay into a single fund, without the option of opting out, before they paid for their private medical aid premiums. This fund would pay for all healthcare needs in the country. In a country with a capable state this would be a difficult undertaking, in South Africa the undertaking is even more onerous. In this country, where the state may not be failing but is certainly flailing it is very hard to see how such a massive scheme will be administered efficiently and with no corruption or misspending. The state has shown itself to be very bad at running most things and there is no reason to think that NHI will be any different.

4. NHI is likely to result in an exodus of health professionals

The public healthcare system is already straining under pressure of having too few staff members, and NHI may see this problem exacerbated. Under NHI, the tariffs that doctors can charge will be capped and there have been warnings from a number of organisations (including professional bodies for doctors) that this could lead to the emigration of doctors and other medical professionals. This will lead to even more strain being put on the South African healthcare system with dire consequences for all South Africans.

5. Throwing money at the problem won’t fix it

South Africa already spends a lot of money on public healthcare – about 14.2% of total government spending is on public health care, more than many other countries around the world. Despite all this money that is spent on public healthcare problems abound in the public sector. One need only think of the Life Esidimeni scandal that saw over 100 people lose their lives, but negligence and mismanagement in the public sector are common. Claims for compensation due to medical negligence are now equivalent to a quarter of the public healthcare budget. Throwing more money at health care will not solve these problems. What will solve them are merit-based appointments, strict accountability for poor performance, and effective action against corruption and wasteful spending, as well as public-private partnerships. Pressure can also be taken off the public health care system by allowing low-cost medical schemes and primary health insurance policies. Poor households should be helped to join these schemes or buy these policies through tax-funded health vouchers. To help spread risks, medical scheme membership and/or health insurance cover should be mandatory for all employees, with premiums for lower-paid employees buttressed by employer contributions for which businesses would garner tax credits.

* Marius Roodt is Head of Campaigns at the Institute of Race Relations (IRR).

** The views expressed here are not necessarily those of Independent Media.