OPINION: The introduction of the National Health Insurance will allow for the majority of people to be included in universal health coverage.
By Dr Mofenyi Malatsi
In the face of the National Health Insurance implementation, there are undoubtedly issues that cannot be ignored and must be addressed in one way or the other in order to mitigate disastrous outcomes.
A major focus has been placed on the supposed management of the fund and the risk of inefficiencies, poor management and corruption that have become the hallmark of arguments that are brought forward by those who do not agree with the NHI Bill, and their points certainly are correct as far as the inefficiencies and corruption that exists in state-owned or managed entities. This is above and beyond the fact that corruption exists on both sides of the spectrum, in both private and public. However, this is no reason to sustain the current unworkable management and organisation of health services in South Africa, a change is needed.
There are successes within the public sphere that are worth mentioning, such as the South African Revenue Services (Sars) which handles trillions of rands annually through tax revenue, and the South African Social Security Agency (Sassa) which in 2022/23 will distribute more than R240bn (99% of its budget) in social grants. The successes of these state agencies when it comes to managing funds are a reflection of good governance structures and good practices which can be learned from.
Part of the main cause and increased risk of corruption lies in the nine individual autonomous provincial departments of health and their budgets that not only purchase but also provide healthcare services and rely on various tenders for some services. The NHI in its capacity as the single purchaser of services in the state will handle very little by way of tenders. Service providers will be required to undergo an accreditation process and if all criteria are met during the accreditation, the provider will enter into a contract based on the services that are required and/or services the provider is able to render. This means that prices and services rendered will be set and fixed and regulated based on the agreement/contract between the purchaser (NHI) and the service provider, whether private or public. This already significantly reduces the risk of corruption through tenders.
Regarding the procurement of goods, particularly health products, the NHI fund will have the leverage to negotiate far more affordable prices on behalf of the providers.
Another obvious fact is that most public hospitals and clinics are in dire structural and functional states, with poor leadership and governance and very little accountability to the communities they serve. This is, in part, a consequence of how the health system is structured, including how it is financed. We do agree that public health facilities need repairing, and maintenance, and furthermore, the construction of new facilities is required.
It is also an obvious fact that the public health system is overburdened, currently providing for the healthcare needs of 85% of the South African population, with limited resources both financial and human resources for health. A major contribution to this is the reduction of the health budget every year approved by parliament. The same budget is supposed to pay for medicines, salaries of healthcare workers, and pay for the maintenance of hospitals and clinics. Whereas the private health sector provides services to 15% of the population, with abundant resources that are often underutilised. The NHI bill will allow for the decompression of public health facilities including clinics for primary healthcare services in the communities where patients live. For example, this will lead to improved access as private GPs in those communities will share in the delivery of primary healthcare services.
It is safe to assume that the 85% of the SA population that is using public health facilities is doing so because they simply cannot afford to contribute to a medical aid scheme. Introducing a low-cost package would still mean that only those who can afford the “low-cost” package will have access to healthcare services that will not be comprehensive in coverage and may still be exposed to financial hardship due to out-of-pocket spending in the form of co-payments. Furthermore, the government will still have to subsidise medical scheme contributions through tax rebates.
It is important to also realise that the NHI will be phased in over several years, a projected 15 to 25 years, and over that period there will be a progressive implementation of various parts of the NHI, from setting up funding mechanism, restructuring and redirecting of existing funds and strengthening of funding mechanisms to the actual provision of services, as per the basic package of care, this includes benefits that will be paid by the fund, which will increasingly become comprehensive as more benefits are included over time.
Notwithstanding the critical need to strengthen leadership and governance, strengthen measures to improve accountability, and strengthen the implementation of policy to ensure the reduction of impunity, all of which are measures against corruption. For anyone to say if the NHI is implemented, the whole health system will collapse is an overstatement and ignores the multiple iterative processes that are required to implement such a reform, milestones achieved over many years in order to arrive at an “ideal NHI” that works for SA to deliver the needed healthcare services that are of good quality, accessible anywhere to all citizens of the state equally. To do nothing about the dichotomy and inequality that exists in the SA health system will lead to its inevitable collapse.
* Dr Mofenyi Malatsi is public health medicine registrar.
* The views expressed in this article are not those of Independent Media.