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Can the NHI achieve Health for All?

[This article first appeared in The Pulse, September 2018 Edition, newsletter of the Public Health Association of South Africa (PHASA)]

By Leslie London

Affiliations: School of Public Health and Family Medicine, University of Cape Town,
and People’s Health Movement

Nothing in the health sector has captured the public eye more systematically over the past 7 years than the drive for a National Health Insurance (NHI), recently culminating in the issuing of an NHI Bill, closing for comments on September 21st 2018. To its detractors, it is unaffordable; over-ambitious; an assault on private insurance and downright dangerous. To the Minister of Health, Aaron Motsoaledi, it is ambitious, but rightly so, because it heralds a complete “reorganisation of the current health system, both public and private.” It is a bold step to address the deep inequities in our current health care system, inequities that are unsustainable and getting worse. It is also a response to growing price rises in the private sector, stagnant medical scheme membership and increasing dissatisfaction amongst medical scheme members with shrinking benefits under rising subscriptions.

However, can the NHI achieve Health for All, as promised? A fundamental misconception about the NHI is that it is only about insurance. In a sense, the term ‘National Health Insurance’ is unfortunate because it suggests it is only about creating one grand medical scheme, when what is planned is, in reality, the restructuring of the entire health system for universal access. Even the Minister, who has been at pains to emphasise equity in his NHI presentations, seems to be falling into the same trap, albeit from a different perspective. His view is that the public sector can only be strengthened if funding in the private and public sectors is pooled first because, he claims, there is no more money in the public system.

However, there is much that can be done that does not require huge injections of money – improved management systems, greater accountability, enforcement of controls over corruption and better training programmes for health professionals at all levels of the health system.  Additionally, we do also need to mobilise substantial additional public money, whilst simultaneously constructing the system to pool private and public funds, so as to make sure our public hospitals and clinics are places where all South Africans experience good quality service. Less than 1% of our facilities met the OHSC standards in 2016/17, and in some provinces and districts, audits scores have gotten worse, not better, since the first round of audits 2 years previously. Getting this right will need major investment in equipment, infrastructure and personnel, not another quality improvement policy. Brazil’s SUS achieved its impressive health outcomes by spending more public money – a LOT more – to set up its Family Health Programme. We should learn from Brazil’s experience that one has to spend more to get more – and save in the long term.  The lack of recognition of the crisis in the public sector has mobilised vociferous public opinion, even amongst those supportive of an NHI.

At the root of the problem lies a belief that achieving the NHI is dependent on the co-operation of medical schemes to work. In the 2011 Green Paper, the medical schemes did not feature very strongly, and their expertise was noted as useful to the extent that it would be drawn upon “where necessary and relevant” “… to ensure adequate in house capacity is developed.” Fast forward to 2017, where the NHI Policy White Paper locates medical scheme administrators, actuaries, private sector actors and other stakeholders with a direct interest in the perpetuation of the private insurance environment within the key committees tasked with implementing the NHI. They are no longer passengers on this NHI, they are in the cockpit, helping to fly the plane. By comparison, Civil Society was excluded from all committees until a wave of protest against the ‘capture’ of the NHI by private sector interests led to a partial revision of the task teams’ composition.

One particular committee charged with consolidating transitional financing arrangements, is responsible for implementing the consolidation of financing into 5 transitional funding arrangements: For the Unemployed; Informal sector; Formal Sector large employers; Formal Sector SMMEs; Civil servants. It is also charged with overseeing the extension of mandatory insurance cover for the formally employed. Evidence internationally is conclusive that once different packages of benefits are established, it is very difficult to change. As Kutzin points out, “where insurance begins by covering the formal sector, they tend to concentrate resources on a relatively small and economically advantaged part of the population. Such schemes do not naturally ‘evolve’ to include the rest of the population. Instead, the initially covered groups, who tend to be well organized and influential, use their power to increase their benefits and subsidies, rather than to extend the same benefits to the rest of the population.”

Although the Bill does not mention this committee, and the Minister remains adamant about one funding pool, he continues in his public presentations to use the slide outlining 5 distinct funding streams, leaving many anxious whether this NHI will get off on the best equity-promoting foot.

The NHI faces many other challenges – the desperate need for better management capacity in the health system, particularly if sub-district teams are going to have to negotiate primary care contracts; a greater focus on prevention; the need to foreground community participation; an urgently required human resources for health plan – to mention only a few. But grounding the NHI in an equitable start-up is going to shape the NHI forever. We have to get that right, and do so from the start. Building the public sector must be the primary focus of the NHI because that is where the most vulnerable access care. Harnessing pooled private and public sector funds must happen but at the same time as we invest heavily in the public sector – that is the only way to create a single fund with a single package of benefits that will advance Health for All.

PHM and other civil society organisations have called for an extension on the deadline for submissions on the Bill so that civil society, unions and communities can meaningfully participate. For more information, see https://phm-sa.org/nhi-bill-request-for-extension-of-public-comment-period/ or contact anneleen@phm-sa.org.

About Tinashe Njanji