Below is a report from the People’s Health Movement public forum on the National Health Insurance
On Saturday 20 February 2016, the People’s Health Movement held a public forum in Khayelitsha to discuss the NHI White Paper, and collect community input. Close to 120 people attended and spent four hours analysing the policy, collecting testimonies, and answering the question “what do you want from the NHI?” The event began with two speakers who framed the discussion, and then opened up for debate.
Dr. Leslie London summarised how the NHI came about, what it intends to do and how it plans to address various problems in the way health care is organised in South Africa. Currently, South Africa is a very, very unequal country and health care is inequitably divided between public and private sectors. Private health care is unaffordable to most, and costs in private health care are rising and out of control. He explained that there will be a single fund that all insurance and tax will support to provide health care to all in South Africa, and there will no longer be a distinction between public and private facilities. Patients will receive services without any payment at the point of care. The NHI is meant to address the financial inequalities in access to health care. By creating a single payer system and making sure that people can get care when they have a serious sudden illness, the NHI is meant as risk protection for health. The NHI will not cover every kind of health care need, only the most important and effective ones. People can still buy extra medical aid if they want to top up but they have to join the NHI – it will be mandatory. He also clarified that the NHI does not address the social determinants of health.
Dr. Lydia Cairncross raised several important points about the NHI: The implementation of the NHI is to take place over many years and the White Paper anticipates that the process will be complete by 2025. The South African population will be registered and receive an NHI card which will be used to access health care at different facilities. Users of the system will be expected to visit their closest health facility and there will be a clear referral system. Users who do not follow the referral system may be penalised/fined if they travel out of their area or skip referral lines. In principle it is good to attend healthcare facilities closest to you but if they remain of poor quality for people who live in poor urban or rural areas, this rule will entrench inequality.
Each health facility (clinic/hospital) will be assessed by the Office of Health Standards Compliance and must meet certain standards before being accredited as an “NHI facility”. Many hospitals and clinics in rural areas and poor urban areas and in fact many public hospitals in general, will not meet these standards at the moment. There is no stated commitment in the White Paper to upgrade these health centres to ensure that they are of sufficient standard to be accredited. This means that it is possible that only the best public facilities and of course many private facilities, will be accredited. The government may end up purchasing expensive private health care instead of building capacity in the public sector. If this happens, health inequality will not be addressed for the majority of South Africans and the NHI fund could end up as a profit making opportunity for private health companies.
The NHI fund will receive money from treasury (the current health budget) as well as an additional health tax. The White paper does not give a final decision on what type of tax this will be. Some taxes are progressive (they reduce the gap between rich and poor) and others are regressive (they maintain or worsen the gap). VAT, for example, is proposed as a possible source for the health tax but increasing VAT will not be progressive taxation. The “health tax” should come from taxation like financial transactions tax or tax on company profits to decrease the gap between rich and poor.
One of the biggest problems with the current health situation is that most health workers work in the private sector which reaches only 16% of the population. For the health system to improve, more health workers need to be brought into the public health sector as a matter of urgency and priority. While the White paper on NHI has just been published calling for equity and improvements in health care, the health workers in the public sector are experiencing budget cuts. Open posts in the public sector are often not funded and there is no effort to fill them in many places. In fact, the reverse is happening with the “freezing” of health worker posts that are vacated in order to save costs. This is completely contradictory to the spirit and purpose of NHI. For our health system to improve, vacant posts must be opened, funded and filled with urgency.
Communities and movements must mobilise to make sure that the NHI plan builds a strong and quality public health system and is not used to produce profit for the private health industry.
From the discussion, the community wants four crucial things from the NHI.
We want an NHI that…
- Is dedicated to strengthening public health systems The most prominent issue raised during this public forum was the need for the NHI to dedicate resources to improve the performance of the public sector.
Specific suggestions included: increasing the number of staff/human resources employed at public sector facilities (in order to shorten unreasonable waiting periods and allow clinicians enough time to provide patients with proper care), ending medication stock-outs, and dedicating funding to building clean and secure facilities with enough space to ensure confidentiality. In addition, participants stressed the importance of prioritizing ambulances and emergency care and making state-of-the-art medical equipment available in the public sector as well as private.The White Paper says that facilities will only be paid from the NHI if they are accredited. This raised some concerns because rural hospitals are likely to struggle to get accreditation because they have been chronically under-resourced. The NHI must first give hospitals/clinics the capacity to meet accreditation standards. If not, people living in underserved areas with unaccredited facilities would essentially be excluded from the NHI, and pay out-of-pocket for substandard care.Finally, community members asserted the need for robust referral systems and protocols for tracking patients who default, and strong monitoring & evaluation systems within the health sector.In conclusion, in order for the NHI to succeed, the public health sector must be well functioning and meet the needs of the people. Building such a system must be seen as part and parcel of implementing the NHI.
- Is accessible for all
The NHI aims to make healthcare financially accessible for all – an enormous step forward. However, there are other equally important aspects of accessibility. Members of the forum stressed the need for more facilities and emergency services in underserved areas, the expansion of after-hours care for community members who work or attend school, and programs to fund transport to healthcare facilities.The group also raised important concerns about obstacles to access. For example, the NHI White Paper says you can only seek care where you live. If you seek care somewhere else, you will be penalized and pay. This is a problem, because facilities in most poor areas are inadequate. We will not see poor people being able to access private sector facilities under the NHI. Therefore, community members strongly urge the government to make the NHI accessible to all (regardless of documentation), and allow NHI card holders to seek care at any public hospital/clinic, rather than being bound to one facility.In addition, the group declared that there must be a plan for improving access to healthcare in rural areas and among the “poorest of the poor” if the NHI is to succeed.
- Invests in education, training, and the capacity-building of health workers
Healthcare staff will be the “foot soldiers” of the NHI, and will require support in order to meet the complex demands of a universally ensured population. Therefore, the NHI needs to invest in training new staff, provide scholarships for health professional training, and build the capacity of existing staff. In particular, participants stressed that more community health workers are needed and that they require improved conditions of service. The group raised the importance of supporting and scaling up the number of healthcare workers at all levels – from community health workers to specialists.
- Engages with the community
The final point raised was the need for the public health sector to engage with the community. This engagement should happen at every step of the process, from organizing public dialogues about the implementation of the NHI throughout the roll-out, to directly providing services to the communities that are most in need of care via community outreach, mobile clinics, etc.In order for people to take ownership over the NHI, they must see evidence that it will reach them regardless of class, race, or geographic location. Finally, the forum concluded that community responses to the NHI will be invaluable in shaping its success, and should be actively sought out.Conclusion
Based on suggestions from community members, PHM pledged to do the following after the meeting:
a) Produce a report based on the meeting
b) Circulate the report
c) Put the report on our website, along with summaries of the NHI White Paper
d) Place the report and summaries of the NHI White Paper in public libraries e) Convene a follow up discussion