The following is our submission we made to parliament on the National Health Insurance Bill of 2019 The submission was made on 29 November 2019
The 2019 NHI Bill is an improvement on the 2018 draft bill. It is more explicit on the need for social solidarity and equity. It clarifies the need to make healthcare free at the point of service with no need for co-payment as well as the progressive removal of the tax rebates on medical scheme membership.
Some parts of the Bill are, however, problematic. It is written almost without context — as if we have a functioning state, a reasonably functional public health sector, and a willing private sector that are free of corruption and capable of introducing and managing the far-ranging changes to the health system that will be required.
More specific issues include the following:
- Lack of detail about upgrading the public health sector, without which the NHI can not work
- The possibility of exacerbating inequality
- Failure to distinguish between Primary Health Care and Primary Care
- Lack of adequate mechanisms for civil society engagement and no accountability in the NHI committee structures
- Lack of emphasis on capacitating the Public Health System through a pro-public NHI
- The possibility that “Universal Health Coverage” could be reinterpreted corporate private health care industry to facilitate profiteering from the NHI Fund
- Then arrow focus on UHC potentially weakening action on the social determinants of health
1. Fixing the public sector
Without a well functioning public health care system the NHI cannot succeed. It is therefore imperative to fix and upgrade the broken public sector to the level required for NHI accreditation. After more than two decades of public sector austerity, many public and rural health care facilities are understaffed and under-equipped and unlikely to qualify for NHI accreditation. The most recent report of the Office of Health Standards Compliance (OHSC) found that only a small fraction of public health facilities surveyed met to meet the norms and standards required for certification. Private facilities are not only more likely to get accreditation but also overwhelmingly urban-based, thus increasing both urban-rural and private-public inequality. There is a possibility that people living in some areas will not have access to NHI-funded health care at all.
2. Risk of exacerbating and entrenching inequality
Registration for the benefits of the NHI must be done at an accredited health facility, which then issues the user with a registration number as physical evidence of membership and then maintains a register of all users and their dependents. This poses the risk that those already marginalised from access to care (rural populations, disabled, elderly) will be further disadvantaged. Facilities that already lack staff, medicines and equipment will not find it easy to register users as smoothly as those facilities already functioning at a much higher level of efficiency. Many public sector facilities lack easy internet access.
3. The distinction between Primary Care and Primary Health Care
The 2019 NHI Bill confuses Primary Health Care (PHC) with Primary Care (PC). The distinction between PC and PHC is generally accepted by the public health community.1 When the Bill mentions PHC, it is actually referring to Primary Care PC.
For example, the Bill refers to PHC as
- “addressing the main health problems in the community through providing promotive, preventive, curative and rehabilitative services”2
- the first level of contact of individuals, the family and community with the national healths system
- the clinic in the public sector; the general practitioner and primary care nursing professional in the private sector, together with primary care dental and primary allied health
Reference to PHC in terms of “services”, “service provision”, or “facilities”, occurs in several sections the Bill, thus reinforcing its interpretation of PHC as essentially having to do with the delivery of health services. Thus the Bill talks about Primary Care rather than the broader Primary Health Care approach as defined in the Alma-Ata Declaration.
This narrow service-based understanding of PHC is not a mere semantic issue. Access to quality health services — Primary Care — is essential but insufficient for promoting people’s health. It leaves out fundamental principles of PHC as codified in the Alma-Ata declaration. These are:
- This list should include palliative Palliative care services are now included within the scope of comprehensive primary care.
- community participation in issues related to health (including in the planning, provision and evaluation of health services), and
- collaborative inter-sectoral action to address the social determinants of health (SDH).
Why this is important in the context of the NHI?:
Community participation helps to optimise health interventions at the organizational, community, and individual levels to improve public health. It helps in priority setting as well as in the development of organisational relationships and trust.3 It also engenders a sense of ownership within the community. Health services are responsive to local needs, with more effective use of resources and better health outcomes. Community-based health workers and properly functioning health committees play crucial roles in facilitating community participation.
Intersectoral action to address crucial SDH could reduce the burden of maternal and child deaths by half.4 This would lighten the burden on the health service enormously and free up resources for key programmes and demands on the NHIF. Notable common intersectoral actions include expanding water and sanitation provision; improving education; adequate housing; reducing socio-economic inequality; promoting gender equality; and involving women in policy formulation and programme implementation.
Furthermore, the global ecological crisis threatens to overwhelm all efforts to deal with the SDH unless we make rapid progress. The Department of Health should therefore advocate strongly for collaborative action on the SDH by other sectors.
4. Democratising NHI Structures:
We note with concern limitations in the inclusion of civil society and public representation in the NHI substructures. Public participation in the Benefits Advisory Committee and Pricing Advisory Committee are essential to ensure accountability in consideration of patient benefits in keeping with the needs of communities and the principles of PHC as they are more broadly defined. While we remain in favour of the principals of UHC espoused in the current NHI bill document, a concerted effort must be applied to strengthen community oriented care in resistance to a continued focus on hospicentric curative care models. Without adequate participation in these sub-structures it is unlikely that community voices will be heard and that the dominant influence of the private sector will persist in the constitution of the NHI Benefits package.
The restriction of civil society involvement to the Stakeholder Advisory Committee is a clear obstacle to transparent critique of NHI processes as they evolve. We therefore call for the inclusion of relevant civil society and community stakeholders in all NHI structures including the Advisory Committees mentioned above.
Clear terms of governance and lines of accountability to the Stakeholders Advisory Committee should be included within the NHI to ensure the Minister of Health and related officials are mandated to engage with this body and ensure that the Stakeholder consultation does not become a checkbox or rubber stamping process.
Furthermore, we call on all parties involved in constituted NHI structures and committees including the NHI Board to declare their conflicts of interest, financial or otherwise – particularly as they relate to the private sector and pharmaceutical/hospital industry. A pro-public NHI must remain committed to a principle of independence from individual benefit. This is a principle from which the NHI and any Rights-based health system cannot deviate if it hopes to counter strong private sector interest groups.
5. Building and capacitating the Public Health System through a pro-public NHI
There is a known and growing body of evidence that only a publicly funded and publicly administered health system can sustainable, reliably and equitably deliver health care to populations most at need. Considering this, NHI should use it’s purchasing power to specifically and consciously capacitate the public sector. This is vitally important if the Fund is to purchase from both public and private providers because, as we have seen in the recent past, it is possible for the purchasing of private sector services to further decapacitate already weakened public systems. While in the case of individual general practitioners or specialists this may be less likely, there is a real danger that powerful private hospital groups may benefit from NHI contracts and resources which could have been used to upgrade and staff public facilities to fulfill the same functions.
We therefore strongly motivate that any private hospital contracts should only be entered into temporarily, and with public sector capacitation as a key principle. This, for example, could mean including the requirement for skills transfer to public sector workers and ensuring that the private contracts are not entered into if a public facility is able to perform the same service. Private hospital providers should be measured against their ability to constructively interface with and capacitate the public health sector as a criteria against which their future eligibility for NHI contracting is measured.
6. Possible reinterpretation of Universal Health Coverage for profit
The Bill establishes the National Health Insurance Fund (NHIF) as the single purchaser of comprehensive health care services to achieve health coverage (UHC).
UHC implies that all people and communities have ready access to the promotive, preventive, curative, rehabilitative and palliative health services they need (equitable access); that the services are of sufficient quality (effective); and that the use of these services does not expose them to financial hardship (affordable) (WHO 2018).5
There is a broad global consensus that UHC has the potential to enhance equitable access to comprehensive health care with financial protection, and it is central to the third Sustainable Development Goal (SDG) which focuses on health. Progress towards UHC entails overcoming barriers to access including out-of-pocket expenses, large distances to health facilities; lack of staff in the public sector; geographic maldistribution of health care providers with concentration in large urban areas; and fragmented funding and risk pools. Section 2.2 (p 47) outlines a set of reforms to address these barriers to access. The purpose of these reforms is to
‘Ensure consistency with the global vision that health care should be seen as a social investment and not be subject to trading as a commodity. The universal health coverage system is a reflection of the kind of society we wish to live in: one based on the values of social solidarity, equity, justice and fairness”
This understanding of health as a social investment and a common good rather than a marketable commodity, and of UHC as a means of building a society based on the values of social solidarity, equity, and justice, recognises the principle of health as a fundamental human right. As mentioned in the Bill, achieving UHC will require public financing based on social solidarity — where young, relatively wealthy and healthy citizens cross- subsidise the elderly, poor and less healthy through a progressive tax-based single payer system.
However, some contest this meaning of UHC. Powerful, well-funded corporate groupings with vested interests in the highly profitable private sector and free-market fundamentalists argue that “coverage” in UHC allows for scheme-based insurance models with voluntary prepayment and a range of financing mechanisms that inevitably discriminate against the poor and least healthy. They have mounted vociferous and possibly well-coordinated media campaigns hostile to the NHI project. Common campaign themes include resistance to the single payer system and arguments for expanded private sector and scheme-based involvement in health service delivery. They present little, if any, evidence that substantial private sector involvement facilitates progress towards equitable health systems and social solidarity.
On the contrary, a substantial body of empirical evidence shows that, to realise its objectives of universality, equity and (particularly in the South African context) social solidarity, attempts to achieve UHC must, from the start, address the needs of the entire population and the whole health system (Kutzin).6
7. A narrow focus on UHC may weaken action on the social determinants of health
There is a risk that the DoH will narrow its focus to UHC (SDG 3.8) and neglect other SDGs that are essential for health.7 These include the elimination of poverty (SDG 1), adequate food and nutrition (SDG 2), quality education (SDG 4), gender equality (SDG 5), water and sanitation (SDG 6), the reduction of inequality (SDG 10), promotion of environmentally responsible consumption and production patterns (SDG 12), and mitigation of climate change (SDG 13). While some of these goals rely on other sectors, the state has shown little evidence of its ability to promote intersectoral action.
Unless leadership for intersectoral action emerges from the Presidency, the DoH must assume leadership and advocate for this.
NHI in its current form represents an alternative funding model for healthcare in South Africa. For this funding model to result in a new health system which is based on the principles of Primary Health Care; is equitable, delivers quality care and is community focused will require a much broader reimagining of our interventions in the social determinants of health and our health services. To build this vision of health and healthcare in South Africa will require the involvement of a broad range of role players from community health committees and social movements to clinicians, academics and public health specialists. We call for a transparent, democratic and accountable process as we collectively embark on constructing this new vision for health in South Africa.