NHI: From aspiration to implementation
- Wits University
Access to healthcare services is a constitutional right but is equal healthcare in South Africa a reality in our lifetime?
A young doctor recently took to social media to bemoan a lack of electricity, making it difficult for her to get ready for work, while the relative of a patient elsewhere complained about a 36-hour wait in a hospital ward for their octogenarian mother to be seen. And no, this was not Limpopo, these incidences were in Liverpool and London, England.
Equitable universal healthcare for everyone, including here in South Africa, would be ideal, but what these UK examples show is that, even in well-funded countries, implementing and maintaining a public health system is increasingly difficult.
The National Health Insurance (NHI) scheme, currently in proposal phase in SA, is a roadmap to universal healthcare. But it has come under sharp scrutiny for its lack of detail and financial modelling.
The right to healthcare, but …
Professor Emeritus Martin Veller, former dean of the Faculty of Health Sciences at Wits, says that the birth of democracy sparked the idea of universal healthcare, but that the last 30 years have shown tthat it may not be possible.
“The principle of NHI is one that is certainly widely recognised as a need, as it is enshrined in our Constitution. How you implement and interpret it is the problem. Certainly, in its current format, it is unlikely to be possible to implement,” says Veller.
The main issue he cites is that the vast sum of funding needed to meet the basic tenets of universal healthcare is not available to government. “Secondly, there are insufficient healthcare professionals to care for the population,” he says, adding that overarching a project of this scale is the “poor track record of how the public sector has been run for the last 60 to 70 years, particularly for the disenfranchised in our society. NHI is not in their favour.”
Veller adds, “Also missing from the discussion are our current healthcare outcomes, which are poor – way below the level of other countries with similar economies. A better healthcare system means that health outcomes, and as a result, the economy, would improve, but the NHI bill is being dangled like a carrot to win favour, despite its obvious limitations.”
“What’s not mentioned is that true universal healthcare has never been achieved anywhere in the world – bottomless funding from the public purse is unrealistic. In the UK, you can wait several years for a hip replacement, during which time your quality of life declines along with your ability to earn an income. It is an interesting cycle; when the amount of money spent on an individual is linked to their earning potential.”
Sectoral and systemic overhaul needed
Adjunct Professor Alex van den Heever, the Chair of Social Security Systems Administration and Management Studies in the Wits School of Governance, is frank about the “grandiose proposal” that the NHI Bill in its current format represents.
“It’s a paper plan. It’s not a real proposal. The problem is that the institutional and fiscal elements are not aligned. It is unrealistic and unimplementable and comes on the back of years of government having done very little in the healthcare system,” he says.
Van den Heever stresses that there has also been no significant structural reform of systems or infrastructure in the public healthcare sector to entice private healthcare to integrate. “This is not how you access the private sector intelligence. Sophisticated design is needed,” he says.
These experts agree that many people do not realise that the NHI proposals in circulation aim to centralise the health budget, eliminating current provincial mandates: “To put healthcare into a centralised government structure has enormous implications for the public sector,” says Van den Heever. “It is not based on the way our systems are designed, nor on the way health systems are designed around the world. The risk of the NHI being run like Eskom is mammoth.”
He adds that patronage, the capture of public entities, and political interference, that all cause massive collapse and failure of any system, pose too great a risk.
What’s the solution?
Veller says a pragmatic approach could work. “We have to accept that we have a two-tier healthcare system that needs closer alignment. It is simply not fair that 85% of the population is denied access to what just 15% have in private healthcare. We must progressively find a way of integrating the two systems.”
He says that the NHI should not be funded by increased taxation and that other means of income should be found to improve healthcare. “From a universal access to healthcare perspective, we must be able to guarantee that the current dispensation not only guarantees healthcare for everyone, but also quality healthcare and outcomes.”
“We must fix the existing healthcare system. The NHI can be achieved only if what we already have is repaired. First, professionalise and depoliticise healthcare – that means the right people, doing the right job, under the right circumstances. Every cent spent, must be well spent.”
While Veller is in favour of a universal healthcare system, he says there is work to be done before we reach a functional option. “It is high time that the public healthcare sector is properly administered and that systems are adequately audited. We must really start looking at incorporating academic health systems into the sector. Where medicine is practised under academia, it is improved and is better for everyone. There is no doubt that academic healthcare is worldclass and should be integrated into the public sector more rigorously.”
Veller says that “at the institutional and individual level, we must incentivise excellence. Measure outcomes and incentivise people to do their jobs well, which happens in Thailand and Sweden.”
To make the NHI work, Veller advocates:
- In the short term: We must improve what we have and make it work, and really work. Get rid of political interference that has prevented it from achieving good outcomes.
- In the medium term: An incremental introduction of private sector participation and buying of services by the public sector. Pricing and competition must be good and that will encourage the public sector to improve, too. If there is good quality control, there will be a gradual integration of the two.
- Long term: Integration. It is simply not appropriate in a country like ours that most healthcare needs cannot be accessed by a large majority of the population. Improved healthcare outcomes have been demonstrated to make economies grow across the world. The question is how to achieve universal healthcare but not the NHI, which requires a funding mechanism.
He concludes: “As it stands, the NHI is unaffordable. The proposal must evolve beyond theoretical constructs. A pragmatic approach, informed by systems understanding and decentralised governance, is essential.”
Only then can we bridge the gap between aspiration and implementation, thereby ensuring equitable healthcare for all South Africans.