THE ongoing debate around the implementation of the National Health Insurance (NHI) is not just about bridging the gap between the haves and the have-nots but more about opening coffers, facilities and professionals up for plunder and mismanagement.
This is the sentiment of many in the country, with experts and private health practitioners vowing to fight it to avoid “going down” with the plan.
Recently adopted by the National Council of Provinces in Parliament, the universal system is geared towards dismantling the current two-tiered healthcare structure, which has, for years, been blamed for benefiting an affluent minority and leaving the majority scrambling for public health care.
South Africa's current healthcare landscape is marked by major disparities, where only 10% of the population controls more than 80% of the wealth. Meanwhile, only 1% spends more than 10% of their household budget on healthcare.
In advocating for the system, Minster of Health, Dr Joe Phaahla, said: “A staggering 86% of the population relies on a strained public health sector, with only 14% regularly accessing private healthcare services.”
Speaking after the adoption of the NHI early this month, Phaahla called it “another important milestone on the journey by the country to realise Universal Health Coverage, to ensure universal access to quality and affordable health care for all South Africans as enshrined in the Constitution”.
He said it was a landmark moment for the country, a mechanism which would ensure ‘equitable access to quality healthcare for all citizens’.
“We are confident that, with the support of all stakeholders, we will create a healthcare system that is fair, efficient, and accessible to all,” he said.
The system, which has been close to 20 years in the making, is designed to pool funds and resources, to provide access to quality and affordable personal health care services to everyone who requires it, irrespective of their socio-economic status.
The fund, to be operated by government in conjunction with health stakeholders and others, will pay for health care, and no fees would be charged at facilities. The NHI would cover all costs of care.
But the pushback against the plan, which still has some work to be done before actual implementation, has been massive.
“Nothing run by government can be perfect, and that is the only way a universal health care plan must be implemented,” Dr Sean Venter from Pretoria said.
Being part of a practice of four doctors, some who do shifts in public hospitals, he said everything, from how patients were triaged to the dispensation of medication, was disorganised.
“Don’t get me started with facilities, equipment, and the environment. When an academic hospital, which is supposed to work like a well-oiled machine, can go days without life saving medication for illness like cancer, have whole banks of lifts not functioning, force surgeons to cancel procedure because theatres have no airconditioning – for weeks at a time – not because there is no money but because of the system, can you imagine how the NHI will cripple those facilities which have everything running properly,” he said.
The good thing about it, according to Dr Alpheus Ngcobo, was that the NHI Fund was meant to pay public and private healthcare providers on exactly the same basis for the same standard of care, allowing people in lower income groups to consult doctors in private practice and use private hospitals.
“But, it does not take into consideration the lack of understanding of health,” he said.
Ngcobo said South Africans did not understand that not everything needed a doctor or specialist, and this was evidenced by how they flocked to hospitals when they should go to clinics. This created blockages for those who really needed facilities and care.
“Millions of rand go into trying to clear queues, ensuring that beds have clean linen, wards are staffed, yet the majority of people found in hospitals could have been treated at the primary health care level.
“When they arrive at hospital they cannot be turned back, the constitution does not allow that, so they fill up parking lots, passages, benches and beds, diverting millions which would save lives and preventing the treatment of people in dire need,” he said.
The financial impact, Discovery Health said, was potentially horrifying. In their estimate, the NHI would cost R859 billion for prescribed minimum benefits against the 2023 public healthcare budget of R233bn. But, they have asked, where would the government find the R626 billion shortfall?
“This means medical scheme members will be required to pay 31% more tax and receive 69% less benefits in return,” said chief executive Adrian Gore.
Saying they appreciated the disparities in access to healthcare and acknowledged that something had to be done to fix that, Gore said that in its current form, the NHI was not the answer.
“Apart from roughly R100bn in tax credits and government employer medical scheme subsidies, roughly R528bn will have to come from raising personal income tax,” Gore said.
The timing of the passing of the bill was nothing more than an election gimmick, Solidarity Research Institute said: “Our research undeniably shows that the NHI is not supported by those in the medical profession. They do not want to be part of it.”
Conditions would be much worse for South Africans and for the country under the NHI, said Solidarity’s network coordinator of the medical network , Peirru Marx.
He said doctors in the network had themselves seen first hand how corruption, deterioration, and mismanagement hampered the public health care system
“This in addition to staff shortages, the lack of availability of essential medication, protracted waiting periods for the acquisition of medical devices, and obstacles with medical procedures due to a shortage of specialists has characterised the public run health care system,” Marx said.
But, not everyone saw it as all doom and gloom. The SA Medical Association Trade Union said the adoption of the Bill and expected submission to the President for consideration and promulgation “represents monumental achievements in South Africa's journey towards accomplishing Universal Health Coverage”.
The union said: “This milestone signifies that the nation realises the importance of Universal Health Coverage as a means of addressing the inequalities that exist in the current healthcare system.”
They lauded what they said was the Department of Health’s inclusive and comprehensive approach, robust stakeholder engagements, transparent communication, and a well-considered phased implementation strategy.
“We view these efforts as key components for the successful execution of this critical healthcare reform. As we move forward, we reaffirm our commitment to advocating for the best interests of healthcare professionals and the public,” the union said.
Section 33 of the NHI Bill spelt the end of private healthcare for the 9 million medical scheme members, as well as many valuable business interests within the R250bn private healthcare industry, the Free Market Foundation said.
“This strategy ignores the fact that public health woes have everything to do with the dismantling of governance frameworks and management ineptitude within the public health department, all repeatedly confirmed through audits by the office of health standards compliance, the auditor-general, and the health ombud.”
The SA Medical Association said they supported the broader objective of the NHI as a means to achieve universal health care but remained concerned about several critical aspects of the current legislation. “The NHI Bill requires extensive revisions to ensure its effectiveness in facilitating sustainable financing for universal health coverage in South Africa.”