The South African government recently published a White Paper on its proposed National Health Insurance (NHI) scheme, and is inviting public comment. Since 2012 a few pilot schemes were introduced with full implementation planned over three phases through until 2026. Minister of Health, Aaron Motsoaledi says that the NHI will be established as a single payer and single purchaser fund responsible for the pooling of funds and purchasing of personal health services. Access will be available to all citizens and those with permanent residence permits through using an NHI card.
Refugees will be covered in terms of the Refugees Act such as emergency healthcare services, services for communicable diseases of public health concern, and paediatric and maternal services. Tourists and foreign students will be required to have medical health insurance coverage or will be required to make an out-of-pocket payment.
The health system will be re-engineered through four streams namely: ward-based Primary Health Care (PHC) ‘outreach teams’; an Integrated School Health Programme (ISHP); District Clinical Specialist teams; and contracting of private non-specialist private practitioners. The Ideal Clinic programme will be implemented, and health establishments will be inspected and certified by the Office of Health and Standards Compliance (OHSC).
The NHI will cover ‘all medically necessary healthcare’, including dental and eye care, and all the usual hospital services using a referral system; emergency services; and, rehabilitation and palliative care. There will be an Essential Drugs List (EDL) covering all free medication.
It all sounds very wonderful on paper. But then so did the Reconstruction and Development Plan (RDP) in 1995; the Growth, Employment and Redistribution (GEAR) strategy in 1996; the Accelerated and Shared Growth Initiative for South Africa (ASGISA) in 2005; the New Growth Path (NGP) in 2010; and finally the National Development Plan (NDP) in early 2013. Success was marginal at best. Lack of skills and lack of resources has meant little progress has been made over the last 20 years as far as poverty and unemployment is concerned. And one must not forget the once lauded credit card format driver’s licence, which was introduced with equal fanfare around 1998. Currently an estimated 90 000 drivers do not have a licence. Then let’s not even start on the third party insurance cover provided by the Road Accident Fund with fuel levies - another centrally funded boo boo.
The government makes some valid points in support of an NHI. South Africa spends about 8,5% of Gross Domestic Product (GDP) on health, split between public and private (4,1% and 4,4%). It acknowledges the country spends more per person on health in Africa but that its health outcomes are no better than some of the comparable countries internationally. ‘The current two-tiered health system is extremely expensive, wasteful and unsustainable. It will cost less to have a one single payer system.’ Essentially this means medical schemes will be booted into touch, while government warns the private sector: health must remain a ‘public good’, and ‘will not be driven by a need to make exorbitant profits at the expense of the users of the healthcare system.’
It is certainly a laudable ambition, and something certainly needs to be done. But the prospects of an NHI succeeding is questionable. One can envision 40 million people baying at the doors of over-crowded hospitals, waving their NHI card for service. Healthcare costs money. There’s no way round this. And the burden will undoubtedly fall on the shrinking tax base. As the government explains, ‘The funding mechanism will ensure income cross-subsidisation between the rich and the poor, between the healthy and the sick, between the employed and the unemployed, and between the young and the old.’ Workers and employers are not going to be happy.
The UK National Health Service was launched on 5th July 1948 with the promise ‘it would be the envy of the world.’ The government there currently admits to a staggering 23 443 vacancies for nursing staff. Nurses there are paid something like an average £295 a week, less than a florist (£298); a bit more than a cleaner (£290). With due respect to a char lady you do not need four year’s training dealing in matters of life and death, and the exams to boot, to wash floors. It does not make sense. Incidentally, the so-called ‘national living wage’ in the UK is set at about £288 a week. Nurses are barely making it, and for what? The message to a qualified nurse is simple: you’re not that important. To which nurses have replied, ‘Well, that’s fine, I’m leaving.’
Hospital conditions in the UK are over-crowded, under-resourced; and, staff are terribly over-worked, especially in the major city centres. The sector is also short of 6 207 doctors. No one wants to work there, which is why many UK NHS trusts and hospital boards are actively recruiting staff from overseas. That’s all very well, but it does not take long for a foreign recruit to realise they are being underpaid and being overworked.
A South African professor who kept a licence to practice there by spending a couple of weeks as a locum providing much-needed skills, was recently advised a change in registered criteria. Now they would have to spend longer in the UK to keep their licence. The latest stint in a Birmingham hospital was enough for the professor to abandon the idea of remaining registered. It just does not make sense when you are desperate for medical skills. But there it is, the UK NHS is in a complete shambles. And they have a far bigger tax base than we have and have been working at it since 1948.
The key questions to ask about South Africa’s plans for the NHI are:
- Will it be able to bring the private sector to heel in terms of conforming to price controls?
- Will it be able to attract sufficient skills into the various hospital ‘streams’?
- Will the NHI card system control fraud?
- Will it get enough revenue from taxes on employment?
The brief answer to all these questions is ‘no’. The NHI will neither have the will nor the ability to pay the required salaries for the necessary nursing skills. For that, read a 50% increase on current salaries. Then there are the working conditions. To improve, these will require vast amounts of capital and a control on theft from hospitals - this last being completely out of control.
The key problems in the UK are lack of resources, low salaries and poor working conditions. That’s what South Africa’s NHI needs to fix and I don’t think it can.
By Nigel Benetton