THE finer details regarding the operation and financing of the ANC Government's controversial planned National Health Insurance (NHI) scheme still have to be worked out and the ministerial advisory committee still has to do a lot of "homework" before a White Paper can be tabled.
However, what's becoming increasingly clearer is that the ANC is determined to start introducing NHI in SA - and as soon as possible.
Hardly had the New Year arrived when President Jacob Zuma emphasised during the ANC's 98th anniversary celebrations that Government was forging ahead with the implementation of NHI as part of a 10-point plan. At the same time, Zuma gave assurances that all stakeholders would be consulted before the necessary legislation is approved by Parliament. But there's a great deal of scepticism in the private sector about how much other opinions and opposition to the legislation will be taken into consideration.
Though plans to correct the inequalities between private and public healthcare - and making healthcare accessible to all South Africans - have been on the party's agenda for many years, they've been strongly prioritised since Zuma took office. And everything indicates Government will do its utmost to get the NHI wheels rolling as soon as possible, regardless of the criticism and scepticism of how feasible the plan is.
Though stakeholders generally agree the current distorted healthcare dispensation -where only about 7,5m South Africans have medical insurance and access to private care, while the majority have to rely on poor and overloaded State facilities - isn't sustainable and that the sector is in urgent need of revision to make it more accessible and affordable, the debate about the feasibility of such a system in a developing country like SA continues to rage.
If it's failed in richer societies - such as in Canada or Britain - how can it succeed in an African country with a large developing population? How will SA's health authorities succeed in bringing facilities in the public sector up to standard more quickly and manage them efficiently if they haven't been able to do so over the past 15 years? How will the exodus of medical practitioners - the core on which the ANC's delivery plans are based - be halted? Those are just a few of the disturbing questions raised.
The differences over the NHI plan were again shown clearly by round-table talks arranged by the Helen Suzman Foundation (NSF), in conjunction with the Open Society Foundation, in December 2009. To lead the discussion, Tebogo Phadu, of the ANC's policy unit and the party's health task team, put the ANC's case for an NHI, while independent health economist Alex van den Heever gave his views on the matter. In many respects, both also represented the views of other parties in the pro and anti NHI camps.
In a summary of the proceedings on the HSF's website, Phadu says the ANC's focus involves a reform path that's "interconnected" and doesn't simply aim at getting the public sector into shape but will result in the integration of the current two-tier health system.
This will result in the establishment of a public NHI fund that will be pooled to pay for services covering every South African citizen. It will involve a free service point with access to public and private healthcare providers, which will cut out wastage in the current system and will control costs by cost-efficient practices, capitation tariffs and wholesale buying, Phadu reported.
The insurance fund will apparently be supported by an SA Revenue Service type of organisation outside SA's national Budget system, will have a great deal of accountability and be managed by specialists and dedicated professionals. It won't be strictly bureaucratic and will be run at a cost of 3% to 4% of the total cost.
In that NHI dispensation there will still be room for medical schemes to be part of an integrated provision system. The system will put the whole healthcare system in a better position to influence the behaviour of suppliers, with the major share of the money in a single channel, said Phadu.
In an interview with industry journal Medical Chronicle, Phadu said the ANC task team's recommendations will be used as the basis for the negotiations of the ministerial advisory committee (appointed in November) with healthcare stakeholders before an official document for comments and public information is issued.
However, Van den Heever is openly sceptical about the feasibility of an NHI, saying inadequacies and problems - including the poor quality of the ANC document that's meant as a starting point for the advisory committee. Van den Heever says the entire debate about health reform has become very complex. It's therefore extremely important to obtain clarity about key conceptual elements, such as finances and institutional design.
He argued the standpoint on a two-tier system represents a distorted debate and diverts attention from what's really necessary in a health system: competent authorities that haven't existed since 1994. He gave many mechanisms, including legislation, as examples that can be used to integrate health systems but aren't or haven't been applied. He says numerous instruments are indeed present in the current system but their inefficient use contributed a great deal to the distorted growth of the private sector at the cost of public health services.
"Trying to implement a financial model to solve an institutional problem created a false debate and is a non-starter. The overall issue of health reform is the subject of the structure that controls health provision - a structure that's neutral and apolitical;' Van den Heever says.
The Medical Chronicle reported in its January issue further criticism comes from Professor Joe Veriava, head of internal medicine at the University of the Witwatersrand. A complicated plan and economic jargon won't solve the problem of an already overburdened system, he says. Public hospitals are already being run at 100% bed occupancy. In some of the wards of the Charlotte Maxeke Hospital there are 12% deaths. "We need more beds, we need more financing and we need workable systems to allow the public sector to use spare capacity in the private sector," he says.
Though the ANC is naturally very eager and in a hurry to carry out its election promise of affordable medical care for all, the financial and technical implications of its NHI plan could possibly become a spanner in the works. It will be interesting to see all the things the ANC does to keep the NHI gears turning
Wilma de Bruin: FinWeek,
