In the absence of any real detail around the funding, benefit package and provision of services under NHI, one questions the motivation behind the ‘naysayers’ cluttering the press of late with their doomsday scenarios.
Without these details, (which the government has committed to releasing by the end of June) the only grounds for questioning the proposed NHI would be the principles on which the system will be based, especially as they relate to the South African scenario.
In 2001 the WHO rated South Africa 175 out of 191 countries surveyed for expenditure versus outcomes on health. Since then, little has changed. Comparing life expectancy in SA to countries such as Brazil, Chile and Mexico, all of whom spend approximately the same or less on health as we do, SA does not fare well. South Africa’s life expectancy for males is 50, while Brazil’s is 68, Chile’s is 75 and Mexico’s is 72. South Africa’s infant mortality rates are equally disturbing compared to these countries, with ours being 69, per 1000 live births compared to 20 in Brazil, 9 in Chile and 35 in Mexico. The Millennium Development Goal target is 24.
South Africa has almost the highest incidence of TB (all forms) per 100 000 population and, of the 15 countries with the highest estimated TB incidence in 2005, SA and its neighbours (Botswana, Namibia, Zimbabwe, Mozambique, Lesotho, Zambia, Malawi and Swaziland) provided 9 countries.
But inefficiencies in health are not particular to the public sector. The fact that there is a divided healthcare system contributes significantly to these dismal results. Health expenditure on the approximately 7.4 million private beneficiaries is six times that which is spent on the 40 million people in the public sector. Also contributing to the inefficiencies is the imbalance in human resources in the private sector versus the public sector.
Where there is one pharmacist for every 1000 beneficiaries in the private sector, there are 17 000 beneficiaries to one pharmacist in the public sector. Similarly, there is one GP for every 540 beneficiaries in the private sector whereas there are 4000 to every one GP in the public sector. This, amidst a growing burden of disease especially in the public sector.
Therefore, on moral grounds, government’s intention to reform the health sector to ensure a more equitable spread of resources and improved access to these resources cannot be faulted. After all, it is unlikely that any South African would want to deny equal access to healthcare to another South African, bearing in mind that people do not choose when to access healthcare services because no-one chooses when to get ill or not.
Medical scheme members least of all should be balking at the idea, because all medical schemes are in fact mini NHI’s. Since 1998, legislation governing medical schemes has dictated that they operate under exactly the same principals as the proposed NHI will. Essentially what this means is that the contributions paid by members each month are pooled for the benefit of all members of the scheme, rather like a ‘stokvel’. So when one member lands up in hospital with a R500 000 bill, it is not some magnanimous benefactor who foots the bill, but the rest of the members. Medical schemes are also not allowed to charge extra based on a member’s risk profile. For instance if he/she is obese and has a family history of heart disease, the medical scheme must charge exactly the same as they would to a young healthy person with no family history of disease.
Many schemes also base their contributions on the amount of money a member earns, which means that the rich subsidise the poor.
Medical schemes are also obliged to offer a defined basket of benefits equally to each member.
Thus far, the information which has been released about the NHI does not deviate from these principles, except that instead of the medical aid fund which only serves the group of people who have chosen to belong, the NHI will cover the entire population. We will still cross subsidise each other. The earners will continue to subsidise the unemployed and the indigent, and the higher earners will continue to subsidise the lower income earners. There will still be a defined and comprehensive set of benefis,
So what’s the problem? That we’ll all be forced to use the public hospitals? Up until the late 80’s public hospitals were the norm whether you had medical aid or not. They were clean, well staffed, efficient and had world-class technology and equipment. What needs to be done is to put in the resources needed to bring them back up to that standard so they can again be the provider of choice.
But will there be enough to go around? One of the main criticisms levelled at the private sector is that too many resources are spent on high cost interventions like hospitals and specialists, instead of putting them towards preventing the illness in the first place. The burden of disease in South Africa is a mixed bag of diseases ranging from pre-transitional diseases relating to poverty (water, sanitation, etc) to infectious diseases, to lifestyle diseases, to trauma. Therefore, under NHI a substantial share of the resources must go to primary and preventative care to avoid high-cost interventions. This will not only improve the country’s health but will also increase productivity. Not to mention improve our dismal health outcomes, where South Africa is ranked near the bottom in the world, and get us closer to reaching our MDG targets.
Will the benefit package be comprehensive enough? Mismanagement and resources aside, currently, with only a fraction of the healthcare resources (both money and human resources) going to the public sector, it offers treatment for almost every condition.
The head of the Task Group on NHI, Dr Olive Shisana has assured that the benefit package under NHI will be comprehensive, which means that it will cover most conditions. What it may not do is provide for non-essential interventions, e.g. cosmetic surgery, orthodontics, elective caesareans. But just like in other countries with NHI systems, these may be available through top up products which could be purchased over and above the NHI package for those able to afford it.
What will happen to medical schemes? Medical schemes have been acting as mini NHI’s in this country since 1869. There is no reason why, as occurs in many other countries, medical schemes cannot be retained under NHI. After all, they are merely conduits for the contributions which are collected, with a Board of Trustees to look after the interests of the members. Indeed, the medical schemes industry is mobilising itself to remain a critical component of the NHI.
What about my doctor? From the outset, the word from the Task Team has been that there will be freedom of choice of providers so long as they are accredited. This will also apply to specialists and private hospitals who will undoubtedly be part of the deal under NHI. . Again, this is similar to the way many medical schemes operate where they prescribe a doctor or hospital or a group of hospitals or doctors.
Obviously, there are a myriad of other factors to consider, but what is clear is that South Africa is one of very few countries where there are two detached health systems , both of which are unsustainable unless something is done about them. What is also clear is that the NHI is a moral imperative for government, and on this basis it is something which few South Africans can argue with.
Dr. Clarence Mini
Board of Healthcare Funders Director
Corporate Affairs Executive – Thebe Ya Bophelo Healthcare Administrators.
