At the Khayelitsha Youth Clinic Site C the reality of South Africa’s overburdened healthcare system hits home. Many have got out of bed before sunrise, some have traveled 600 kilometers to be here, for the long wait for the hope of seeing a doctor. This clinic tells the story of a land where eight out of 10 people can’t afford to see a doctor. At least here it’s free. But the shortage of doctors means a snaking queue that stretches down the street every day.

“When a patient from the Eastern Cape (600 kilometers away) comes to our clinic with a broken neck to be seen by a doctor here, you need to say that is unacceptable,” says Dr. Zahid Badroodien, who works in this clinic every day, 30 kilometers south east of one of South Africa’s richest cities, Cape Town.

“This facility sees 200 people a day and we turn people away. We have three or four doctors here depending on the day. We need more people to come into the system.”

This clinic is just a small cog connected to a large lumbering wheel that tries to treat 40 million people in South Africa. Government says that over 80% of South Africa’s population can’t afford medical aid and 30% of the country’s doctors try to treat them. The majority of the country’s doctors work for paying customers who can afford medical aid.

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This is why the South African government is fighting for three letters. They call it the National Health Insurance (NHI) and it should mean more hospitals and more care leading to free health. In other words, it’s another medical aid scheme; but the government promises it will cover you regardless of your social status or wealth.

“Our country believes that access to healthcare is a human right. This means every single one of us is entitled to receive healthcare. It should not depend on how rich we are or where we happen to live. The right to obtain healthcare is written into our Constitution,” says Aaron Motsoaledi, the Minister of Health who sees this as his legacy.

In order for NHI to be a success, it will cost R256 billion ($19.5 billion) by 2025, according to government estimates. They plan to find the money for this through tax.

“The amount spent on the healthcare for each person with a medical aid scheme is five times the amount that is spent on each person who relies entirely on public health facilities,” says Motsoaledi.

“Even for South Africans who earn a good income, healthcare has become a burden because private medical costs have skyrocketed in recent years. Working people are spending a large chunk of their salaries on medical aid and this often causes financial constraints in their household income,” he says.

Motsoaledi has been the driving force behind the NHI. He is considered to be one who practices what he preaches. In 2013 and in 2015  he chose to be admitted in public hospitals rather than going to private facilities. Motsoaledi is also a qualified doctor who worked in rural KwaZulu-Natal. He has seen the state of public hospitals firsthand. Motsoaledi is a champion of the fight against TB and HIV/Aids treatment that has saved the lives of millions of South Africans. But, finding the money for NHI and keeping medical aids in line could be one of his greatest battles.

There is controversy long before NHI happens. Government plans to withdraw tax incentives from medical aid schemes, worth R20 billion ($1.5 billion), which will go into the NHI fund. People will be free to pay for private health insurance, but they will also be forced to make contributions to the NHI fund.

“Private care at present is often needlessly expensive,” says Motsoaledi.

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According to Precious Matsoso, Director General at the Department of Health (DOH), the NHI will not kill off the private healthcare system, but says it needs to learn to adapt. One concern government has with medical aid is when medical cover is exhausted and funds run dry; it means people remain without cover for the rest of the year.

“Under the interim period, medical schemes will continue to function, however they will be reformed to be aligned to the NHI. This means that they will start to offer services consistent with the NHI. There will be fewer options and schemes. Prices will be reduced, making medical schemes more affordable. In doing so, there will be a cross-subsidization,” says Matsoso.

There will be some room for negotiation. Overall the NHI plans merely to pay for health for the masses and doesn’t intend to manage doctors and hospitals. Here, it is prepared to enter into contracts with private business.

Another question is whether government is even capable of managing what will become one of the largest state-owned enterprises in the country. South Africa’s track record is dubious, with the likes of Eskom and South African Airways under scrutiny for losing millions.

Government shares the concern that the quality of care in public hospitals is deteriorating in the areas of staff attitudes, waiting times, cleanliness, drug shortages, infection control and safety and security.

The South African Medical Journal (SAMJ) released a report in June stating that the most significant reason doctors gave for leaving the public sector was dissatisfaction with working conditions.

There is a substantial difference in the standard of working conditions between the public and private sectors. The survey, from 2,225 doctors, showed 60.73% of public sector doctors said availability of supplies was inadequate versus only 10.15% of private doctors. What’s more, 66.37% of public sector doctors indicated concern over lack of equipment and infrastructure, with 38.78% indicating hygiene and management was not of a good standard.

Both public and private sector participants reported that nursing and other support staff was inadequate. However, almost half of the doctors working in public service were dissatisfied with support staff versus 21.5% of private sector doctors.

The report, conducted by the Colleges of Medicine of South Africa (CMSA), and including members from the South African Medical Association (SAMA), found further reasons for doctors leaving were emigration, better opportunities in private practice, as well as being unable to apply for posts as they were frozen.

In KwaZulu-Natal, which has a population of 10.2 million, a serious blow came when a group of oncologists left over poor working conditions. With only two state cancer specialists remaining, both practicing from Grey’s Hospital in Pietermaritzburg, the province faces an unprecedented backlog with patients waiting for treatment from as far back as 2011.

This threat to the KwaZulu-Natal health department is just the tip of the iceberg. Other provinces, such as the North West and the Free State, are under strain, says Badroodien.

This is before the NHI has even been implemented.

“It’s not just the funding or the lack of doctors, it’s the other things tied to it: the lack of skills, the lack of resources, and all the external issues, like the NHI. The national health department now finds itself at a tenuous junction. The NHI is something we do need, but you need to look at the numbers. The DOH is trying to squeeze money from cracks,” says Badroodien.

All this while the queues of patients grow longer.

Examples of what the NHI package will exclude:

  • Cosmetic surgery that is not necessary or medically indicated but done as a matter of choice
  • Expensive dental procedures performed for aesthetic purposes and eye-care devices, such as fashionable spectacle frames
  • Medicines not included in the national essential drug list
  • Diagnostic procedures outside the approved guidelines and protocols as advised by experts groups