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What Next For The NHI?




(Photo by PHILIPPE LOPEZ/AFP via Getty Images)

There has been enough debate and deliberation around South Africa’s proposed National Health Insurance Bill for unified health coverage. Covid-19 has turned the spotlight on it again, and there’s more news expected in February 2021.

I FEEL GOOD,” WERE THE LAST WORDS 33-YEAR-OLD Charlie Mpogeng remembers his brother, Herman Motlhabane, saying to him before his untimely passing on the morning of July 17.

Motlhabane died, his relatives not knowing it was because of Covid-19 as his test results were only made available two weeks after his passing.

He had complained of a flu before being hospitalized.

“It was during that time of mass hysteria when everyone was like ‘if you have the flu, have it checked out’,” Mpogeng remembers as he walks to his brother’s grave at Westpark Cemetery in Emmarentia, west of Johannesburg. Even as he speaks, a tractor is digging up more graves around him, for other hapless victims who have succumbed to Covid-19.

By the end of July, 1,932 people had died of the pandemic in South Africa’s Gauteng Province, Motlhabane one of them.

With a disruptive virus still on the prowl to claim more unsuspecting lives, political establishments everywhere are sitting up and revisiting their healthcare systems – or the lack of it.

In South Africa, the focus has returned to the National Health Insurance (NHI) Bill, proposed to improve and strengthen the health financing system and provide quality, affordable medical care to all.

“The pandemic also showed the need for the public and private healthcare sectors to work together,” Dr Zweli Mkhize, the country’s health minister, said at a press briefing in October. “This is one of the core principles of the NHI.”

To further enable this, the National Health Laboratory Service (NHLS) and The National Institute For Communicable Diseases Of South Africa (NCID) have fallen under one umbrella,
to ensure tests are adequately and accurately captured, but also to ensure labs can exchange skills, information and resources as and when the need arises.

“At the start of the pandemic, there was a critical shortage of test kits. At that time, the labs

would count all the kits that were available in the country and then distribute them equitably amongst each other, regardless of whether the lab was private or public and it’s important

to point out that both public and private labs co-sponsored each other in ensuring equitable distribution,” Popo Maja, the spokesperson for the national Department of Health in South Africa, tells FORBES AFRICA.

Healthcare workers were counted as “one workforce” during these dire times, working freely between public and private sectors and some moving to work at field hospitals. Due to the high demand for hospital beds for Covid-19 patients, the government agreed with private hospital groups about pricing and acceptance of state patients. According to Maja, such negotiations have previously taken years

and were often facilitated by lawyers and courts, at times without resolution.

“Covid-19 reminded us that we depend on each other. We have been able to forge cooperation between private and public,” Mkhize further stated in a one-on-one interview at the fifth annual FORBES AFRICA Philips Future of Health Summit in November. “We need a system that will ensure equitable access to quality healthcare irrespective of class and status or financial standing. Universal health coverage is now a global aspiration.”

The NHI Bill has been deliberated for years and the next development is expected to happen in February 2021. The Parliament’s portfolio committee on health dealing with the bill said that it plans to submit a report on the comments by then. According to ‘BusinessTech’, the pandemic had an impact on the process regarding the NHI and parliament which had to go through a mountain of submissions on the bill.

And though the Department of Health is confident that the pandemic has proven that the NHI is necessary, others believe differently, in consonance with the fact that the bill has sparked much debate from various quarters over the years.

“Our economic situation has deteriorated so drastically, that if it was unaffordable before, it’s even more unaffordable now. I mean the estimates of costs are hundreds of billions of rands,” says Jack Bloom, Democratic Alliance Gauteng Shadow Health MEC, to FORBES AFRICA.

Bloom goes on to explain that right now, the state should be focusing on fixing the administration issues in the health sector, including those around poor hospital infrastructure, frustrated medical personnel, and delayed surgeries and treatments.

However, Dr Nicolas Crisp, public health specialist and NHI advisor to Mkhize, remains optimistic that the NHI can alleviate some of the problems. He believes that by having the NHI, some of the strain on the private sector can be alleviated.

“This is an ethical matter that needs to be debated between clinicians. It’s not a political matter. And it’s not a purely budget matter. It’s an ethical clinical discussion around what can you give to a patient and it’s about what the evidence shows to be the best outcomes for the inputs,” Crisp says.

He believes that countries with a single health system have tended to do better than those with more than one. Decisions and actions can be taken swiftly with one system as instructions don’t need to be directed to multiple networks. Countries like the United Kingdom and Vietnam already boast such systems.

“So it doesn’t matter who’s actually delivering the services, it’s that there’s a coherent mechanism of making decisions and disseminating those decisions. And there’s a coherent mechanism of collecting data to one central point,” Crisp offers.

He has been a medical practitioner in the public sector from the 90s, consulting not only in South Africa but in other parts of Africa including Nigeria, Ghana, Tanzania, Botswana, Namibia, and Lesotho. Crisp became the advisor in July this year to assist with the design and development of the administrative and operational capacity to implement the NHI. For just over a year, Crisp has been working with the Department of Health in South Africa looking at the practical implications and requirements to support the NHI fund.

“It is extremely complicated. Let’s take just the public sector. At the moment, the money to run the public health services comes from the national fiscus; it is distributed to the provincial governments, the government, and then they are the ones who decide what percentage of that equitable share will go to health, then they inform the National Treasury and the National Department of Health that this is the amount of money they set aside for health,” Crisp explains, adding that the private sector is not any better.

There are two ways to pay for healthcare in the private sector. One is where if you are fortunate enough that you can afford it, and you insure yourself through a medical scheme. However, the terms and conditions of this are that you only manage to cover what you can afford, and when it runs out, some are required to use public services.

“The second way that we pay for healthcare in the private sector is that when the need arises, we scramble and raise money,” Crisp explains, “And for people who are middle income and relatively poor, the only way they can raise money is to sell assets or to scrounge from their neighbors, friends, and family, and to basically blow their cash reserves to pay for their healthcare. So it’s very tenuous, and it’s insecure.”

But what do the healthcare workers feel about the NHI in South Africa in these pressing times?

It’s all good and well to consider the patient but what of those who are in the frontline, tending to them?

Solidarity, a trade union, tells FORBES AFRICA that it believes the NHI can and will destabilize the healthcare sector.

The primary research they did in 2019 amongst medical practitioners in both the private and public sectors threw up a negative response towards it.

Morné Malan, the union’s strategic specialist for research and communication, says the report indicated that 83% of medical professionals believe that should NHI be implemented, it will lead to a drastic increase in immigration to other countries; 41% said they would personally consider taking steps to immigrate if

it is implemented and 21% of healthcare professionals indicated that they have already started taking steps towards immigration.

“The feedback that we’re getting from the industry itself is that there’s very little confidence in government, and there’s very little confidence in the system itself. And you know, this is a crucial factor. Because these are the professionals who are going to be at the frontline,” Malan says.

Other than the practical implications around NHI, is the financial and fiscal aspect that it will cost billions. And the concern from the trade unions is who will have to pay for the NHI.

“Only around 12% of South Africa’s population pays taxes. Most countries, which do have universal healthcare systems, or I should say, which do have nationalized or socialized medicine, the figure is closer to around 30% plus,” Malan says.

“It is the current system that is unstable,” Maja says. “The government currently uses the same amount of money to fund 16% of the population that uses private healthcare as it uses to fund 84% of the population that uses public facilities. The public healthcare system is under enormous pressure due to a growing population and rise of non-communicable diseases amongst other issues.”

However, the National Education, Health and Allied Workers’ Union (Nehawu) say they have always supported NHI as it provides universal healthcare to everyone, and healthcare should not be divided into the “haves and have-nots”.

Nehawu spokesperson Khaya Xaba explains that the coronavirus has proven the need for one healthcare system, and not two.

According to Nehawu, the need is urgent, as currently, the private sector only treats 14% of South Africans, who have medical aid; while 86% of South Africans are treated by the public sector.

“I believe that the outbreak of the coronavirus in the country has proven beyond reasonable doubt that we need the urgent implementation of the NHI,” Xaba says.

“Through the NHI, we believe that working together between the two sectors and collapsing them into one will be able to deal with the needs of the country. We will be able to attend to everyone who’s sick, even if they don’t have money.”

Covid-19 may be a stark reminder of the urgent need for a unified healthcare system, but is all of South Africa ready for it yet?

Only time – and perhaps another treacherous jolt from nature – will tell.