South Africa&#8217;s National Health Insurance bill aims to bridge the gap between private and public healthcare sectors. However, concerns about impact on private medical aid coverage and potential for reduced innovation and employment within the healthcare sector have sparked confusion around its implementation.



South Africa stands on the brink of a significant transformation in its healthcare sector with the passing of the National Health Insurance (NHI) bill on June 14, surpassing the first legal obstacle to implementation. The legislation aims to bridge the gap between the private and public healthcare sectors, promising to bring equity to a system that has long been divided.



However, the bill has not been without its detractors, who express concerns about potential government inefficiency, the impact on private medical aid coverage, and the potential for reduced innovation and employment within the healthcare sector.



“Technically, I don’t think it’s feasible,” says Professor Alex Van den Heever, an expert on healthcare governance at the University of the Witwatersrand in Johannesburg, to FORBES AFRICA. “The aim is to ensure that somehow that both the public and private services are of an equivalent standard of care… and that is beyond the capacity of this government at this point in time.”



The South African healthcare system has been grappling with a stark divide for decades. Public healthcare infrastructure has been marred reportedly by poor service delivery and corruption, as evidenced by challenges in Tembisa Hospital procurement, the closing of Charlotte Maxeke Academic Hospital, and continued staffing and supply issues at Chris Hani Baragwanath Academic Hospital, to name a few.



In contrast, private medical aid services have filled this gap, collaborating with private hospitals to provide world-class medical care, albeit at exorbitant rates. The cost of private healthcare has become a significant burden on the South African economy, with the average South African medical aid subscriber paying over $100 per month in a country where the average person earning minimum wage makes around $400 per month.



The NHI, first announced as part of the ANC ruling party’s national conference in 2007 and later introduced to Parliament in 2019, passed earlier this year. The legislation seeks to address the disparities between public and private health, envisioning a state-run medical insurance scheme that leverages both public and private facilities and resources, thereby ensuring that individuals seeking healthcare have access to the same facilities and benefits as those enrolled in private medical schemes.



“The issue we have with the current proposal of the NHI… is Section 33 of the bill, which states that once the NHI is fully implemented, medical schemes would no longer be allowed to provide any cover that is provided by the NHI,” said Discovery Health CEO Ryan Noach in an interview with BizNews last week.



Discovery Health accounts for 40% of South Africans with medical insurance. “It’s not because we have an aversion to government business, but rather because we believe their chosen contracting model doesn’t align with our fully integrated approach to administration and managed care services.”



The bill has raised several concerns among critics and private sector medical providers.



Further critiques include the vague wording of the bill itself, with little clarity as to the &#8220;basic healthcare services&#8221; to be rendered, and how it will be funded as per &#8220;mandatory prepayment&#8221;, neither of which are officially defined.



However, a government factsheet recently surfaced indicating that funding for the NHI might be sourced from a mandatory private income tax as well as payroll tax, without specifying what taxation rates might be levied. The 2015 whitepaper on the NHI provides possible indicative tax rates of payroll and personal income, ranging from 1% to 4% for payroll and a surcharge on taxable income across different scenarios over the next five years.



Van den Heever drives home the challenges of this method of financing for the NHI, stating that the 2015 whitepaper is threadbare and lacks crucial financial analysis. Moreover, payroll taxes and income surcharges are likely to place a further burden on an already strained tax base, the middle class – not high-income tax earners, who primarily earn through dividends and other instruments. “Tax dymanics come in to play,” says Van den Heever. “When you overburden your tax base and you increase tax rates too high, you actually get less revenue.”



Healthcare in South Africa is in need of improvement – the country currently spends around 8.5% of its Gross Domestic Product on healthcare, with the lion&#8217;s share of this funding going to private medical insurance–while such insurance services less than 20% of the population according to recent Council for Medical Schemes Data. This trend runs counter to global movements towards universal care and mirrors circumstances in countries such as the United States, where healthcare has become a prohibitive expense.



The NHI aims to correct this imbalance, aligning with the country&#8217;s commitment to Universal Health Care as part of the 2030 National Development Plan. However, experts such as Van den Heever do not believe that the NHI is the place to begin. “Nothing in the NHI proposals is going to change what’s going on… what the government wants to do is raise taxes and allocate that into the system, while they’ve done nothing about corruption.”



The South African government’s position remains firmly committed to the NHI’s implementation; “Government considers the passing of the NHI Bill by the National Assembly as a key milestone to ensure all the people of South Africa have access to the same clinic or hospital,” said Minister of Health Joe Phaahla in a recent press release.



However, there is as yet little clarity as to how this implementation will occur.



With historical inequality deeply ingrained in healthcare along economic and racial lines, it’s no question that the issue of health services in the country needs redress, as per rights declared in the country’s constitution. However, with a lack of clarity in law, the future of the bill once it becomes practice remains uncertain.

Cholera Outbreak In Hammanskraal

A Step Towards Equitable Healthcare In South Africa But Concerns Around Implementation

Twenty eight million. That’s the number of people in Africa who will die from cardiovascular illness, diabetes, and other non-communicable diseases, according to the World Health Organization. That’s 46% of all deaths in Africa by 2030. Half of these deaths, according to a 2017 article in the BMC Public Health journal, are because hospitals aren’t good enough.
“Large numbers of our people continue to die prematurely and to suffer unnecessarily from poor health. Treatable conditions are not being treated on time and preventable diseases are not being prevented,” says South Africa’s Health Minister Aaron Motsoaledi on his department’s website.
It is because times are tough in South Africa. Gross domestic product growth was -0.7% in the first quarter of 2017, while unemployment increased to 27.7%. Medical aid is expensive. It costs about R4,500 ($340) a month, on average, for a family of four. That is almost half of South Africa’s average salary of R10,680  ($815) per month, according to BankservAfrica. It means a mere eight million people, out of 55 million, can afford cover.
To make matters worse, last year, 16 of the top 20 medical aid schemes had to reach into investment funds to stay afloat. It also meant that, this year, scheme members received price increases, on their cover, far higher than consumer price inflation.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/suffering-waiting-wrong-side-divide/" target="_blank" rel="noopener">READ MORE: Suffering And Waiting On The Wrong Side Of The Divide</a>
It is so bad the South African government wants to start National Health Insurance (NHI), the first step to free healthcare for all, by 2025, bankrolled by the tax payer.
The NHI White Paper says the money that people pay for private health should be directed to funding the NHI. According to Paula Armstrong, an economist at Econex, an economic consulting firm, even though medical schemes received about R18.5 billion ($1.4 billion) from a medical scheme tax credit, in 2014/15, redirecting some of this money won’t be enough and it is the poor who are likely to suffer.
“The removal of medical scheme tax credits will affect poorer medical scheme beneficiaries disproportionately. In total, 21.86% (1.9 million in 2016) of medical scheme beneficiaries will move above the affordability threshold with the removal of tax credits. The disproportionate effect on relatively poorer households will need to be considered when evaluating the rationale for removing medical scheme tax credits to help fund the NHI,” she says.
Some medical aid schemes are suffering anyway. Between 2000 and 2015, according to Alexander Forbes, the number of medical aid schemes reduced from 144 to 83. If government presses ahead with free health, they are going to lose out even more.
“I see small schemes consolidating and move into larger risk pools… Bigger pools provide bigger sustainability and that’s where I think we will see smaller schemes suffering, going forward,” says Gerhard Van Emmenis, Principal Officer of South Africa’s second largest open medical scheme, Bonitas Medical Fund.
The big question is how many of these medical aid schemes will survive.
“We do believe, at Bonitas, that we should have both, private medical schemes and NHI. You can’t just destroy or dismantle national assets like medical schemes that have proven over the years that they can contribute to the healthcare industry,” says Van Emmenis.
According to the White Paper, NHI will tackle the most needy first. That is healthcare at schools, childhood cancer, women&#8217;s health, the elderly and the disabled. Most of the people will have to wait.
“For NHI to be a success, collaboration between medical schemes and government is essential. There needs to be agreement on the roles of both players as well as which benefits will be covered by the NHI and which can be offered by the medical schemes.”
<div id="attachment_33740" style="width: 506px" class="wp-caption aligncenter"><img loading="lazy" decoding="async" aria-describedby="caption-attachment-33740" class=" wp-image-33740" src="https://www.forbesafrica.com/wp-content/uploads/2017/10/Gerhard-Van-Emmenis-Bonitas-e1506931303492-300x199.jpg" alt="" width="496" height="329" />Gerhard Van Emmenis, the Principal Officer of Bonitas. (Photo by Motlabana Monnakgotla)</div>
According to Van Emmenis, specific conditions, such as mental and dental, may not be fully covered by NHI. This is the gap where private schemes could find business. Van Emmenis says medical aid schemes should find a way to work with government, instead of fighting it.
“Primary healthcare might be accessible to everyone, but then there’ll always be a complementary environment with dental benefits and a lot of other things, which is not necessarily life threatening but can improve the quality of your life. You may need packages that will attend to stress, for instance… That’s where we are going to play a part in the future,” he says.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/healthcare-got-available-everybody/" target="_blank" rel="noopener">READ MORE: Healthcare Has Got To Be Available To Everybody </a>
The problem is, there is no clarity on whether people will be allowed to belong to a private medical aid scheme in the future of free health. To make it worse, the cost of the NHI is likely to be heavy, according to Econex. It is expected to increase healthcare costs from R121 billion ($9.2 billion) for the 2015/2016 fiscal year to R256 billion ($19.5 billion) for the 2025/2026 fiscal year. The government argues it is not going to be expensive but Econex says the annual health budget is likely to increase by R200 billion ($15 billion), and not the R108 billion ($8.2 billion) stipulated in the White Paper.
NHI not only faces money problems but also has scarcity at hospitals and a blundering bureaucracy. To add to that, it would use a standard price list that may be cheaper for patients but, in the long term, less rewarding for doctors. Doctors could work longer days for less money and could look outside Africa for work.
“You’d get an orthopaedic surgeon that only works on hands and is a specialist in that… That guy will detect what sort of charges he’ll charge for his services. You can’t just take it away and decide to pay all orthopaedic surgeons the same money. I can promise you which one will be on the first plane leaving the country, it will be the guy who’s a specialist. If a doctor leaves this country today, it takes us at least seven years to replace that doctor,” says Van Emmenis.
The private hospitals that are left will also suffer.
The 2014 National Income Dynamics Study, by the Southern Africa Labour and Development Research Unit at the University of Cape Town, surveyed 28,000 people in 7,300 households and found that 41.5% of them used private healthcare in their last medical visit.
“The reality is that many people use a combination of both sectors. It means the number of people with medical aid does not equate to the number of people using the private health sector. The converse is also true with some medical scheme members using public hospitals or state clinical protocols for the treatment of specific conditions such as tuberculosis,” says Van Emmenis.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/surgery-safaris-facelift-africa-needs/" target="_blank" rel="noopener">READ MORE: Surgery Safaris &#8211; The Facelift Africa Needs</a>
Van Emmenis says Bonitas is in favor of healthcare being cheaper and wider, but wants more consultation.
Matthew Prior, Funder Relations and Health Policy Executive at hospital group, Life Healthcare, concurs.
“Until the NHI benefit structure has been defined it is difficult to say what the impact will be. In addition, the role of private medical schemes is couched in vague terms, as the benefits that will be offered by the NHI have yet to be determined,” he says.
Life Healthcare had about 600,000 admissions, in 2016 alone, excluding outpatient and emergencies, and 95% of those were patients covered by a medical scheme. Prior says Life Healthcare agrees with the fundamental objective of the NHI but much depends on how it is implemented. He says improving the nation’s health, by addressing the challenges within the healthcare sector, is a massive undertaking and a responsibility that government should not shoulder alone.
“Although the White Paper mentions shortage of staffing, there does not appear to be a coherent plan to increase supply of medical professionals to meet NHI demands. A massive re-organization of the entire healthcare system, where there is an acknowledged shortage of management skills, places any fundamental change to the healthcare system at risk,” he says.
Prior says it is also not accurate to assume that by changing the financing structure and directing more money to the public sector will, on its own, improve the delivery of quality healthcare to all South Africans.
“The key issues around healthcare resources, management skills and leadership must be properly addressed. Recruitment of doctors on contract from foreign countries is a necessary measure in the short-term but it does not build long-term, sustainable capacity in the country,” he says.
Making matters more complicated, research by Econex shows that removing medical aid tax credits will make medical aid schemes too expensive for one in five.
“Members leaving private healthcare will place additional burden on an already overburdened public sector. One would also need to carefully monitor whether organized labor will accept the impact of the tax credit removal on net income,” says Prior.
If history is anything to go by, this is not the end for medical aid companies. About 10 years ago, South Africa introduced the Government Employees Medical Scheme. It got many worried, but some private medical aid companies, like Bonitas, grow regardless.
“Bonitas had 85,000 members that belonged to government that had to go to GEMS. We had about 216,000 members and everybody thought Bonitas was going down, but today we have about 350,000 members… So with the possibility of NHI, we have shifted our emphasis and visions to developing products that can and will be complementary,” says Van Emmenis.
Private money is likely to survive the biggest shake-up in Africa’s health system, whatever the weather.

Batten Down The Hatches

If you have got hard currency, you can afford to come to Africa to look good or feel better for less. Fourteen million people, spending between $3,800 and $6,000 per visit, are travelling the world looking for medical treatment with a beach holiday.
It&#8217;s a market estimated to be worth between $45 billion and $72 billion, and South Africa is sitting at the top table, according to Patients Beyond Borders (PBB), a US-based firm that has given medical tourism advice for a decade. The country has the advantage of good hospitals, English speaking doctors and breathtaking landscapes.
They call it medical tourism and it&#8217;s growing among the wealthy and not-so-wealthy. Even those who don&#8217;t have so much money are heading to hospitals in countries like South Africa where their hard currency makes it cheaper and also helps them escape hospital waiting lists in their own land.
Even in these hard times, PBB expects this multi-billion-dollar industry to increase by up to 25% per year over the next 10 years.
One entrepreneur who is banking on this is Cape Town-based Faith Cartwright, who founded Medical Tourism SA three-and-a-half years ago. Cartwright, a hospitality and guesthouse owner, noticed many of her guests were in South Africa for medical procedures.
&#8220;Who wouldn&#8217;t pay if they knew that they had to go through two years of pain waiting for a knee operation? Imagine you have decided you want children and you are told you can&#8217;t go through fertility treatment because you are 39 and cannot get an appointment,&#8221; says Cartwright.
&#8220;I thought ‘what if medical tourists like these could be given access to private medical care, have their accommodation and travel needs taken care of, and plan safaris and other tourist excursions, all through the same service provider?’&#8221;
Sitting by the harbor at the V&amp;A Waterfront, a popular tourist destination in Cape Town, it is easy to see why many decide to find a hospital bed here. Above us are the stunning peaks of Table Mountain and just down the road you can book a tour to see a great white shark, helicopter rides or pirate cruises. All this to the sound of seals, seagulls and many languages, as wealthy tourists from around the world stroll by with their bulging shopping bags.
<div id="attachment_33732" style="width: 510px" class="wp-caption aligncenter"><img loading="lazy" decoding="async" aria-describedby="caption-attachment-33732" class=" wp-image-33732" src="https://www.forbesafrica.com/wp-content/uploads/2017/10/FaithCartwright-Medical-Tourism-e1506930410225-300x165.jpg" alt="" width="500" height="275" />Faith Cartwright, the founder of Medical Tourism SA. (Photo by Jay Caboz)</div>
Cartwright has as many customers as there are tourists on this street on this morning.
&#8220;It&#8217;s the reason why I&#8217;m so busy. Just this morning I was facilitating 65 women from Botswana to meet a doctor in Johannesburg at a fertility clinic. Sometimes you do get a good feeling about the work. But it can also be hard work and frustrating. It is rewarding when you know you are helping someone who has been struggling for years to get pregnant,&#8221; says Cartwright.
&#8220;Fertility is a big thing here. We get a lot of it from all over the world, but in Africa, there is a particular stigma that if you can&#8217;t get pregnant, you can be kicked out of your community. I also see a lot of requests for bone marrow transplants and women looking to slim themselves with gastric bypass surgery.&#8221;
It&#8217;s the start of the high tourist season in Cape Town and Cartwright is on call 24/7. For this 48-year-old mother, her time needs to be managed down to the minute.
&#8220;Thanks to the weakness of the rand, hundreds of medical procedures are available at a comparatively low cost, with most surgeries coming in at roughly a third of the price for an equivalent procedure in the UK. Affordable breast augmentation, for example, costs around $8,000 in the UK, but only about $3,600 in South Africa. More minor treatments, such as botox injections, can be even cheaper – $310 in the UK versus $70 in South Africa,&#8221; says Cartwright.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/suffering-waiting-wrong-side-divide/" target="_blank" rel="noopener">READ MORE: Suffering And Waiting On the Wrong Side Of The Divide</a>
It is not just the rich and famous that makes these journeys either. Cartwright has seen hundreds of clients from all walks of life.
&#8220;Our clients range from the ones who can afford to be pampered to those who can barely afford it. We&#8217;ve had people staying in Cape Town eating [maize meal] for 21 days straight, because that is all they could afford over their IVF (in vitro fertilization) treatment; they were so desperate to have a child,&#8221; she says.
&#8220;I had a woman come from Australia who failed 17 rounds of IVF and South Africa was her last option. She now has a daughter and came back to South Africa to try for a second.&#8221;
Using US prices as a reference, across a variety of specialties, PBB estimates South Africa to be 25% to 40% cheaper.
“Most nations in Africa continue to struggle to build out their healthcare infrastructure and are thus not yet suitable for the contemporary international medical traveler. South Africa (particularly Cape Town and Johannesburg), are exceptions, offering an array of medical care for regional and long-haul travelers, including cosmetic surgery, cardiology, dental care, joint and spine work, and ophthalmology,” says Josef Woodman, CEO of PBB.
It is not all rainbows and butterflies. Business isn’t helped by the lack of efficiency when crossing borders.
Cartwright tells of a US couple, a husband (the sperm donor) and wife, looking to come to South Africa for IVF treatment. It meant both needed to apply for South African visas. There was an error in the husband&#8217;s application, and, because of new visa regulations that required applications in person at a South African embassy, it meant he had to fly to the South Africa embassy twice. By the time they entered their application correctly he missed their window. The wife had to come to South Africa alone, and they had to find another sperm donor.
&#8220;As she was walking off the plane I asked her where her husband was. It was only then that she told me their story. Not only was it a huge waste of money for two flights to the South African embassy, but they lost out on their flight tickets and reservations in South Africa, which need to be paid for in advance before applying for your visa,&#8221; says Cartwright.
&#8220;This is where the medical tourism industry can help, resolving issues when you hit a brick wall. I would have been able to help them both get here. The process of IVF is incredibly stressful without worrying about the technicalities of international travel,&#8221; says Cartwright.
Another challenge is putting Africa on the map. Many patients know little about the country they are visiting and often make the mistake of booking doctors in Johannesburg with their accommodation in Cape Town, 1,500 kilometers away.
&#8220;Abroad, people still think we&#8217;ve got lions and elephants in our backyards. It&#8217;s very seldom I hear a good story about South Africa. Most of the things people know are about our crime, our president and that we have no water in Cape Town.&#8221;
&#8220;We need to tell the good story. South Africa is an amazing place. It&#8217;s got first-class treatment. What really stands out is that we are English speaking. It&#8217;s a calling point and a huge thing. Imagine when you go to a country like Thailand and you can&#8217;t read the road signs. Now imagine trying to be a patient there who needs medical treatment.&#8221;
While the costs for those traveling into Africa may seem affordable, it is a different story for those living in it. In South Africa&#8217;s case, the recently tabled White Paper on National Health Insurance (NHI) wants to give medical aid to all South Africans to make healthcare accessible to the poor. Its implementation has been hotly contested.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/healthcare-got-available-everybody/" target="_blank" rel="noopener">READ MORE: &#8216;Healthcare Has Got To Be Available To Everybody&#8217; </a>
Many fear this will be the tipping point that brings the country&#8217;s health system to its knees and results in qualified doctors emigrating. The uncertainty surrounding the impact of the NHI on the private sector, and other compounding issues like an overburdened public healthcare system, could be why medical tourists choose not to come to South Africa.
&#8220;There are a huge amount of doctors in South Africa. The NHI only affects South Africans and not my clientele. In fact, I think it will encourage more doctors to work in the [medical tourism] industry.&#8221;
&#8220;The healthcare industry needs to look at more innovative ways of looking after its patients. I get calls from lots of South Africans trying to get help [with surgeries]; most don&#8217;t even know where to find a good doctor. Most South Africans can&#8217;t afford to go overseas and pay for a surgery. My uncle died of a brain tumor while he was waiting for a date to operate,&#8221; says Cartwright.
Ultimately, the success of medical tourism will depend on exchange rates, prices, quality of medical care and hospitality services on offer to tourists. Even Cartwright is keeping an eye out for opportunities elsewhere.
&#8220;I&#8217;ve been thinking seriously of emigrating to the United Kingdom and setting up base there. My plan would be to fly down to South Africa once a month and check up on the base here. Working from South Africa is too far away. Moving to the UK is quite a good move for the business. It’s central, with access to clients from Europe and America. It&#8217;s an hour&#8217;s flight to many of the medical conventions and conferences, which are great places to network. It&#8217;s also a good idea because there has been a rise in wellness travel, doing yoga retreats and all that. It’s taking off in the UK and Europe and I&#8217;d like to get in on this wave. South Africa would be an awesome destination for wellness tourism.&#8221;
Cartwright remains optimistic. She believes that medical tourism can offer a window of opportunity for doctors who still want to work in the private sector.
&#8220;I&#8217;ve found the Tanzanians to be the most sincere and humble. I&#8217;ve found that Nigerians, if you look after them, they will become part of your family for life. The people come and go. I try not to remember their names because I am so afraid of breaking their confidentially. But when they leave, we become a huge part of their lives.&#8221;
For Cartwright there is no time to stop, relax and watch the waves. She leaves the Waterfront with a phone to her ear, as usual, talking to her next medical tourist with money to spend.
<h3>Golden Oldies</h3>
A 2014 study by VISA  found the United States to be the largest hub for medical tourism. Thailand, Singapore, Germany, Korea, and Spain are quickly catching up.
Their data showed by 2025, travelers over the age of 65 will more than double their international travel to 180 million trips, accounting for one in eight international trips globally. Older travelers can afford bigger trips and are more focused on comfort and health than saving money.
The ageing traveler will transform travel and one area that is already growing in response is the medical tourism industry as more travelers opt to combine medical treatments with vacation.
&#8220;We believe that medical tourism is primed for accelerated growth as more of these older travelers seek new treatments, as well as lower-cost or higher-quality care not available in their home country,&#8221; the report concludes. &#8211; SOURCE: Mapping the Future of Global Travel and Tourism (2014) VISA

Surgery Safaris – The Facelift Africa Needs

Many in South Africa’s private healthcare industry see the government’s plan for National Health Insurance (NHI) as a death knell to their businesses. Hermann Kohloffel, the Managing Director of NHC Medical Services, sees it as a chance to improve healthcare for all South Africans.
“No matter how you slice and dice what we see coming from NHI, how we see it as a threat or a concern, it’s an opportunity. The reason why it has to be seen as an opportunity is because healthcare has got to be available to everybody. No matter how we argue about the costs, you cannot leave somebody without care. You’re not going to leave somebody suffering with cancer and say ‘well, because you don’t have the money, we’re not going to look after you’,” he says.
Kohloffel says the reason the private health centers can turn ailing people away is because they know those patients can turn to the state for help.
“The state is ultimately the saviour of the damned and the have-nots. If this was a country that just had one system, let’s say just the private system, what would happen? You’d be forced to help that person. Nobody could in good conscience kick that person out onto the pavement&#8230; If you look at other countries’ health systems, the state is the only system. The state doesn’t turn around and say ‘because you don’t pay tax, we won’t help you’.”
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/batten-down-the-hatches/" target="_blank" rel="noopener noreferrer">READ MORE: Batten Down The Hatches</a>
South Africa’s Minister of Health, Aaron Motsoaledi, says that private healthcare is sometimes unjustifiably expensive. Kohloffel agrees and says patients often pay for expensive procedures, when a cheaper option is available and will get the same outcome.
“Healthcare continues to escalate at a cost substantially higher than inflation and usually more than the GDP of the country. This automatically causes a problem because then there’s always a deficit in the funding of healthcare. As we progress as medical professionals, the technology cost is becoming a debatable factor. If you look at an X-ray, for example, the fact that today you get a digital X-ray and you get an X-ray in 30 milliseconds, doesn’t change the outcome. The patient either has pneumonia or doesn’t,” he says.
“The cost of that care, against the quality of care that you are ultimately getting, has got to be debated… It is crippling the current private healthcare system and is the main reason why patients are buying down.”
Kohloffel refers South Africa’s current health sector as an imperfect world with an imperfect system.
“You wonder how it is possible that an appendectomy in the private health system will the cost the patient between R40,000 ($3,000) and R60,000 ($4,600). In the public system you can do an appendectomy for about R3,500 ($270). You may not survive the public hospital without scars, mental and physical, but how is that disparity even possible?”
The public and private sector needs to sit together and remember that they’re both working to achieve universal healthcare, says Kohloffel. He says the private and public health sector can learn from each other.
“What we do really well is collect money, we limit our bad debts and liabilities, pay off investments and all the rest of it. What the public sector does really well is take a miniscule budget and, despite tenderpreneurship and other interesting things that come along to try and grapple at that money, they make it last for 365 days.”
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/suffering-waiting-wrong-side-divide/" target="_blank" rel="noopener noreferrer">READ MORE: Suffering And Waiting On The Wrong Side Of The Divide</a>
The private sector needs to try and provide solutions, rather than criticizing the NHI.
“This doesn’t happen for two reasons; first the status quo is always more comfortable, and the second thing is a lot of people see change as a threat. It’s far easier to criticize than to come up with solutions… So the private sector is not stepping forward to embrace what the government is saying needs to be achieved, and the government does not necessarily want to hear about the stumbling blocks that are in the way of achieving a political necessity as well as what’s in the best interest of creating a sustainable solution for coming generations using a collaborative approach. Currently we need accessibility to the Department of Health so we can talk solutions and not keep having doors closed because we are the private sector.”
NHC Medical Services has four health centers in the Gauteng province – in Bryanston, Honeydew, Northcliff and Centurion. It plans to open a center in Thohoyandou, in the northern Limpopo province. It also has a network of over 1,000 doctors across the country.
Kohloffel says <a href="https://nhcltd.com/" target="_blank" rel="noopener noreferrer">NHC Medical Services</a> will need to adapt once NHI is introduced. He sees it treating patients in a preventative manner.
“In winter, we all sit there like vultures hoping for the flu season to come in. The flu comes in via some Boeing from the northern hemisphere, drops the flu here, and suddenly everybody is sick and we rub our hands together because we’re making more money. Now you’ve got to change the mindset to a system where you don’t want that plane to arrive with sick tourists and, if it does, have a strategy to reduce the chances of us catching it through other preventative measures, such as flu vaccines and vitamin boosts.”
“We are going to go from being a fee-for-service providing care organization &#8211; so when you’re sick you see me, when you’re not sick, you don’t see me &#8211; to being a preventative care-based organization. We’ll have to start to look at how to screen our patients for cardiac problems, diabetes, cholesterol and all the rest of it. It’ll no longer be for patients to have an event and then we say now we need to manage your cholesterol. So, now we don’t want people to be in hospital, we want to prevent them going to hospital.”
Private healthcare will focus on areas that NHI won’t cover.
“NHI does not cover cosmetic dentistry, it will not cover breast enlargement, and so on. People will have to buy private insurance for that,” he says.
Kohloffel’s optimism over NHI doesn’t mean he is burying his head in the sand.
“I think we’re in for a big wake-up call… NHI, for us, is going to be a big challenge. Is it going to be a financial threat? Well, people have to get used to the fact that life is going to change. Life is going to change as you know it as a consumer, and as we know it as a provider of care, if this system is implemented in its current shape and form.”

‘Healthcare Has Got To Be Available To Everybody’

At the Khayelitsha Youth Clinic Site C the reality of South Africa&#8217;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&#8217;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.
&#8220;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,&#8221; says Dr. Zahid Badroodien, who works in this clinic every day, 30 kilometers south east of one of South Africa&#8217;s richest cities, Cape Town.
&#8220;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.&#8221;
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&#8217;s population can&#8217;t afford medical aid and 30% of the country&#8217;s doctors try to treat them. The majority of the country’s doctors work for paying customers who can afford medical aid.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/batten-down-the-hatches/" target="_blank" rel="noopener">READ MORE: Batten Down The Hatches</a>
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&#8217;s another medical aid scheme; but the government promises it will cover you regardless of your social status or wealth.
&#8220;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,&#8221; 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.
&#8220;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,&#8221; says Motsoaledi.
&#8220;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,&#8221; 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.
&#8220;Private care at present is often needlessly expensive,&#8221; says Motsoaledi.
<a href="http://www.forbesafrica.com/cover-story/2017/10/02/healthcare-got-available-everybody/" target="_blank" rel="noopener">READ MORE: &#8216;Healthcare Has Got To Be Available To Everybody</a><a href="http://www.forbesafrica.com/cover-story/2017/10/02/healthcare-got-available-everybody/" target="_blank" rel="noopener">&#8216;</a>
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.
&#8220;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,&#8221; says Matsoso.
There will be some room for negotiation. Overall the NHI plans merely to pay for health for the masses and doesn&#8217;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&#8217;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.
&#8220;It&#8217;s not just the funding or the lack of doctors, it&#8217;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,&#8221; says Badroodien.
All this while the queues of patients grow longer.
<h3>Examples of what the NHI package will exclude:</h3>
<ul>
<li>Cosmetic surgery that is not necessary or medically indicated but done as a matter of choice</li>
<li>Expensive dental procedures performed for aesthetic purposes and eye-care devices, such as fashionable spectacle frames</li>
<li>Medicines not included in the national essential drug list</li>
<li>Diagnostic procedures outside the approved guidelines and protocols as advised by experts groups</li>
</ul>

Tag: NHI

FORBES AFRICA SOCIAL MEDIA

A Step Towards Equitable Healthcare In South Africa But Concerns Around Implementation

Batten Down The Hatches

Surgery Safaris – The Facelift Africa Needs

‘Healthcare Has Got To Be Available To Everybody’

Suffering And Waiting On The Wrong Side Of The Divide