Election fever stokes the NHI fire

18 April 2019
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When in the grip of election fever, it becomes even more difficult than usual to decipher facts from the deluge of rhetoric and obfuscation proffered by politicians. 

The dose dished up by Health Minister Dr Aaron Motsoaledi in his piece “Democratise Healthcare” (The Star 27 March) is riddled with mistruths and misdirection. It so overtly serves him to muddy the waters by blaming the private healthcare sector for maladies afflicting his public department. That's because he is the overseer of its massive deterioration throughout the 10 years he has been Health Minister.

He creates an historic and nostalgic narrative about Prof Chris Barnard's ground-breaking heart transplant in 1967 and that patient Washkansky, “...didn't have to worry about who would pay for the operation”. He then laments, "The introduction of the 1967 Medical Schemes Act .... was laying the foundation for the worst form of inequality in healthcare the world has ever seen".

He affirms his position on the need for National Health Insurance (NHI) “...to give meaning to the constitutional obligation that identifies access to healthcare as a human right”.

His peculiar brand of drawing conclusions is akin to blaming the existence of private security companies for government's failure to deliver adequate policing. What makes his conclusions even more bizarre is that almost a million public servants enjoy heavily tax-payer subsidised medical scheme cover to avoid using the dysfunctional public system.

The private health sector has challenges which mostly relate to affordability, but the irony is that many of these are derived from the regulatory framework that government foisted upon it in 1998. If government had heeded various stakeholder concerns over the past two decades, we would have not seen as substantial an increase in private sector costs.

Nonetheless, the Minister is pressing ahead with NHI, intertwined with parallel proposals for the Medical Schemes Act. The essence of these proposals is that NHI will deliver an as yet undefined set of benefits to all citizens at no cost for the patient at point-of-service. Medical Schemes will play a complementary role, only being allowed to cover services that the NHI does not provide. And here's the rub - since private citizens will save money by no longer needing medical scheme cover, government will raise a NHI tax and pool that together with the existing public budget to give everyone equal access to healthcare. Effectively, nationalisation of the private sector.

The reality is that governments worldwide are struggling to meet the healthcare demands of citizens. Their corrective solutions are to impose user-fees to ensure access only when essential, cutting benefits or impose waiting periods. Usually these are done in line with tax subsidies and incentives for private providers, allowing expansion of private sector participation, thereby alleviating government obligations. His NHI proposals are diametrically opposite to these global trends.

In any event, if we are to use our government's public healthcare record as a proxy for the quality of care that will be delivered under NHI, then we should all be very, very worried. An inspection report issued last year by the Office of Health Standards Compliance (OHSC), a public department analogous to that of a clinical Auditor General, paints a horror picture!

It outlines that a meagre 1% of inspected public facilities passed, 62% are either non-compliant or critically non-compliant and another 23% are conditionally compliant with serious concerns. This means 85% of these facilities are unable to deliver quality healthcare, varying from poor to non-existent - unambiguously reflected in medical malpractice claims against the state that have risen alarmingly from R28bn in 2015 to R80bn in 2018.

Although he seldom acknowledges the extent of the very severe problems in the public sector, the Minister's whipping-boy remains the private sector, who are labelled as anti-poor and anti-NHI.

But again, the facts here do not suit the Minister. SA's per capita public health budget is not amongst the low end of developing nations - it's not even sitting in the bottom half on a comparable scale. Yet other countries with equal or lower per capita budgets are able to achieve better health outcomes than we achieve, sometimes substantially so. A read of the OHSC report is highly instructive in understanding why our public sector perennially underachieves so badly.

If Minister Motsoaledi is genuine about meeting constitutional obligations on access to healthcare for all citizens, as he is so poignantly quoted above, then he should be more concerned with fixing the substantial problems in his own department and promoting the private sector through progressive reforms to extend more affordable private cover to a growing citizenship.

The fanciful notion of building a NHI, that has virtually no prospect of succeeding given the massive price tag and struggling economy, appears to be more necessary for electioneering than it does for any meaningful desire to deliver healthcare and actually, for once, meeting the constitutional obligations imposed on government.

Michael Settas is an independent consultant specialising in the health funding industry.
He is a member of the FMF’s Health Policy Unit
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