Pause the NHI, fix the public health sector first

The frenzied reactions to health minister Zweli Mkhize’s new National Health Insurance (NHI) Bill demonstrates that healthcare is an emotive subject for South Africans, with diverse ideologies and often fiercely opposing principles put forward by various stakeholders.

But it also shows one remarkably consistent facet common to all participants:  the desire that every citizen should have access to quality healthcare that does not impose financial hardship.

Mkhize’s reported experience of delivering  the baby of a distressed 13-year-old girl in KwaZulu-Natal in 1986 emphasises that healthcare cannot be commoditised and rolled out on cue.

The girl was not even sure she was pregnant, had no family support and was in dire need of care, compassion and assurance. At the time Mkhize was a medical doctor, as well as counsellor and humanitarian.

Healthcare is the most emotive service most people will ever use. I use the term “service” because that is precisely what it is. It is a service that will not only heal you, but will also provide comfort and hope during treatment and convalescence.

This is why attaining quality health outcomes requires extensive multifaceted organisational skills with effective human and financial resource allocation. This is delivered most efficiently within a decentralised structure,  as the health department is currently structured. Most of the provincial budget allocation devolves downwards through the district health authorities.

The problems besetting the public sector are not its decentralised structure — it's the patronage that has entrenched endemic corruption, fraud and mismanagement.

The NHI proposal wants to take us away from this decentralised structure to one that is nationally controlled. Besides the obvious governance concerns around the NHI fund, this effectively robs doctors and managers of their autonomy — from being able to deliver care that is appropriate for the prevalent disease burden and type in their district.

The number of medical personnel working for the state has grown by 32% from 234,000 in 2006 to 309,000 in 2016. Per capita, the number of citizens per medical provider has improved by 23% over the same period. This ratio has improved by between 17% and 60% across virtually every major medical discipline and simultaneously allocations to the provincial health budgets have increased by more than 7% annually over the same period.

Human and financial resource have not been lacking in the department! Yet much of the rhetoric about the NHI has revolved around misleading claims that the private sector robs the public sector of human and financial resources.

So, if in real terms human and financial resources in the state sector have grown substantially since 2006, the obvious question is why have matters got worse? The narrative around a lack of resources in the public sector simply does not hold water.

The NHI appears to be crowding out any focus on fixing existing health sector problems. These dysfunctions are eating away at the state’s capacity to deliver care. Patients are suffering right now. They cannot wait until 2026 for the NHI to bring about restitution.

There is no doubt that Mkhize has brought renewed energy and vigour to the health ministry and a candid acknowledgement that the public healthcare sector has major problems.

I repeat the challenge from Mark Heywood of Section 27 to the health minister this week: Can we set aside discussions on the NHI for the time being and please fix the public sector?

Michael Settas

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