It is not inevitable that National Health Insurance (NHI) will be another corruption-riddled and malfunctioning state-owned entity; instead, it could be a success along the lines of the South African Revenue Service (Sars) and the Airports Company South Africa (Acsa), says Dr Nicholas Crisp, the Department of Health’s deputy director-general for NHI.
Crisp said this in response to a question during a discussion on Radio 702 this week.
The host, John Maytham, put it to Crisp that many people do not believe the government has the competence to deliver NHI considering the failures of other state-run entities.
Crisp said this was “a fair concern and a fair comment”.
“I’m a citizen like everybody else in the country who has these same concerns and shares the same issues with South African Airways and Eskom and so forth,” he said.
“But we have to plan for a future. We have to take responsibility for fixing the things that don’t work. And we don’t fix them by 1 April next year or even the year after. We fix them on a continuous and ongoing basis,” he said.
“Can we as South Africans fix what is wrong? Yes, we can fix what is wrong. We’ve done it before. And we are able to maintain good organisations in this country. Every now and then, someone has an attack on them, but look at Sars today, which is also an organ of government, and it’s an entity of the state, and yet today it’s fine. But we went through a patch where there was an attempt at state capture, and it had to go through quite a lot of trauma to get itself back on its feet.
“The airports company [Acsa] runs to my mind pretty efficiently. We’ve never seen it in trouble […] It’s not under any scrutiny […] A huge company that’s running quite a complicated service […] And there are many of them [state-owned companies that are not in trouble]. Unfortunately, there are these few that are really bad apples and bad news and have given us all grey hairs and made us very unhappy.”
Crisp rejected the contention that only the government supports NHI. He said it was supported by many people, particularly the poor and marginalised, non-government organisations, the Congress of South African Trade Unions, several political parties, and “our biggest backer”, the World Health Organization.
‘Many years’ to implement
Asked why he thought a country that manages its public healthcare system poorly will “suddenly” make a success of something more ambitious and complex, Crisp said there was “nothing sudden about NHI”, which will take “many years” to implement.
“We are working into the future,” he said, adding that reforms of this size in other countries have taken from 15 to 30 years to implement.
Crisp’s remarks about the timelines required to implement NHI are interesting considering that the NHI Bill states that the second (and final) phase of NHI “must be” implemented from 2026 to 2028.
Why can’t people be given a choice?
Maytham also alluded to the contentious section 33 of the NHI Bill, which will allow medical schemes to offer only complementary cover for services not reimbursable by the NHI Fund once the Minister of Health has determined that NHI has been fully implemented.
He asked Crisp why people could not be granted the freedom to choose private health care, even if they forfeited the medical tax credits.
Crisp said giving people freedom of choice was less of a problem in countries where the gap between the rich and the poor was not as big as it is in South Africa. The small private healthcare sector will invariably attract more resources, particularly medical specialists, leaving the public sector under-resourced and undermining the principle of social solidarity.
He also rejected the view that NHI will remove privately funded health care, saying medical schemes will be able to cover benefits not paid for by the NHI Fund.
The NHI Fund will pay for a common package of benefits that will be delivered in accredited public or private facilities, access to which will be determined by a facility’s proximity to where a person lives or referral by a primary healthcare provider (a general practitioner or a clinic), he said.
Most medical scheme members have only hospital plans, and most of these people are likely to migrate to NHI because it will cover services they are currently paying for out of pocket, Crisp said.
The case for NHI
The reason for NHI is the current healthcare system is complicated, duplicative, and inefficient, and does not achieve the outcomes we should be getting for the money that is spent, Crisp said.
The aim of NHI is to undo the duplications and remove the complexities. Instead of nine provincial health departments and 72 medical schemes, and “any number of providers” that must find their way between those different funders, there will be one common fund with one set of benefits, not 250 different packages, that will pay for people’s health care when they need it, Crisp said.
He said if the changes envisaged by NHI are not implemented, the public health service will collapse. Cuts to the health budget made it difficult to fill posts, putting an increased workload on staff, who left for higher-paying jobs in the private sector where conditions were better.
According to Crisp, the private healthcare sector has become “a free for all” that was “extremely unregulated for complex reasons”, including decisions taken by the Competition Commission that made it difficult to control prices.
‘NHI could result in less corruption’
Maytham’s other guest was Dr Eric Buch, professor of health policy and management at the University of Pretoria.
Buch agreed with Crisp that the health system has structural problems and said the NHI Bill “goes a long way” to deal with them.
The public health system was under-performing, not solely because of corruption and inefficiency. As detailed in the Health Market Inquiry, the private healthcare system’s problems related to high costs and over-servicing driven by the fee-for-service model, he said.
Buch said NHI is an attempt to implement a structural change in the health system that will get the country out of two key “conundrums”:
- Thirty years into democracy, “the defining feature” of the health system is inequality; and
- The system does not provide value for money.
According to Buch, the governance model for NHI was much more in line with global thinking on health systems and what creates efficiency and performance.
However, he said the NHI Bill does not address the issues of concern to the average person, particularly around quality of care and choice of providers.
People want to know whether they will be forced to obtain treatment in an “inadequate” public hospital, whether they will be subject to rationing, and whether they will be left without care if the NHI Fund does not have enough money to pay for their treatment.
The concern that NHI will foster more corruption was legitimate. However, he said it was equally as likely that NHI’s contracting model could result in “a lot less” corruption because public healthcare providers that contract with the NHI Fund will have to deliver services of a decent quality to earn an income.
Although the NHI Bill was a step in the right direction in fixing the structural problems in the healthcare system, Buch said many risks still had to be addressed, including health professionals’ concerns about their future.
He challenged people who opposed NHI to present a better structural alternative that will achieve access to quality health care for all South Africans.
It is not the NHI per se that is the concern, it is being under the control of the ANC and its cadres that is feared. Once rid of this irreparable, corruption infested party, the NHI could be one of the fairest tools in the hands of a government by the people, for the people.