Discussions on the National Health Insurance (NHI) Bill may be shifting from the “why” to the “how” but as much as specifics remain worryingly vague, even more elusive is the belief that the government has the ability to match its ambitious rhetoric with effective governance and delivery of NHI.
A “trust deficit” was an underlying sentiment expressed at a day-long conference on health industry insights and innovations at the Gordon Institute of Business Science (GIBS) last week. Health sector representatives who attended also said the “devil is in the detail” of the bill.
Some of these details – and perhaps also the devil – were outlined by Sasha Stevenson in Spotlight last month, pointing out that the current iteration of the bill is marked by over-centralised power that lies in the minister’s hands, rather than Parliament’s. Accountability and management structures at all levels also remain ill-defined and this extends to the Office for Health Products Procurement, a newly included structure in the draft bill. Patients’ avenues to complain and for recourse are also limited.
Addressing the conference, Health Minister Zweli Mkhize acknowledged that universal health coverage as an efficient reality for South Africa has been met with widespread doubt, disdain and even derision. “People are put off by maladministration, incompetence and corruption and what we are hearing from all these state commissions of inquiry,” he said.
“We want to build structures that will reinforce oversight of the NHI Fund with things like SIUs (Special Investigative Units), technology and training. We want to correct the things that are wrong in the system and build up in a phased manner so that in the next five years we will start seeing a difference in how services are run.”
Mkhize said one oversight measure included working with countries that had established universal healthcare models. He said a first batch of 30 managers from the Department of Health would be sent to countries like the United Kingdom, Japan and France to build human capacity. He also said academic institutions and a number of health professional bodies were “all in” with the government in playing their roles in finally getting an NHI in place – something he said that had been on his agenda for 30 years.
He added that the government was taking lessons from Japan, which has the highest population of the longest-living people in the world. Japan started its journey towards universal healthcare in the late 1920s when their economic outlook was woefully bleak.
“There will be no right time to start the NHI, but we must start now as an investment in health and an investment in developing human capital and the prosperity of the country,” Mkhize said.
He acknowledged that the bill before Parliament had controversies and had induced everything from anxiety to wild speculation to fear mongering.
“We have had some people saying this bill is unconstitutional, [but] that is just politics. Others say the NHI will bankrupt South Africa, I beg to differ; we will start with what South Africa can afford and this will evolve. People have also said that the NHI is about nationalisation of private care, but there is no way that we can be taking over a private facility,” he said.
Mkhize said contracts and partnerships with the private sector represented an opportunity to “harmonise the sector”. Medical aids, however, have noted that the bill downgrades their role significantly to one of a “top-up” or “complementary” funder. The minister was not specific about funding for the NHI or its ultimate costs, but mentioned options like taxation, mandatory surcharges and collection through employers.
And while Mkhize said conversations still had to be had about the bill, which is out for public comment, he left the conference after taking only three questions.
He missed the responses that followed, including from GIBS faculty member Marius Oosthuizen, who presented the findings of the business school’s recent research into the implications and opportunities of the NHI for the pharmaceutical industry, healthcare funders and providers.
Oosthuizen mapped out future socio-economic and political scenarios for South Africa and matched these with the minister’s NHI wish list. His analysis suggested that there would be enormous hurdles even in a best case scenario.
“People talk about the nine lost years, but not about the nine years it will take for recovery,” said Oosthuizen.
His most fragile scenario showed a vicious cycle of radicalism, populism, low economic growth, mounting debt, downgrades and the upward creep of unemployment. “In this scenario there will be no NHI,” he said.
However, Oosthuizen pointed to “flickers of light” from institutional reform, such as changes in the National Prosecuting Authority, and opportunities offered by technological advances in the medical and health sector that could be capitalised on what he called “co-creation”. The technologies include the trend towards e-medicine such as remote consultations, entrepreneurs and start-ups working independently on interventions such as 3D-printed devices and parts to reduce healthcare costs. There is also a continued surge of body sensors and wearables that make health increasingly digitised and managed personally.
“It raises the question of what we are doing with these trends, technologies and opportunities,” Oosthuizen said, adding that the government should use these technologies better, build capacity, fix infrastructure in the public system and improve public-private partnerships.
“Government is trying to fix the right problem with the wrong instruments and running ahead of the population on NHI before proper engagement. Trust is needed and trust is the consequence of actions. We need leadership, not more talk shops or another summit with another social compact. We need an agenda around real decisions,” Oosthuizen said.
Speakers also raised concerns over the lack of direction, leadership and details in the NHI. Lerato Mosiah, CEO of the Health Funders Association, said active participation was still lacking and the bill was already at its public comment phase. “There is no debate that we have to have an NHI, but how will we roll it out? We want to engage, but our role isn’t clear… We need understanding way ahead of time so we know how to plan going forward.”
Similar sentiments were expressed by Aneria Bouwer, director and tax expert at Bowmans law firm. Bouwer said that while tax to fund the NHI was expected to only to kick in with the phased-in introduction of the NHI in 2026, taxpayers remained in the dark.
“There is a lot of concern over losing medical aid tax credits, additional tax burdens and doubt about whether services on the NHI will be on par with what taxpayers are getting paying for medical aid right now,” she said.
Along with all the unanswered questions, Dr Lance Lasersohn, vice-president of the South African Society of Anaesthesiologists, said there were also many assumptions being made by the government and some inadequate number crunching that weakened the basis on which the NHI Bill currently stood.
“I would argue that we in South Africa don’t have the same level of high intrapersonal trust that a country like Japan has,” he said, adding that a second assumption was that the private sector would have capacity to provide quality services to the 85% of patients who currently rely on public healthcare.
Lasersohn had previously said the NHI could drive more specialists and doctors out of the public sector and out of the country. He pointed to the already dire shortage of doctors of a ratio of 60 doctors per 100,000 people and 25 specialists per 100,000 people.
“Building infrastructure is the easy part, building specialists and having time to do it is a different story – it can take up to 17 years to train a specialist.
“We need to establish trust with government and we need to ensure that doctors are able to ply their trade, and that they are able to give patient-centric high-quality care. This is what our members we polled have said is the most important to them, not remuneration first. We need to nurture this resource and build up slowly towards NHI,” he argued.