The DA’s alternative health plan for South Africa: Yes or No?

By Di Caelers

There’s no arguing that South Africans, especially the poorest of the poor, have a Constitutional right to access healthcare services. Whether it should be free for everyone at the point of care, as is proposed by the government’s National Health Insurance project, is however up for debate in a country grappling with a health system badly in need of some treatment of its own.

The Democratic Alliance says it has the answer, offering in its Our Health Plan for Universal Health Coverage an alternative to the National Health Insurance (NHI), which it says it can deliver in just five to eight years.

In the case of the NHI, the national health department published its latest policy proposals in the Government Gazette on December 10 2015, and the comments and representations on the White Paper continue to roll in. But estimates are that it could take as long as 15 years to implement.

The DA argues for its plan with a stance with which it’s difficult to disagree; that for too many years South Africans’ circumstances of birth have determined access to life-saving healthcare. Everyone will also likely agree the status quo entrenches inequality and skews access to quality healthcare.

But the truth is that rhetoric won’t take the country any closer to actually achieving desperately needed equity in the healthcare arena.

The DA’s plan is well-researched and rich in detail; the common complaint across the board has been that the opposite is true of the NHI, even at this later stage in its road to implementation.

DA health spokesman Dr Wilmot James says his party’s plan is affordable for South Africa, and can be implemented within the existing health budget. There would be no new taxes; to free up resources, he said, they proposed realising an additional R6billion to boost the health budget by bringing the current medical aid tax credit of R17bn on budget. The remainder (R9.43bn) would go towards helping reduce medical aid costs, by subsidising, and so reducing, members’ monthly contributions.

“This would mean that medical contributions would no longer be tax deductible,” James explained.

Predictions for the NHI, on the other hand, are for costs as high as R256bn by 2025, according the White Paper estimates. News reports in July this year also had several commentators warning these estimates were done with an optimistic assumption of 3.5 percent annual economic growth. In addition, while a number of funding options for NHI have been proposed, these lack detail, and many questions about where the money will come from remain unanswered.

James added: “By bringing the medical aid tax credit on budget, and allocating some of it to build better services in the public health sector, those with medical aid are cross-subsidising those without.” He called it an “act of health justice”.

Sounds fine. But going on to hold up the Western Cape as an example of how it’s all going to work out should probably raise some red flags.

It’s true that healthcare in the Western Cape is amongst the best in the country. It’s true that that province boasts a maternal mortality rate which, at 84 deaths per 100 000 live births, is almost half the comparative rate for the country.

But that certainly doesn’t mean everyone in the Western Cape is enjoying equitable healthcare across the board, or that facilities can necessarily withstand scrutiny.

Just last month Business Day revealed data from the Office of Health Standards Compliance, obtained via a Promotion of Access to Information Act (PAIA) application, which pointed to serious problems at public hospitals and clinics, including in the Western Cape.

That paper said just two of the 149 clinics evaluated in the Western Cape, “generally considered to have a well-run health administration”, scored more than 70 percent in the most recent inspection.

Also last month, unions and health professionals in that province warned that a jobs freeze in the health sector meant a crisis was inevitable.

Junior Doctors Association of South Africa chairman Dr Zahid Badroodien said in the Cape Argus: “We foresee a worrying trend developing in which our health system will be void of senior expertise needed to train and mentor doctors in developing their skills in order to best serve patients.”

The DA plan focuses heavily on training, including an extra R1-billion in conditional grants to the Health Education and Training Platform, but staff retention is obviously of paramount importance to ensure there will always be teachers to teach the newcomers.

Admittedly, however, the Western Cape’s health service emerged head and shoulders above other provinces in almost all indicators in the Health Systems Trust’s South African Health Review 2016. So there is clearly plenty that is also being done right.

So what does the DA’s health plan foresee?

James said it essentially ensured a comprehensive package of quality services within the public health system. It would be free at the point of access to everyone, while retaining and reforming the medical aid system.

For those without medical aid, the promise is improved service at clinics and hospitals, better maternal and childcare provision, and free, efficient access at the point of service to emergency services in urban and rural areas.

But that could well be easier said than done, many might argue. Even the DA concedes in its plan that efficient delivery of services in the public sector is compromised, and has been for the past 20 years, and that the primary healthcare system is “simply inadequate”.

Those with medical aid are promised reduced medical aid costs, and access to more efficient ambulance services, free at the point of service.

On the financial front, the plan would provide :

  • An added R1-billion a year to train medical, nursing and health professional staff.
  • An added R2-billion a year for expanded maternal and child health programmes, for which qualifying clinics and hospitals would compete.
  • An added R1-billion for a single number national public-private emergency service governed by an independent board.

James added that medical scheme reform, in terms of the DA plan, would see schemes compete on the cost and quality of health services they cover, rather than on the risk groups they target.

There would no longer be a situation where schemes were disadvantaged by, for example, an over-supply of older, sicker members. So a scheme with only young members would consequently transfer funds to such a disadvantaged scheme, so ensuring each scheme could price its benefits according to the same demographic profile.

Medical aids are big business in South Africa, and whatever plans the DA has for them, they’re unlikely to fall into line without any fuss – especially if they deem the plan doesn’t benefit them.

Although it’ll almost certainly be more palatable that the NHI system, which will, as it stands, allow them to provide only complementary or top-up cover once the project is fully implemented.

Schemes collect R140-billion a year in contributions, even though fewer than 20 percent of South Africans actually have medical cover.

A final obvious red flag is that the proposed system makes no provision for healthcare for the hundreds of thousands of refugees and asylum seekers whose permanent status in South Africa is pending.

The report offers a universal subsidy only to “every South African citizen and legal resident”, irrespective of whether or not they’re covered by the public or private health system.

It’s a concern that’s been argued by human rights activists and advocates for years, but excluding this group from any future health plan for the country is very short-sighted.

What we do know if that free universal healthcare is possible, even in so-called third world countries.

The Cuban health system is recognised worldwide for its excellence and efficiency. Even in the face of extremely limited resources and economic sanctions by the United States, it has guaranteed access for all, and obtained similar health results to those of the most developed nations.

Closer to home, Botswana’s successful health system is dominated by the public health sector, which operates 98 percent of health facilities.

That country’s delivery system is based on the primary health care model, which the DA health plan and the NHI also favour.

Whether the DA will get the chance to implement its plan nationally obviously depends on the voters. But whether South Africans support the NHI ideal, or the alternative offering from the opposition, what’s clear is that the health system as it stands isn’t working as it should, and that an overhaul is absolutely essential.

 

Di Caelers is an experience health journalist and was commissioned by Spotlight to write this article. If you would like to offer a response, please write to thom@section27.org.za

 

The National Health Insurance pilot programme

NSPReview8
Kotyana Clinic has had solar panels for about three years, but they were never connected. The clinic has no electricity or running water. Photo by Thys Dullaart.

 

A National Health Insurance (NHI) scheme is being piloted in South Africa. Close monitoring will help us decide whether it works and importantly if it will support the implementation of the NSP.

In August 2011 the Department of Health (DoH) published a Green Paper for a proposed National Health Insurance (NHI) scheme in South Africa.The primary goal of which is to “ensure that everyone has access to a defined comprehensive package of healthcare services.” As a result, any developments pertaining to NHI will be of importance to those monitoring the implementation of NSP. NHI should be seen as a key component of broader health reforms currently taking place in South Africa. For example, the new Office for Health Standards Compliance (OHSC) has begun the process of auditing health facilities in South Africa. It’s findings will inform the work of the new Facility Improvement Teams and will aid the development of national norms and standards for ensuring quality of public health facilities. Public comment has also been invited.

While this work is encouraging, the new NHI plans have been criticised for their lack of clarity. This lack of clarity has a bearing on the implementation of the NSP. Precise details about the structure of the system, for example, and how it will function, remain unclear. Two years after the Green Paper was published, an anticipated government White Paper has still not been issued, and operational details remain opaque. How will the NHI administrative structure be organised? What role is envisaged for the private sector (as providers or funders)? What will the NHI actually cost, and who will provide this funding? For the OHSC to succeed, effective community participation is essential. But how the public will be engaged in the development of the NHI scheme remains unclear.

Redesigning the primary healthcare (PHC) system

Achieving universal healthcare coverage will depend on shifting the central focus of health service delivery from the tertiary hospital level to the community level. Particular emphasis must be placed on rural areas and on marginalised and vulnerable groups. A more equal distribution of skilled health workers is also important. At the district level, we need to ensure that there are enough doctors, nurses, specialists, and community health workers to deliver promotional, preventative, curative and rehabilitative services. To support a more comprehensive range of services, including those outlined in the NSP, primary healthcare delivery will need to be integrated, so that different levels within the healthcare system are able to support each other better. Newly-formed District Specialist Teams have started this process by investigating how GPs will be contracted into providing support at PHC facilities, and how school-based PHC services will be re-introduced. Greater levels of civil society engagement will also be required if the new system is to be designed effectively and maintain accountability.

11 NHI pilot districts

In April 2012, piloting of NHI commenced in eleven pilot districts in all nine provinces of South Africa. This initial phase allows the DoH to evaluate the proposed administrative and service delivery reforms necessary to implement an NHI. It also allows for the identification of barriers to efficient healthcare planning and, hopefully, ways to overcome them. Budgeting and management lessons will be evaluated.

But our initial assessment of the pilot phase found little evidence of a coordinated implementation strategy. Most of the district administrators, facility managers and healthcare workers were unclear about what the NHI piloting phase hoped to achieve or what they were expected to do.

At the end of July, the National Department of Health presented its first 12-month progress report of the NHI sites. The findings of the report were based on questionnaires, pilot district reports, and site visits with the District Health Management Teams. While the tone of the report was generally positive, it is evident that there are at least four key weaknesses in the pilot phase.

Budgets spent late

The first of these is the failure of the DoH to provide adequate budget guidance. By the end of the 2012/13 financial year, only 77% of the budget allocated to the pilot districts through conditional grants had been spent. Most problematically, 90% of the available funds were used only in the fourth quarter of the financial year. This, as the report admitted, was because the DoH failed to provide clear guidance about which NHI initiatives the funds could be used for. The surge in spending occurred only after the DoH revised its grant criteria. (Annual district health expenditure reviews were completed. However, the annual report did not include the outcomes of the reviews or indicate if or when they would be made available to the public.)

Budgeting problems are likely to persist. The 2013/14 NHI Pilot District plans have yet to be made available, despite the fact that more than a third of the financial year has already passed. Once again, communities will be unable to monitor the district sites because they do not have the necessary information about what is being implemented in the current financial year and at what cost.

The absence of clear guidance reflects a significant failure on the part of the DoH to comply with the regulations and laws governing public planning and budgeting. This has also negatively impacted both our ability to evaluate the costs of establishing a properly functioning NHI system, and our ability to capture useful managerial insights.

Infrastructural improvements are falling behind

A second significant challenge has been the lack of adequate improvement to the infrastructure in the pilot districts. The report explained that, in some instances, progress was slow because of poor coordination between the National Department of Health and the Department of Public Works. Preparations for the new NHI services and innovations necessarily depend on improvements to the standard of the available facilities and the coordination of functions between the DoH and the Department of Public Works.

As part of its review of the piloting process, the DoH compared the standards of the NHI pilot facilities in 2012/13 with the baseline assessment. In the new assessment, mean scores across most domains had declined, including cleanliness (-6%), the availability of medicines and supplies (-8.7%), staff attitudes (-3.6%) and patient safety (-5.8%). The provision of a comprehensive package of primary healthcare services is the foundation of South Africa’s new NHI scheme. Only a third of NHI pilot site facilities had the necessary staffing levels, infrastructure, pharmacy services, and equipment to support these.

It remains unclear if the size of the budget allocated during the NHI pilot phase is sufficiently large to support the planned service scale-up. The failure of the DoH to discuss this issue in their report was a conspicuous omission.

Uneven progress

A third key problem in the pilot phase of the NHI scheme has been the uneven progress across the districts. The Eden District (Western Cape), Pixley ka Seme District (Northern Cape), Tshwane District (Gauteng) and uMgungundlovu District (KwaZulu-Natal) all significantly outperformed the OR Tambo District (Eastern Cape) and Vhembe District (Limpopo Province). For example, only 2% of primary healthcare facilities in the OR Tambo District and 15% in the Vhembe District were able to provide the full package of primary healthcare services. In contrast, more than 80% of the facilities in the Eden District, 76% of the facilities in the uMgungundlovu District, and 65% of the facilities in the Pixley ka Seme District had sufficient capacity.

This unevenness is mirrored in the larger human resource capacity disparities across the districts. Approximately 90% of all posts for doctors at hospitals in the districts of Eden and uMgungundlovu are filled, compared to 60% in the OR Tambo District, and 29% in the Vhembe District. Similar differences were noted with regard to the nursing posts at hospitals: while 92% of the nursing posts are filled in the Eden District and 97% in the uMgungundlovu District, only 51% and 36% of the nursing posts are filled in the OR Tambo and Gert Sibande Districts respectively.

These disparities extend to the primary care level: 95% of the nursing posts are filled in the districts of Eden and uMgungundlovu, while only 37% and 30% of the nursing posts are filled in the OR Tambo and Vhembe Districts respectively. Even these statistics may not reflect the severity of the organisational problems on the ground: the organisational charts are so out-of-date and so poorly managed, that they do not reflect the current staffing hierarchy at these facilities. They are therefore unlikely to provide any indication of how close the facilities are to meeting the basic requirements of the new NHI scheme.

The fact that the DoH has clearly failed to prioritise or adequately fund outreach services during the pilot phase of the NHI scheme is of particular concern. Based on the DoH’s own assessment, it is clear that little progress has been made to ensure that community health care workers, rehabilitation professionals and nurses have the necessary transport, equipment and support for undertaking home-based care. If primary healthcare is the foundation of the NHI, as the DoH claims, then the resourcing of an effective outreach and referral system should be at the forefront of the piloting process.

Clinic committees and hospital boards

The fourth key weakness evident in the report is the lack of progress in establishing clinic committees and hospital boards. These structures are meant to serve as the principal institutions of community participation in primary healthcare service delivery. While all the districts were reported to have hospital boards and clinic committees, closer scrutiny of the report revealed little detail about how these bodies function and the extent to which they facilitated meaningful community participation.

The available information suggests that there are already unacceptable variations in the quality of the structures which are intended to facilitate public participation. In the Pixley ka Seme District in the Northern Cape for example, four out of thirty-six clinic committees are described as “functioning optimally” in the report. In contrast, in the OR Tambo District, all the hospitals have boards “but functionality is an issue”. The Gert Sibande District has no protocol for the establishment of clinic committees, and has used the provincial protocol for Hospital Boards instead.

Meaningful public participation in the health system is critical. An environment which empowers community members to exert influence and oversight over healthcare can help communities to ensure that health services are tailored to their specific health needs.

The weaknesses and failures noted during the piloting phase can be explained, in part, by the historical neglect of many of the districts. But the purpose of the NHI pilot districts is to determine how reforms under the NHI could be implemented, particularly in deprived and neglected districts in South Africa.

Piloting therefore needs to prioritise reforms and interventions that promote greater equity, efficiency, effectiveness and participation. Thus far, the NHI piloting scheme has largely failed to do so.

Without a coordinated piloting effort which encompasses all levels of the healthcare delivery system we can only ever expect uneven implementation. The involvement of the national, provincial and district level administrations in the pilot scheme requires carefully developed plans. Such plans need to be based on the resource needs of the districts rather than the ability of local interests to negotiate beneficial deals. Future NHI plans must reflect a proper assessment of district requirements with reference to the NSP. Putting such plans in place will help us realise the core objective of the NHI scheme: ensuring that all South Africans are able to lead a long and healthy life.

Daygan Eagar works at the Rural Health Advocacy Project (RHAP) and is the manager of the Rural Proofing Programme; Thokozile Madonko is the coordinator of the Budget Expenditure and Monitoring Forum (BEMF).