A medical brain drain could be a consequence of the Medical Schemes Amendment Bill and the National Health Insurance Bill gazetted last week, says a Sunday Times report. Experts believe many doctors would reject the planned charging cap and some warned that the changes would drive doctors to emigrate, leaving the health sector worse off.
But there was guarded support, too, for the concept, if not the detail. The Board of Healthcare Funders of Southern Africa expressed its support of the NHI, but said it would "continue to engage the minister around a practical and judicious approach to the NHI".
The legislation was gazetted last week for comment by South African Health Minister Aaron Motsoaledi.
Under the NHI Bill, the health insurance fund would be the biggest purchaser of health services in South Africa and consumers would have to contribute to it. The Bill proposes price controls in the private sector: “The fund may withdraw the accreditation of a service provider if the service provider . . . fails to adhere to the national pricing regimen for services delivered.”
Medical lawyer Neil Kirby of Werksmans said in the report that in view of the scarcity of doctors, it would not be a good strategy to freeze out those who did not stick to NHI rates. “The prudence of excluding healthcare providers, in an already strained system starving from a lack of available expertise, is highly questionable if not irrational,” he said.
Norton Rose Fulbright director Michelle David said doctors would not want to be told what to charge. “It is not likely to be accepted by all stakeholders (doctors and hospitals) that the largest purchaser of services will also be able to set tariffs.” David said doctors were likely to challenge NHI in the courts, as they had challenged price control before.
Johann Serfontein of HealthMan, a consultancy that represents doctors in private practice, said: “I think there is an underlying assumption that specialists will be employed by private hospitals.”
The report says this is currently not the case as the law ensures doctors work for themselves but are based at private hospitals. “A survey done by the South African Private Practitioners Forum showed that 55% of specialists do not want to be employed by hospitals. So, one can safely assume those will be the ones considering emigration,” said Serfontein.
Graham Anderson, principal officer of Profmed medical scheme, also warned that if doctors were not happy with the tariffs they had to charge they would emigrate. He said emigration was the main cause of members leaving Profmed, which caters to people in the professions.
“Private healthcare is an essential service. If they are going to trash the private sector in order to get the public sector up and running, doctors are going to go. If the doctors emigrate then other professionals, who can afford to leave, will go because they want healthcare for their children.”
But, the report says, Brian Ruff, a former medical aid executive and founder of private health group PPO Serve, was positive about the focus of NHI. “Private healthcare is unaffordable. It was developed without adequate planning and regulation of how many hospitals and doctors are needed for the (private) population. Nobody is held accountable for the management of the cost or the quality of outcomes of the patients,” he said. “South Africa has a very hospital-centred system. So much care happens unnecessarily in a hospital bed that could be done outside hospitals, such as at a GP’s office or day clinics.”
The Board of Healthcare Funders of Southern Africa also supported the NHI proposals – the BHF represents 45 medical schemes‚ administrators and managed care organisations in South Africa and an additional 23 medical schemes across Southern Africa.
"As an industry representative body‚ we support the intention and action aimed at ensuring that the greater population of the country receives quality healthcare.
"We are committed to the NHI as a vehicle that will enable the country to achieve universal health coverage‚ not just for the 8.9m lives covered in private healthcare but the 56m lives of our entire (South African) population.
"We will continue to engage the minister around a practical and judicious approach to NHI and to seek guidance on where we can contribute towards enabling its success‚" BHF Southern Africa chair Dr Ali Hamdulay said.
According to the report, Hamdulay said it was "imperative" that the private sector work closely with the Department of Health, "and share their views‚ insights and knowledge to positively shape the healthcare landscape. It’s now time for action and close collaboration."
Sasha Stevenson, an attorney at Section27 writes in the Daily Maverick: “Regrettably, we believe the Bills fail to provide a realistic path to universal health coverage. Whatever word you choose to describe it there is consensus that the health system is possibly at its lowest point in 2018. We need to grapple with why this is the case and then target resources, policy and if necessary legislation to systemic reform.
“The minister’s (Motsoaledi’s) logic, reflected in the NHI Bill, is that the crisis flows primarily from the maldistribution of resources between public and private health systems, which adds immensely to the burden on the public system. This is undoubtedly an issue. He believes that fixing the funding issues will fix the quality and access issues. We believe not.
“We believe that until the public health system is drastically improved and the private health system properly regulated for price and quality, it will not be possible for the system described in the Bill to function. The NHI Bill describes an admirable vision of an equitable health system. But it does not lay out a path to remedy the current crisis.
“Phase 2 of the NHI Bill process (2017- 2022) envisages completing the accreditation of all health facilities. Yet it does not acknowledge the deepening dysfunction of the health system or provide a set of steps that will be taken to remedy the ailing system, let alone transform it into one capable of providing universal health coverage.
“How will this be done when the Office of Health Standards Compliance reported that only five of the 696 hospitals and clinics that it inspected achieved over 80% compliance with the national norms and standards?
“How will Gauteng, at the moment subject to effective post-freezing due to millions of rand in overspending and contingent liabilities that have left it unable to employ essential medical staff, be able to put forward its public health facilities for accreditation?
“The current state of the system follows the now concluded phase 1 of NHI Bill process, which ostensibly included the testing of effective health system strengthening initiatives. That we are seeing continuing health system weakness and have not seen an independent evaluation of phase 1, is cause for great concern.
“In our assessment, much of the current system’s dysfunction is a product of governance and management challenges. While it is easy for some to blame the minister for all governance problems, this is to detract and perhaps to distract, from the real governance issues that bedevil the system.
“In provinces, there remains little separation between political and administrative leadership, with politics overriding the needs of the system and its users, ensuring the deployment of unsuitable cadres and the signing or cancelling of contracts. Factional politics within the ANC, allows this undermining of the health system and the people who rely on it.
“The proposal relies, as part of the solution, on the functioning of a super-structure (the NHI Fund) with immense power and responsibility, including that of healthcare service providers. Splitting the purchaser of services (the fund) from the provider of services (health facilities) may encourage some efficiencies and strengthen the fund’s bargaining power.
“But it is difficult to see how this would forcefully address underlying governance issues. In the same way, the Bill contemplates the creation of a wide array of new structures, such as contracting units, but largely remains silent about how they would be immunised from the same rot that infects parts of the health system today.
“Until corruption and mismanagement is seen to be decisively dealt with such reliance will be a hard sell for South Africans who have witnessed the large-scale looting of SoEs and the failure of national funds such as the Road Accident Fund as well as, the failure of provincial departments of health.
“The NHI Bill focuses on the creation of new structures. Other matters, such as the roles of the national and provincial departments of health and of medical schemes, remain unclear. After eight years of deliberation on NHI, this lack of detail is concerning. 5
While we would never argue that all details need to be resolved before talking about a change in funding mechanisms for health, the paucity of detail makes it difficult to imagine how we can effect the fundamental re-organisation of the health system that the Bill envisages.
“Of course, there are parts of the NHI Bill that we unreservedly endorse: it provides that beneficiaries may access covered health service benefits by accredited providers at no cost, which will help ensure that financial barriers do not impede access to healthcare. It also reinforces the referral system, which will reduce the cost of care for the system.
Strengthened information management systems, as contemplated by the Bill, will help facilitate transparency and promote accountability. We welcome these aspects – but they have to be considered within the feasibility at this stage of the overall framework created by the Bill.
“The Medical Schemes Amendment Bill is more concrete and we will support many of the proposed amendments. It proposes to prohibit co-payments, which are a major barrier to access to healthcare in the private sector.
“The Bill also gives enhanced powers to the Council for Medical Schemes to enable it to more effectively regulate schemes. Notably, the council is empowered to amend rules of schemes that fail to comply with its directives. The Bill also goes some way to enhance the protection of beneficiaries, for example, by eliminating waiting periods for all children and people who have not been members of a scheme for less than 90 days and shortening waiting periods for those who have not been members of a scheme for more than 90 days. The amendments also strengthen consumer protection provisions.
“Section27 will be studying the two Bills carefully and will make submissions to the Department of Health as requested.
“We call on civil society and stakeholders in health to engage in a balanced and objective analysis of the Bills and the development of proposals that could assist the department in moving towards an equitable healthcare system for all in South Africa. Universal health coverage must not remain a mere vision any longer. We need a clear plan, now.”
Both Bills are likely to lead to heated debate with private sector providers over what is a fair rate for their services, says a Business Day report.
The NHI Bill seeks to establish a fund that will contract with accredited public and private sector providers to pay for healthcare services for its beneficiaries, as the government realises its ambition for providing universal healthcare. A crucial aspect of this plan will be the mechanism established to determine what the fund will pay hospitals, doctors and other healthcare professionals.
"It is likely to be a difficult process to determine a fair price for both sides," said Insight Actuaries & Consultants joint CEO Barry Childs in the report.
Some doctors’ interest groups have already declared they are ready for a court battle, notably about uniform tariffs and stipulations that doctors would have to register as primary care providers in areas where needed, according to Rapport. One of the concerns for doctors is that it is intended that primary care providers will be paid on the size of the population they serve and range of services they offer.
The report notes that practising doctors feature sparingly in the proposed structures to set tariffs and decide which benefits should be covered. In terms of the Bill, a Benefit Committee to decide benefits ‘within the means of the Republic of South Africa’ would consist of the nine heads of the country’s medicine schools, nine representatives from the provincial Health Departments, a representative from the World Health Organisation, one from the Council on Medical Schemes and two from hospital associations.
On the Pricing Committee, the Minister will appoint the director general of health, a deputy director general from Treasury and 11 representatives from labour, the actuarial field, health economy and people with expertise in service delivery. No doctors’ organisation is guaranteed a seat.
The SA Private Practitioners’ Forum reportedly warned that many doctors will simply not be prepared to take part in the NHI and they will challenge any attempt at uniform pricing in court.
Henru Krüger, of HealthMan, says the government has already tried to regulate doctors’ fees through the National Health Reference Price List and this was successfully challenged in court. The Alliance of South African Independent Practitioners Associations also reportedly indicated it was ready to take the matter to court.
The Bills are intended to move South Africa towards universal access to quality healthcare. Business Day reports that proposed changes to the Medical Schemes Amendment Act include the eradication of co-payments for medical aid members when medical aids do not cover their full doctor or hospital bills. Vaccinations‚ primary and preventative care and contraceptives have to be paid for by medical aids‚ which generally do not cover preventative healthcare. The Bill also proposes the abolition of medical aid brokers.
An NHI fund would be mandatory‚ and everyone who could afford to would pay towards it. It would be like a giant state-run medical aid. The fund would pay for all state and private healthcare in the country‚ including private specialists and hospitals.
The bills have drawn mostly cautious praise. Here is a selection of reactions.
The report says that Discovery Health CEO Jonathan Broomberg welcomed the NHI Bill as a step in the right direction for universal healthcare and praised the priorities it sets. "Very appropriately‚ the NHI Fund will have an initial focus on priority projects for vulnerable groups where the need is the greatest.
"We welcome the focus on critical health priorities such as oncology and high-risk pregnancies, as well as the investment in critical preventative measures such as the school screening programme."
He said Discovery Health supported the Bill’s general approach and the fact that medical aid schemes would continue to operate alongside the NHI. "The draft Medical Schemes Amendment Bill contains numerous complex amendments to the Medical Schemes Act. We are still studying the details of the draft bill and will provide more detail on our views as soon as possible."
The Public Servants Association (PSA), meanwhile, welcomed "with caution" aspects of the two Bills. GM Ivan Fredericks, said: "The abolishment of medical co-payments is especially welcomed as relief for workers who struggle with monthly medical aid scheme contributions." However‚ the PSA‚ which represents more than 240‚000 public sector employees‚ cautioned that the amendments should ensure that medical aid schemes and service providers do not have flexibility to simply adjust premiums and fees to recover costs.
In its reaction, Government Employees Medical Scheme (GEMS) principal officer Dr Guni Goolab, said the Bills had come at just the right time‚ before a much-awaited provisional report that looked at costs in the health sector that will be released at the end of the month.
“The NHI indicates the long-term future of the country in terms of healthcare but simultaneously with the publication of the Medical Schemes Amendment Bill‚ it confirms that there continues to be a role for medical schemes as we move towards universal healthcare‚” said Goolab.
He also welcomed the focus on the main areas that both schemes and members complained about. “A number of the amendments speak to challenges that both members and the medical schemes have been experiencing up until now.… All of them have been raising concerns about contributions increasing above inflation and also exposure to co-payment. The amendments speak to these concerns.”
The NHI Bill leaves critical questions unanswered, including how it will be financed and what mechanism the government will use to determine a fair rate for paying private service providers. A Business Day editorial notes that many players in the private healthcare industry will be willing partners, but only if the price is right and they get paid on time.
Nor is it clear how NHI will remedy the corruption and lack of accountability that characterises so many provincial health departments. Equally worrying is the vagueness around the future of medical schemes.
The editorial says the minister has for years prevaricated on this politically sensitive issue, one minute saying he will not stand in the way of anyone who wants to pay for medical scheme cover in addition to their mandatory National Health Insurance contributions, the next insisting schemes should be relegated to providing only complementary cover.
While he now says they will continue to play a role, the Medical Schemes Amendment Bill contains a clause that may well sound the industry’s death knell: it says the registrar of medical schemes may restrict the benefits schemes offer to eliminate duplication of cover provided by the National Health Insurance fund.
The editorial says to the minister’s credit, some of the Medical Schemes Amendment Bill’s proposed changes are long overdue and promise a better deal for consumers, including much tighter scheme governance and a better system for dealing with complaints.
The challenges confronting the government as it presses ahead with National Health Insurance are immense. The editorial argues that it is vital that it runs a thorough public consultation process and heeds the input of the many experts who truly do want to see a better healthcare deal for the nation.
If not, it risks breaking what little still works.
Health-e News reports that Motsoaledi was visibly frustrated by questions relating to how the NHI would be funded: “This question is asked of me all the time, where do we get the money? … (I)t is the job of the Treasury and Cabinet and government, not (of) the minister,” he said.
But, the report says, he did say that there would be some form of mandatory pre-payment for health services: “Once the NHI is in the law, all South Africans will need to contribute into it… and people will contribute according to their capacity to do so.”
But he admitted that “we don’t know” what Treasury’s ultimate decision will be. Describing the current situation where provinces procure health services as a “disaster” and inviting corruption, Motsoaled said that the NHI envisaged one central procurement officer, and a separation between the “purchaser and supplier of services”.
Professor Alex van den Heever, who heads social systems administration and management at the University of the Witwatersrand, said that the NHI Bill “gives too much discretionary power to the health minister for operational issues”, and this made the scheme vulnerable to being “captured”. “The NHI can never be implemented as proposed, as it is not appropriate to put billions – about R170bn a year currently – in the hands of one politician,” he said.
Van den Heever said that there were some good proposals in the amendments to the medical schemes, such as the tightening up of definitions. But replacing the prescribed minimum benefits that all schemes were obliged to pay with unspecified “comprehensive benefits” was not helpful. In addition, he said medical schemes’ reserves were designed to protect members and the 25% reserve was only three months’ worth of members’ contributions.
“The Bill does not actually ban brokers, as the minister claims,” added van den Heever. “Currently, a medical scheme administrator allocates you to a broker and you have to pay the fee. The amendment says members have to agree to this arrangement and the fee.”
The Rural Health Advocacy Project’s Russell van Rensburg said in the report that the NHI Bill was “in some ways a missed opportunity”. While an NHI Fund will be established, van Rensburg said that “a useful measure for the current phase could have been the consolidation of public sector health spending under the management of the NHI Fund to drive public sector delivery”. Instead, he said, under the Bill provinces still remain the “custodian” of public sector healthcare.
The public has three months to submit comment on the Bills, and Parliament is likely to hold public hearings to facilitate public participation.
The Bills are progressive pieces of legislation that will revolutionise healthcare provision, especially for the benefit of the poor, the South African National Civic Organisation (Sanco) is quoted in an eNCA report as saying. Opposition to the proposed law was largely influenced by sections of the private healthcare sector and pharmaceutical companies currently deriving "excessive benefits from medical aid schemes that have no interest whatsoever in expanding affordable medical care to the poor", Sanco acting spokesperson Motlalepula Rosho charged.
She added that the laws as tabled would substantially reduce the cost of healthcare in the country which she said was the highest in the world.
Four factors are likely to determine the success or failure of the NHI. These are funding, collaboration between the public and private sectors, the availability of a skilled workforce and management – including avoiding corruption, Nicholas Burger, a healthcare consulting analyst at market research company Frost & Sullivan said in a Fin24 report.
Burger said the NHI is likely to be funded using a “mixed model”, or different sources of revenue. “It could require shuffling funds that are directed towards other programmes in order to satisfy parts of the NHI.”
According to the budget delivered in February, Treasury allocated R4.2bn to the NHI until March 2021. Motsoaledi said he has his eye on the R60bn in reserves that the medical aid industry had piled up.
Burger said that the biggest likely winners from the NHI will be the underprivileged. “Ideally, they would be the biggest winners. It would only be fair as healthcare is a basic human right.
“Obviously there will be quite a bit of uproar from your upper echelons, who select private healthcare. They would argue that they are already paying exorbitant amounts of tax.”
The NHI will require collaboration between the public and private healthcare sectors. According to the report, he said it is unlikely that the NHI will make medical aid schemes redundant. However, they will lose members. “There will always be the option to use the medical aid schemes. They will obviously collaborate with government.”
Burger said: “Medical schemes are holding their cards quite close to their chest.” This is particularly the case when it comes to releasing comprehensive data regarding their clientele and their healthcare records.
Burger said that when seeking medical help, patients would need to be registered with the NHI and could then select their preferred healthcare provider, who would need to be registered on the database. “You can rest assured that there are going to be many teething problems. It is going to be an evolving process.”
The report says the bureaucracy the NHI would involve is one concern. Burger, however, said that there are examples in developing nations where relying on referral pathways and leaning on digital solutions has been successful. “We can draw on examples in Botswana and Rwanda. Obviously comparing the NHI to the UK systems or other systems in Europe and elsewhere is not valid.”
The Free Market Foundation (FMF) has launched a scathing attack on Motsoaledi’s bold plan, warning that with the South African economy having shrunk in the past quarter by 2.2% and given the decline in the tax-paying base, the implications would have “disastrous consequences”. FMF director Temba Nolutshungu said in a report in The Citizen: “We can assume that the money to pay for the NHI will come from the taxpayers and other taxpaying entities,” said Nolutshungu. “The implications are that the small tax base will bear the brunt of subsidising the NHI.
“I cannot understand how the minister of health, with such a disastrous and tragic history in the public healthcare sector, can come up and conceptualise such a disastrous healthcare policy and be obstinate in getting it implemented.
“This is the same minister of health on whose watch we have seen the Esidimeni tragedy.
“We have also recently been touched by a case which should have outraged all South Africans, of a man who had gone to collect the remains of a relative who had died under tragic circumstances in a mental asylum.
“He is reported to have been given a bag that had a few traces of the corpse that was intermingled with rat droppings.
“It is beyond belief that this same minister on whose watch this and other tragedies are happening in the public healthcare sector is still holding his position and has the audacity to go ahead with a potentially disastrous NHI.”
The ideal proposal that should be considered, said Nolutshungu, was that private healthcare providers in the private sector “should be left alone and government should purchase healthcare for people who cannot afford it”.
The report says referring to the Obamacare, a health insurance system introduced in the US by former US president Barack Obama, Nolutshungu said the scheme “had its own challenges that have now come to the fore”. “Developed and prosperous economies like the US can absorb consequences of disastrous policies for a while. But they do come home to roost,” said Nolutshungu.
South Africa was an emerging economy “that has to grow very substantially to address many challenges such as the unacceptable employment levels, upwards of 45%”. He said it was “crucial for policy makers to accept this and other negative economic indicators as points of departure for policies they intend implementing”.
Asked how government could succeed in redressing decades of imbalances of the past created by apartheid, Nolutshungu said it was important for government to “grow the economic pie and enact policies that are going to be conducive to the proliferation of businesses, especially the small business sector responsible for the greater share of job creation”.
He explained: “This means a policy environment that is going to make it easy for people to go into business. Government does not create wealth but consumes where it employs. Even with the public works programme, it is done at the cost of taxpayers.”
The report says Nolutshungu reminded government of the failures in socialist countries where healthcare was nationalised. “Evidence is there for all to see. It has proven to be disastrous,” he said.
The cost factor is highlighted by the Institute for Race Relations (SAIRR), which said that the introduction of NHI was likely to cost South Africa more than R600bn at its start in 2026, with costs continuing to escalate thereafter. The Citizen reports that SAIRR head of policy research Anthea Jeffrey cautioned government on the “dire implications” of introducing a medical health scheme South Africa could not afford.
“No proper costing has ever been done on the NHI. The projected R256bn in the 2025 figure provided in the 2017 white paper is a 2010 figure, which is badly outdated and entirely unrealistic.
“South Africa cannot afford it, especially now that growth is so low and public debt so high. In addition, the tax increases which were earlier mooted to fund it – a 1% point in the VAT rate, or a 4 percentage point increase in the top marginal rate of personal income tax – have already both been introduced, simply to plug the holes in the government’s revenues.
“The country has a very small and already overburdened tax base.
“In December 2017, the Davis tax committee, which had been charged with investigating the funding of the NHI, warned that it would not be sustainable without much faster growth. Such growth is most unlikely to be achieved,” warned Jeffrey.
Jeffrey is quoted in the report as saying that the country’s crisis-ridden public health institutions would make the NHI difficult to introduce. “At present, 85% of public hospitals and clinics could not be accredited to take part in the NHI because they are unable to comply adequately with basic healthcare norms and standards, such as maintaining proper hygiene and having medicines available.
“These problems cannot be overcome without much better management, including financial management. In addition, there needs to be much stronger accountability for wrongdoing, as illustrated once again by the former Gauteng health MEC Brian Hlongwa’s story of being implicated in a R1.2bn graft.”
She said the NHI would lead to existing medical schemes being “squeezed out of existence, leaving the middle-class dependent solely on the NHI.” Added Jeffrey: “Many may find this unacceptable and those with the option to emigrate will have increased reason to do so. Such emigration would reduce an already very narrow tax base, in which about 600 000 people pay 64% of all personal income tax. Cut that number of taxpayers in quarter or in half, and the tax available to fund all other needs will be much reduced.”
Jeffrey said “porous South African border posts”, which made it easy for economic migrants to enter the country without difficulty, would also have adverse implications for the NHI.
“As long as our borders remain so porous, it will be difficult to control the number of people who come into the country and then rely on our health services. This means that the NHI may – in practice – have to cater for more than 56m people, which will be a further challenge,” she said.
The NHI would make all South Africans dependent on a single state-run medical scheme: the NHI fund. “This will set the fees to be charged by all health practitioners across the country. It will set the prices for all medicines and medical devices. It will decide on the healthcare protocols to be used and the new technologies to be allowed, most of which are likely to be excluded due to being too expensive. It will be responsible for paying every doctor, specialist, nurse, and other healthcare practitioner, and delays in payment are likely to be legion.”
“The NHI fund will have to ensure that all medical equipment and facilities at hospitals/clinics are properly maintained. If payments are made late, suppliers will cut off their services, as already often happens in the public sector, and the public will suffer,” said Jeffrey.
She said the NHI fund would “require a huge bureaucracy, the costs of which will also be enormous.” “It will be far less efficient than current private medical schemes. Many of the contracts for supplies it enters into may also be tainted with corruption, as the Brian Hlongwa story shows.
“Since it will have a monopoly over healthcare, people will have no choice but to rely on it, irrespective of how poorly it functions. Long waiting times for all medical treatment are sure to arise, with people having to wait months or sometimes years for their healthcare needs to be met.”
The report says the IRR recommended that “a significant portion of the poorly-spent healthcare budget should be allocated directly to low-income households in the form of tax-funded healthcare vouchers”.
Polity reports that the civil rights organisation AfriForum has also referred to the Brian Hlongwa/Gauteng Health saga saying that these latest revelations show why the proposed NHI was still-born.
A report of 122 pages by the Special Investigating Unit (SIU) contains, among others, startling details of how R1.2bn went missing due to widespread corruption while also describing the gross maladministration at Gauteng Health.
Dr Eugene Brink, strategic advisor for community affairs at AfriForum, says the state can presently not even manage its current funds correctly, but wants to take even more money from the public to finance the NHI. “The South African Medical Association (SAMA) said earlier this month the Gauteng Health Department, which is supposed to be stronger than the departments of more rural provinces, is starting to become just as dysfunctional as the departments in the Eastern Cape and North West.
David Makhura, Premier of Gauteng, also this year openly acknowledged the corruption and fraud in the Gauteng Department of Health. Furthermore, the Life Esidimeni tragedy also exposed the poor management and oversight presiding at the Gauteng Health Department.”
Brink does not believe that money should merely by thrown at something which is clearly dysfunctional. “They need to at least get their house in order before money can in the slightest be collected from the taxpayer again to finance their wishful thinking. Otherwise more money will in addition simply be misallocated while the public health sector still remains dismal.”
The report quotes AfriForum as saying that within the next three months it will submit commentary regarding the NHI Bill and this corruption will most definitely form part thereof.
President Cyril Ramaphosa says the NHI is on its way, whether we like it or not. Business Day reports that he has confirmed fears expressed by experts, activists and unions that the system has collapsed but said the NHI Fund would bring stability to the stressed system. He said the universal healthcare coverage meant the financially fit must help subsidise those who are not, and that was the trend across the world.
"Our job as the governing alliance, as the ANC, is to make sure all South Africans have access to the best healthcare. Right now our hospitals are burdened and our healthcare is in crisis, and we believe the only way to (correct) this is to pool all resources and everyone makes a contribution," he said.
Ramaphosa, referring to opposition to the plans expressed by medical aid companies, among others, said: "There are vested interests; those who want to hold on to the current system that is bringing a huge burden on the health system. They will oppose it, but this is one issue we are going to see implemented whether people like it or not."
Motsoaledi, defending the Bills in IoL, says: “It is not an exaggeration that the NHI is the health equivalent of the land question. It is so fundamental to our democracy and the kind of society that we want to create that we have no luxury of postponing it.
“Those who are opposed to land re-distribution argue that the programme will threaten food security, that it will put thousands of farm workers out of employment, that it will undermine investor confidence, that it will stifle economic growth and basically kill the agricultural sector. They quote all sorts of studies to support their reactionary view.
“But they fail to say one thing. The current colonial land ownership pattern is not sustainable. It is unjust. Land dispossession was in the first instance, the primary reason why our people waged a struggle for liberation. There can never be real political stability and economic prosperity unless we genuinely address the land question.
“Colonial dispossession of land robbed Africans of their capacity to use the land. Now that Africans have limited capacity, they are blamed and the argument is made that giving them land would undermine the economy and food security.
“That argument is what we are experiencing in health care presently. When public health finds itself in trouble, history is conveniently forgotten and the argument is that the poor and their government brought it upon themselves through poor management, incompetence and corruption. Granted, there is corruption, incompetence and mismanagement in some provinces and facilities, but these are not the causes but the symptoms of the problems. These days we are often forbidden to talk about history as if it has no bearing on the present and the future. At the risk of being attacked for daring to quote history, I shall do it any way.
“I shall demonstrate my facts through a story related to me by a doctor who went through this historical turmoil, as he was employed as a doctor when the public health-care system was still at its prime around Johannesburg.
“Two important events occurred in 1967, which ironically contradicted each other. The first event was the first heart transplant in the world which was performed in a white public hospital by Professor Chris Barnard. The patient did not have to pay anything out of pocket, he did not have to know how much a heart transplant cost. All he needed was quality health care that would save his life, and he got it.
“In the same year, the first Medical Schemes Act was promulgated, under an Act of Parliament, and among the objectives was that it would serve whites only. After the 1976 Soweto uprisings, the public health-care system was progressively underfunded and the medical schemes were used to privatise what was good, though white, public health-care system. Later, out of pressure during the struggle, medical aid cover was opened for blacks, though tribally segregated.
“Bonitas Medical Scheme was for Africans and Pro Sano was for coloureds and Indians. In other words, blacks who could afford were allowed to join in.
“The consequences of the continuing underfunding of the public health-care system was that hospitals started failing; there were no funds for capex and equipment and no funding for human resources.
“One of the major and dramatic events unknown to the public is that this led to a very capable cardiothoracic team at the Johannesburg Hospital, which was serving whites exclusively, leaving for the private sector, joining the Milpark Hospital. Because whites who could not afford private health care were now left destitute, overnight, the cardiothoracic team at Baragwanath Hospital which was serving exclusively blacks was migrated to Johannesburg Hospital to fill in for the departed team. This means that blacks were left with nothing. Senior doctors were then allowed to do private work and the consequences were very negative to the public health-care system.
“Very unfortunately, this trend continued unabated as more and more private hospitals came into the fore with whites running away from public health facilities, just as they did from education facilities after democracy.
“Any health system where the better paid, employed people and the affluent have a separate health-care system based on medical aids and other citizens are left in a separate system, is a recipe for disaster.
“It is actually a violation of section 27 of our constitution. And for people to believe we must leave this type of system as it is, even though it is working for only 16% of the population, albeit, black and white, are outright immoral and unethical.
“I am stating these facts because there is a belief that what happens in private health care has no bearing whatsoever on the public health-care system. This argument is devoid of historical truth and facts and is borne out of anger and frustration. Considering how the public health-care system has been stripped bare over the years, a situation worsened by corrupt, incompetent and greedy people among us, this is understandable. But facts will remain facts.
“Our democracy will be meaningless unless we are able to provide quality health care to all, without regard to their economic or social status. That is the essence of the NHI. We want to ensure that the health resources of the country are made available to all the people, whether they are rich or poor. In fact, we want to design a system in which the rich will subsidise the poor, the healthy subsidise the sick, the young subsidise the old. Currently, the rich who are on medical aid have access to both the public health-care system and the private health-care system. But the poor, who do not have medical aid, only have access to the public health-care system.
“We want to end this and ensure that all citizens have equal access to all health facilities be they public or private. We are consistently told that we should first address the challenges in the public health-care system before we impose the NHI on everybody.
We are told that we should leave the private health-care system because it is working well and it is funded by private money. Those who make this argument fail to properly diagnose the problem.
“Firstly, the problem of health in South Africa has little to do with a shortage of funds in the health-care system.
“The real issue is that too much money is spent on too few people. According to World Health Organisation (WHO), a country should have good health outcomes if it spends around 5% of its GDP on health. South Africa already spends 8,7% of its GDP on health. We are in the same category as most European countries who spend about 9% of their GDPs on health, but our health outcomes cannot be compared with those of European countries.
“The real problem is how these resources are shared. Of the 8,7% of the GDP that we spend on health, 4,5% is spent on 16% of the population, the well-to-do who have medical aid. The rest of the 84% of the population have to make do with the remaining 4,2% of the GDP. Health resources are too concentrated in the private health-care system. Just as a matter of illustration, one Johannesburg private hospital has more gynaecologists than all the gynaecologists found in Limpopo, Mpumalanga and North West hospitals combined. Limpopo has 43 hospitals, Mpumalanga has 34 and North West has 22, but all these 99 public hospitals have fewer gynaecologists than one private hospital in Johannesburg.
“Unless you confront the real issue of how resources are distributed, you will never be able to address the crux of problem.
“The other myth that we must explode is that the private health-care system uses private money. This is simply not true. Medical aids are heavily subsidised by the taxpayer. Last year, GEMS, which is a medical aid for civil servants, got a subsidy of R17.8bn and this figure will rise to R20,5bn this year. Other public servants not on GEMS got R1.8bn last year and this year they will get R2.2bn in subsidy. Those in the parastatals got R7.2bn last year and this year their subsidy will be increased to R8.3bn.
In total, the state will subsidise medical aids to the tune of R31bn this year.
“Furthermore, everybody who is on medical aid, whether they work for the state or in the private sector, get tax credits and rebates. The total amount for this was R20bn which will grow to R26bn. In total, R57bn of state funds will be channelled to those who have medical aids.
“The National Development Plan (NDP), the country’s vision for growth, has actually flagged two issues unambiguously. It said in implementing NHI, South Africa has two problems to solve, namely the exorbitant cost of private healthcare and the poor quality of care in the public health system
“Clearly, the NDP regards these two as the terrible twins of the health-care system. Hence, they need to be tackled simultaneously. It is wrong to pick and choose the one that favours your individual needs. As a state serving everybody, we need to tackle the exorbitant cost of private health care, while we also tackle the poor quality in public health-care system.
“Some people have said that the NHI sounds like a good plan but have raised concerns about cost and how it would be funded. On this one, we should make something quite clear. NHI is not just the policy of the ruling party in its implementation of universal health coverage. It is actually an effective plan to deliver on a constitutional mandate. Our constitution enjoins us to provide health care to all. The constitution does not say only those who can afford should be given health service, it calls on the state to provide health care to all.
“Questioning the cost of NHI is deja vu for some of us. When we wanted to increase the number of people on ARVs, we were asked a similar question – where will the money come from? Some even argued that we must first improve the quality of care in public hospitals before we can upscale the number of people on ARVs.
“The answer I always gave them was, can we afford not to give them the ARVs? And today, can we afford not to give quality health care to all citizens? Imagine if we had listened to that argument, how many lives would have been lost, and how much the economy would be affected.
“It would be wrong to try to put a cost to life. There are things that we should do regardless of their cost. But there are people who insist that we should give estimates on how much the NHI will cost the country.
“No country in the world has ever tried to do that, nor was it even tried in this country when the first Medical Scheme’s Act was enacted in 1967. Today this matter is arising because we are now talking about poor people, mostly blacks.
“There are too many variables to give a right answer. For instance, some private hospitals charge as much as R7,500 for circumcision. But we perform that operation for as little as R950. What we will not do, is to pay R7,500 instead of R950. Those who are saying that NHI will be unaffordable believe that we are going to peg it on this R7,500, because they regard the tariffs in the private health care as the gold standard rather than a serious aberration.”
Van den Heever believes that the NHI Bill centralises too much power in the hands of the health minister and does not clarify how the scheme will be governed. “The NHI Bill gives too much discretionary power to the health minister for operational issues, and this makes the scheme vulnerable to being captured,” he is quoted in a Health24 report as saying.
“It is not appropriate to put billions – about R170bn a year currently – in the hands of one politician,” said van den Heever, who spent 10 years as an advisor for the Council on Medical Schemes.
According to the Bill, the Health Minister will be responsible for appointing virtually all those who will implement the NHI, including the head of the NHI Fund, the head of the complaints division and the head of the OHSC, the body that will decide which health facilities will qualify to serve the public.
In other reaction the South African Society of Anaesthesiologists said the Department of Health should engage more with the private health sector to ensure that questions raised by the NHI.
According to a report in The Times, the society said the sector wanted the quality of service provided by these specialists to be maintained and ensure that its members were not pushed away from the service. “The fact is‚ this is what we are trying to maybe impress on the department of health‚ is that working conditions are vitally important for clinicians and being able to deliver quality healthcare‚” said Lance Lasersohn‚ the society’s vice president.
He said the goal of the NHI‚ which wanted to contain the cost of healthcare and make sure it was accessible to all‚ was laudable. “We have to get to the point that the whole public‚ from the lowest income earner‚ the unemployed to the highest income earner‚ has access to good quality. The issue is in the how‚” Lasersohn said.
Lasersohn said the rhetoric from the Health Department was that the cost of private healthcare in South Africa was the highest in the world. He said this was not true because the private sector in 2015 had 8.8m lives insured and paid total benefits of R138bn. “They have spent in the private sector $1‚211 per person. It is far cheaper than any of the wealthy countries‚” Lasersohn said.
Lasersohn said although the country showed it could build stadiums in a short time to host the Soccer World Cup in 2010‚ the difference in healthcare was that building hospitals was not going to provide access to healthcare.
[link url="https://www.timeslive.co.za/sunday-times/news/2018-06-23-doctor-exodus—feared-as-nhi-proposes-bold-cure/"]Sunday Times report[/link]
[link url="https://www.dailymaverick.co.za/article/2018-06-26-sorry-but-the-nhi-bill-is-just-not-the-right-medicine/#.WzHkWPZuJYd"]Daily Maverick report[/link]
[link url="https://www.businesslive.co.za/bd/national/health/2018-06-22-disputed-health-bills-likely-to-alarm-private-healthcare-providers/"]Business Day report[/link]
[link url="https://www.netwerk24.com/Nuus/Gesondheid/siekteplan-artse-ruk-op-20180624"]Rapport report (subscription needed)[/link]
[link url="https://www.businesslive.co.za/bd/national/2018-06-22-what-stakeholders-think-of-sas-proposed-new-healthcare-laws/"]Business Day[/link]
[link url="https://www.businesslive.co.za/bd/opinion/editorials/2018-06-25-editorial-an–unclear-bill-of-health/"]Business Day editorial[/link]
[link url="https://www.health-e.org.za/2018/06/22/massive-changes-proposed-to-private-medical-schemes/"]Health-e News report[/link]
[link url="https://www.enca.com/south-africa/proposed-new-health-laws-will-help-the-poor-sanco"]eNCA report[/link]
[link url="https://www.fin24.com/Economy/nhi-brings-radical-change-and-critical-risks-20180624-2"]Fin24 report[/link]
[link url="https://citizen.co.za/news/south-africa/1961513/nhi-plan-would-have-disastrous-consequences-free-market-foundation/"]The Citizen report[/link]
[link url="https://citizen.co.za/news/south-africa/1961509/south-africa-cannot-afford-the-proposed-nhi-expert/"]The Citizen report[/link]
[link url="http://www.polity.org.za/article/afriforum-corruption-at-gauteng-health-department-shows-why-nhi-cannot-work-2018-06-22"]Polity report[/link]
[link url="https://www.businesslive.co.za/bd/national/health/2018-06-22-cyril-ramaphosa-says-nhi-is-on-its-way–whether-you-like-it-or-not/"]Business Day report[/link]
[link url="https://www.iol.co.za/news/opinion/nhi-is-the-health-equivalent-of-the-land-question-15657848"]IoL report[/link]
[link url="https://www.health24.com/News/Public-Health/nhi-puts-r170-billion-in-the-hands-of-one-politician-20180627"]Health24 report[/link]
[link url="https://www.timeslive.co.za/news/south-africa/2018-06-27-more-engagements-needed-on-planned-nhi-anaesthesiology-society-says/"]The Times report[/link]