Contracting NHI services to private sector may weaken public health

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Contracting out health services to the private sector may be a short-term solution to the problem of human resources and infrastructure in the public sector, but in the long term, may paradoxically weaken the public sector, writes Lydia Cairncross, a health activist and surgeon working in the public health sector, in Spotlight.

When engaging in the discussion around the National Health Insurance (NHI), Dr Lydia Cairncross, a health activist and surgeon working in the public health sector writes in Spotlight that it is important to state, by way of introduction, a few key points:

“First, that South Africa has inherited deep social and economic inequalities and as a result is in the grips of four major and concurrent epidemics: infectious disease; maternal and child morbidity and mortality; trauma and violence, and a growing epidemic of non-communicable diseases such as hypertension, diabetes and cancer.

“Second, access to quality healthcare is only a part of the much-needed response to these epidemics. True health improvements in the country can only be achieved through addressing the social determinants of health such as housing, sanitation, access to clean water and adequate nutrition, and sustainable decent work. With the discussion on funding reforms to the health system, the fundamental issue of addressing these determinants of health is often neglected.

“And third, we have two parallel, divided and non-complementary health systems that are both in deep crisis. The crisis in the public sector is a matter of common public comment. Long clinic queues, unacceptably long waiting times for life-saving treatments, lack of human resources, infrastructure and effective systems are all real and ongoing problems. It is also important to note that the public system is itself unequal with an emphasis on curative care and urban centres at the expense of primary level care and rural health facilities.”

But, Cairncross writes, the crisis in the private sector, though often less visible, is similarly dire.

She writes: “Of the many issues to discuss regarding this important piece of health legislation, I will focus on two areas:

“If the NHI is to be implemented by 2026, it is hard to imagine that all public facilities will have been upgraded and accredited in time to benefit from the new system. This is a serious concern as, in my view, only a publicly funded and publicly owned health system can sustainably and consistently deliver quality, equitable care to the entire population. While large tertiary public hospitals in urban centres may meet the necessary targets, surely a health reform that aims to promote equity and access must ensure that smaller, poorer, often rural facilities are also able to be providers within the new system.

“Secondly, while the argument can be made cogently for contracting individual private providers at the primary level of care, such as general practitioners, where their contracting may in time result in integration into the public system, there are significant problems which may occur with contracting in with private facilities. Contracting out health services to the private sector may be a short-term solution to the problem of human resources and infrastructure in the public sector, but in the long term, may paradoxically weaken the public sector by decapacitating facilities and possibly promoting a flow of human resources from public to private.

“To this end, the NHI, as a strategic purchaser, should be expressly pro-public sector and focus strategically on building capacity in under-resourced areas such as clinics and hospitals in poorer urban communities and in rural facilities.”

Spotlight report

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