'Little to show' for money spent on NHI pilot projects

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Despite the SA government having pumped more than R1bn into 11 National Health Insurance pilot districts overfive years, medical care in these areas has not improved much – and in some cases has worsened, reports the Sunday Times.

Doctors, dentists, nurses, physiotherapists, activists and business people recently filed their responses to the NHI white paper, which details an initiative to improve clinics and create a single state-run medical aid — which would spell the end of medical aids in their current form.

The report says according to various submissions, there was little to show for the money spent on the NHI pilot project, and the state sector remained in appalling shape. Some submissions criticised the lack of information about the NHI scheme, saying little could be learnt from the 11 pilot projects or about how the money had been spent.

The report says in February, the National Treasury allocated a further R4.5bn for the improvement of healthcare at the NHI pilot sites – financial reports show that between R1bn and R2bn has been allocated to the NHI pilot project, although much of this has not been spent. The most recent government report on the NHI, presented last year to parliament, acknowledges the poor state of clinics and confusion over how the extra money dedicated for the NHI has been spent. The Treasury, the Health Department and district officials have clashed over how the money ought to be spent. The Health Department said clinics had claimed they needed R130m for equipment, yet to date R150m had been spent and NHI pilot district clinics still did not meet minimum standards for equipment.

The Helen Suzman Foundation said in its submission that much of the 2014-15 grant had been under-spent – yet a shortage of funds had prevented the recruitment of 150 GPs to work in under-served areas last year. It said that its “normative starting point is that the platform of health services accessible to all South Africans should be as high as it possibly can be, and that no-one should have to choose between foregoing necessary health care and financial ruin. In these respects, we believe we are in agreement with the White Paper.

“But we also maintain, as the White Paper does not, that there are no prizes for guessing solutions which lie outside the budget constraint, and that chasing shadows diverts attention from the improvements which can be made.”

A brief by the Helen Suzman Foundation’s Andrew Barlow looks at the developments in the NHI White Paper and the effect on the private sector with such proposals.

A brief by the Helen Suzman Foundation’s Agathe Fonkam looks at how the resources are allocated in terms of primary health care (PHC) under the NHI White Paper.

The South African Private Practitioners Forum, which represents about 2,600 specialists, said in its submission that according to an audit by the Office of Health Standards Compliance, two-thirds of state clinics and hospitals did not offer the standard of healthcare required and should be decommissioned.
“The first phase of the implementation of the NHI is nearing completion and very little progress has been made regarding the quality of government services,” said Chris Archer, the forum’s CEO. Also, the SAPPF said, “there is still much uncertainty contained in the White Paper. In particular, the extent of private sector involvement in the NHI is still unclear and the Treasury costing models have not been updated in four years. We are conscious of the fact that both the public and private the health care sectors faces significant challenges and are in need of reform, and we intend to participate constructively in the debate as to how these challenges are best addressed. SAPPF supports a pragmatic approach to health care reform and believes that any proposal which seeks a radical overhaul of the health care system should be carefully considered and empirically researched prior to implementation.”

Section27 said: “We are deeply concerned about the dire state of the health system. The Office of Health Standards Compliance’s assessment has indicated that on average health facilities across the country achieved 46% for quality, service and medicine supply at clinics. This suggests that most health facilities are unlikely to be of a standard to support NHI.”

Health Department economist Vishal Brijlal said only 322 of 3 500 clinics met the “ideal clinic” standard measuring quality, service and infection control, but it was working on improving infrastructure and staff to rectify this. He said the department was modernising IT systems and patient records to decrease crowding in clinics and reduce waiting times.

The Free Market Foundation, in its submission said: “the White Paper does not explain how South Africa, which is a relatively poor country, will succeed in providing equitable health care to all through the envisaged NHI system, when even wealthy countries have failed in their attempts to do so. When you add to that increased costs, antiquated infrastructure and an ageing population, it is seriously doubtful whether the government is justified in wanting to introduce a single payer NHI-style system.

“New investment in the health sector is an essential priority given the potential crisis, but government has a poor track record in investing and maintaining public sector infrastructure. It is, therefore, reasonable to assume that new investment will not be forthcoming in the future. It is essential for the private sector to continue to play a significant role in South Africa’s health care. Considering the fact that medical schemes provide the main channel for accessing private health care, it goes without saying that legislation which impacts this sector will directly affect the private provision of health care.

“South Africans will lose their world-class private health care firms if government’s health-care plans continue in the direction of nationalisation. Individuals’ freedom to choose their own health care, which is such a vital and personal service, will be severely curtailed under the proposed system. If government views “health care for all” to be politically essential, it could require the population to privately and individually purchase mandatory cover to insure against catastrophic health-related events but otherwise leave people to provide for their own and their families’ medical-related and other needs.

“Furthermore, instead of the government undertaking the management of taxpayer-provided funds intended for covering the medical costs of the poor itself, it should put the task out to tender. In the same way as people have many options to choose from in household insurance, car insurance and myriad other products and services, publicly-funded patients will then have a multiplicity of medical schemes to choose from. Competition between public hospitals and clinics, and with private facilities, to win business from taxpayer-funded public health insurance beneficiaries, will thrive and ensure that the best service for the best price is given.

“Government’s ‘laying the foundations for NHI’ before the merits of the proposed system have been adequately discussed is putting the cart before the horse and comes at a cost for every person in South Africa, rich or poor.

“Finally, the NHI White Paper is thick on populist rhetoric and thin on critical details to make an informed decision on the health and economic impacts of the proposal. South Africa is facing an important tipping point that affects not only each and every one of us but also our children and grandchildren and generations to come. We can either choose systematic deregulation of the private sector on both the funding and provision sides, or we can choose even tighter controls where all of our health care decisions are governed from the cradle to the grave.

“We need to have the courage to recognise the impending disaster and correct the mistakes before they are made. If South Africans want better health outcomes then we should be focussing on the institutions that we know result in higher levels of economic growth.

“South Africa’s proposed National Health Insurance (NHI) is premised on a principle of compulsion – an anathema to personal and economic freedom. It is only with economic growth and increased incomes that South Africans will gain greater access to medicines and hospital services. Government, therefore, should focus on adopting policies that foster economic growth by increasing the level of economic freedom in the country. The evidence that greater levels of economic freedom and increased wealth lead to better health outcomes is clear and unambiguous.”

The Democratic Nursing Organisation of South Africa (DENOSA) has highlighted some key points in its submission to the White Paper on NHI. This includes the need to employ more health professionals at Community Health Centres (CHCs), reopening of previously closed nursing colleges, and inclusion of Essential Equipment list for facilities as well as the need for the Office of Health Standards Compliance (OHSC) to work with provincial national core standard teams to ensure compliance of health facilities with the set targets are some of the areas that DENOSA highlighted in its submission.

The Rural Health Advocacy Project said in its submission that without due consideration of factors such as geography (distance and topography), demographic characteristics, epidemiological profiles, high levels of socio-economic deprivation and inequities in the resourcing of care, the NHI will simply duplicate historical and structural neglect that continues to define much of rural health.

It says there are opportunities, however, to systematically account for these factors in the design and structure of the NHI.

According to the Institute of Race Relations submission, the proposed NHI system is premised on a number of flawed assumptions. It overlooks many of the gains already made in managing the heavy burden of disease confronting South Africa. In addition, it disregards key reasons for the poor performance of the public health care system. These failings make for a skewed diagnosis of health care problems, leading to a skewed assessment of how these problems can be overcome.

Full Sunday Times report NHI White Paper NHI submissions SAPPF submission Section27 submission Helen Suzman Foundation submission Helen Suzman Foundation brief Helen Suzman Foundation brief Free Market Foundation submission Denosa submission RHPN submission IRR submission

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