The ‘reorganisation’ of the national Health Department, an ’embryo’ unit to build capacity, and the ‘backbone’ of a national electronic patient record system that will contain the health details of all citizens by February 2020. These are the first details of the shape of the National Health Insurance scheme, outlined by Health Minister Dr Zweli Mkhize in his budget vote speech, reports Legalbrief Policy Watch.
Conceding that “it will be impossible to convince the public about the virtues of NHI unless the health infrastructure is rebuilt as a matter of urgent priority”, the minister said a “team of experts in finance and health … infrastructure” has been established “to seek creative financing mechanisms” and “alternative” delivery models.
While the yet-to-be-tabled National Health Insurance Bill is being processed in Parliament, “the structure of the national Heallth Department will be reorganised” and a dedicated NHI implementation unit established. Pam Saxby writes in a report on the Legalbrief Policy Watch site that the official version of Health Minister Dr Zweli Mkhize’s budget vote speech describes the unit as an “embryo” NHI fund and staff capacity-building platform.
Unfortunately, she writes, the speech was only published on the department’s website well after close of business on Monday, which may explain why the mainstream media overlooked so much valuable information provided by the Minister on government plans for preparing public health facilities to implement the long-awaited system.
Saxby writes that as has been widely reported, Mkhize provided no information on the primary source of revenue for NHI. However, he did refer to a “social compact” on building a health system fit for its implementation. It was one of the outcomes of last October’s presidential health summit.
Mkhize also confirmed that, as the “backbone” of a national electronic health patient record system, a registration system has been developed on which the details of “all South Africans” are expected to have been captured by the end of the 2019/20 financial year. According to the Minister, nearly 43m users have already been registered. With the aim of improving management and governance, within the “next six months” the organograms of all state-run health facilities are expected to have been reviewed and the system of delegating responsibility “adjusted to ensure appropriate levels of authority for effective decision making”. In addition, EU funding and bilateral agreements with Japan, the UK and France will be used to “build the capacity of managers to implement NHI”.
Saxby writes that in this regard, Mkhize mentioned “twinning arrangements” also involving “academic institutions”.
Saxby writes that according to Mkhize, the team’s “clear directive” is to “accelerate the refurbishment of all old hospitals and clinics and deliver new ones within five-to-seven years”. While a “significant amount’ has been budgeted for this, in the Minister’s view it is ‘grossly inadequate”. Nevertheless, the “entire” infrastructure build programme has been costed – informed by an audit of all public health facilities. “Preliminary indications are that … (it) is feasible,” Saxby quotes the Minister as saying.
Mkhize had said earlier that doctors, nurses, dentists and hospitals will treat everyone when NHI is rolled out, selecting them on the basis of how sick they are, rather than on their ability to pay. The Times reports that on Friday last week Mkhize gave parliament more details on how NHI would work.
In its draft form in 2018, the Bill suggested NHI would be a single government-run medical fund, financing health services for rich and poor, and reporting to the minister of health. But, the report says, it is not clear what changes have been made to the Bill by government since last year.
Mkhize said that under NHI, healthcare would be the same for everyone, private and public, saying health workers “will be available to provide services equally”. “Currently, poor people often get second-rate healthcare, while wealthier people are able to afford good treatment. The power lies in our hands … NHI is a way of providing good healthcare to all our people.”
The report says experts and companies have questioned how NHI would be funded. Estimates of the annual cost have ranged between R259bn and R350bn. Mkhize did not explain where the money would come from, but said NHI would be the answer to current funds shortages in the health system. “In the long-term, the investment in NHI will create a funding mechanism that will permanently resolve underfunding.”
Mkhize said at present there was insufficient funding allocated for the health system. “The current baseline (of funding) is below the expected level of funding, considering the population size, disease burden and the expected quality of services required.” “We are engaging National Treasury to explore various modalities to adequately fund health services.”
The report says he admitted that the R19bn allocated for the next three years for dilapidated and decaying infrastructure was “grossly inadequate”.
Babies would be registered on the NHI computer system when they were born, and also registered at Home Affairs, the minister said. The health department was working with treasury to find funds to ensure vacant doctors and nurses posts were filled, he said.
The report says he also committed to increasing the use of community health workers by government. These people provide nursing support services by visiting patients at home to track why they missed appointments to fetch medicines or find sick people who need referral to a clinic.
He said 30 managers at various levels of the health system would travel overseas to receive NHI training within the next four weeks.
Mkhize’s address at the department budget vote of R51bn focused on fixing the healthcare system and its infrastructure so there will be a base able to implement the NHI fund. Business Day reports that this included addressing staff shortages, and re-organising management. “It will be impossible to convince the public about the virtues of the NHI if it is built over a dilapidated and decaying infrastructure,” Mkhize said.
He said an amount of R19bn has been set aside for the three-year, medium-term expenditure framework period to refurbish, maintain and build four hospitals and 34 clinics at R6bn; 85 hospitals and 120 clinics at R5.2bn; and maintain 485 clinics at a cost of R8.9bn. “While this is a significant amount, it is grossly inadequate. The department has done an audit of all facilities and have costed the entire programme of infrastructure build,” Mkhize said.
He is quoted in the report as saying a team of experts in finance, health and infrastructure from both the National Treasury and Health Department has been established to seek creative financing mechanisms and alternative models of delivering of health infrastructure.
“They have been given a clear directive to accelerate the refurbishment of all old hospitals and clinics and deliver new ones within five to seven years,” Mkhize said.
He said this would form the basis on which the NHI will operate. “Preliminary indications are that this is feasible. Based on the developed plan, I will engage provinces and other stakeholders on this matter.”
The final draft of the Bill has not yet been tabled in parliament or made public‚ but Mkhize revealed some details in his speech to parliament, says a Sowetan report.
1. NHI will share all the money available for healthcare among ALL people‚ suggesting medical aid premiums will be added to single-government run fund. Mkhize: “NHI is a way of providing good healthcare for all by sharing the money available for healthcare among all our people. The health benefits that you received will depend on how sick you are and not on how wealthy you are.”
2. Services will be for everyone‚ suggesting hospitals will not be divided into public and private facilities. Mkhize: “Hospitals‚ clinics‚ doctors‚ specialists‚ dentists‚ nurses and all other health workers will also be available to provide services equally.”
3. The health department wants more money from Treasury if NHI is to work. Mkhize said the funding shortfall for health department must be corrected “without further delay”.
4. The health department has admitted there is a severe shortage of staff with more than 4‚100 vacant doctors posts in hospitals – that must be resolved before NHI. Mkhize said there are 4‚143 medical officers‚ (doctors) 3‚932 nurses posts that are unfilled He said there were plans to fill 2‚689 doctors posts and 2‚371 nurses posts.
He also said there were too many people working as administrators in provincial and national health rather than on the frontline.
5. There is an app for that. The health minister said: “There is an app being developed for patients to report when medicines are out of stock at their clinic or hospitals.
6. Money for medicines must not be for salaries. Mkhize said budgets for medicines must be ring fenced‚ so it doesn’t go to paying salaries. This has happened. A study published in the Health System Review stated that health department staff costs between 2006 and 2015 exceeded inflation by 38%. In the end‚ by February health departments had accumulated R14bn in debt to suppliers because money for drugs and consumables like gloves and syringes had been shifted to pay for salaries.
7. The Health Department wants to fix dilapidated hospitals for NHI to work. A team between national treasury and health has been established to find “creative financing” in order to fix old hospitals and clinic and deliver new ones within 5 to 7 years
Mkhize said the money that had been allocated over the medium term to fix ageing hospitals and clinics was “grossly inadequate”.
Mkhize said in his budget speech that 2,680 of the 4,143 vacant positions in public health would be filled in this financial year. These included nurses, health professionals such as radiographers, physical therapists, pathologists and community health workers. The department will also absorb 2,625 interns.
Business Day reports that another intervention is focused on quality improvement to ensure that facilities meet compliance standards. The department will work on improving management and governance by eliminating “bloated and inappropriate structures” and corruption, and ensuring efficiency.
Mkhize said the department would spend R39.1bn on building new hospitals, and maintaining and refurbishing others. He said a team of experts from the department and Treasury had five to seven years to do this. The report says NHI will be based on primary health care and the department will create a network of community health workers and community care-givers to support the delivery of services. The department will also expand contracting general practitioners at primary health-care centres.
The report says the minister introduced an implementation unit to “form the embryo of the NHI fund and a platform for capacity building for staff”. The department will send about 30 managers to foreign countries to learn about national health systems, “so that they can actually learn on the spot”, according to Mkhize.
Meanwhile, Henru Krüger, COO of the Alliance of the South African Independent Practitioners Associations, said in the report that Mkhize’s statement was positive. “It’s something new, it’s something fresh from the previous sort of ministry that we had and the previous president. So, I think it’s a bit of Ramaphoria coming through with the new president and the new minister.”
He said that the statement gave the first glimpse of a basket of services that would be offered under the NHI. “So I think we are getting primary health care on the right track. it’s really going towards family medicine and that’s what we need, the whole spectrum from the cradle to the grave instead of disease management on HIV or TB,” he said.
According to the report, Krüger said that the most positive was the contracting of GPs because it was something for which doctors had been waiting. He said that all that was missing was information on what services GPs were meant to offer, to start costing and getting themselves ready for the NHI.
“In 2018, Cabinet approved that the Bill be released for public consultation over a three-month period, from June to September 2018, News24 reports Minister in the Presidency Jackson Mthembu announced. “The inputs received from this process have been incorporated into this latest version, which will be subjected to another rigorous parliamentary process,” Mthembu said.
Mthembu said the Bill will give effect to the National Development Plan to provide for universal quality healthcare services to all South Africans, irrespective of their socio-economic backgrounds. “It will address the current health system that serves only 16% of South Africans whilst excluding the overwhelming majority.”
The report says the Bill provides for the establishment of a NHI Fund as a public entity reporting to the Minister of Health, to be governed by the Public Finance Management Act. Mthembu said once the Bill has been passed, the existing draft implementation plan will be amended accordingly to give effect to the transitional arrangement of rolling out the NHI in phases, including the repeal or aligning existing legislation.
According to the report, former health minister Dr Aaron Motsoaledi said last year that the transition was expected to take approximately 15 years in three phases. Phase two began in 2017 and will end in 2022. In theory, the system should finally be ready by 2026, he said at the time.
Meanwhile, the report says the Democratic Alliance (DA) has indicated that the Bill will not go through Parliament “uncontested.” DA MP and spokesperson on health Siviwe Gwarube said that a report on the feasibility of the NHI pilot projects had never been made public. “The road to universal healthcare is not limited to this problematic piece of legislation. More concerningly, is the establishment of yet another state-owned-enterprise which will open up the public purse to looting by the politically-connected few.”
She said the DA had long held the view that universal healthcare was possible, but that the NHI, as proposed by the ANC government, was too expensive and not feasible. “The ANC forcing through the NHI will not go uncontested, the DA will fight this and propose a credible plan that will ensure that every South African has access to proper and quality public healthcare,” Gwarube said in the report.
Gwarube argued in a report in The Times that the costs of proposals in the Bill were nothing more than a thumb-suck. “And the NHI pilot projects across the country have failed in a spectacular fashion,” she said. Gwarube said the Bill would create a “perfect breeding ground for mass corruption and slow delivery of care”.
Mkize said other nations that had systems similar to NHI were not rich when they implemented it. “Most countries that had implemented NHI had done so when their economy was lowest. UK did so, Japan also did so,” he added. “We were there with them. They have explained that you can’t be more wealthy to implement NHI, just go ahead,” he is quoted in the report as saying.
Health Department director-general Precious Matsotso said it would not be clear how much the implementation of NHI would cost until the Treasury had completed a costing exercise.
The report says Mkhize admitted that while there was still gross underfunding of public healthcare, the private sector was experiencing “over-servicing and unnecessary wastage”, and the two systems needed to be corrected. He further posited that South Africa must be prepared to pay whatever it cost to provide the best service for its citizens, as universal healthcare was a social solidarity issue.
Mkhize added that the mentality of privileged South Africans, which leaned towards saving money, should change and the focus should be about saving lives. “Investing in health and giving good quality healthcare to our people is ensuring that we can have a healthier population, we can have development of human capital and we are investing in economic growth,” he said.
Japan had reaped the benefits of universal healthcare, with a life expectancy of 85, up from 35 a century ago. “Right now they have one of the world’s most aged populations … advancing the productivity of their population, increasing the working age to beyond 72,” Mkhize is quoted in the report as saying.
If you thought that Cabinet’s approval of the Bill was the end of discussions, here’s why you’re wrong, writes Laura Lopez Gonzalez for the Bhekisisa Centre for Health Journalism in a report on the Daily Maverick site.
Lopez Gonzalez writes that delivering his first budget speech in parliament as health minister, Mhkize took to reciting a proverb that may become a tone-setting quote for his tenure: NgesiZulu kunesisho esthi umkhonto uphelela etsheni. “Loosely,” Mkhize said, “that means the spear of a coward gets destroyed by the unending effort to sharpen it instead of getting on with the battle.” Mkhize then explained: “We must stop sharpening the spear now and march to battle and implement the NHI. There will never be a perfect plan or perfect timing.” ANC MP and former KwaZulu-Natal Health MEC Sibongiseni Dhlomo then took to the floor. “People say just fix your clinics and hospitals, and then everything will be okay (to roll out the NHI),” he argued. “Our research shows that no country in the world waited for all things to be fixed before implementing an NHI.”
Lopez Gonzalez writes that he’s right. “From India to Brazil to the UK, no one had a perfect healthcare system before moving to universal health care. For instance, just three years before Mexico implemented its version of the NHI, almost 80 women died as a result of pregnancy or childbirth for every 100,000 live births, putting it among the top 100 deadliest countries in which to give birth, WHO data from 2000 shows. But because the country pushed through with universal access to healthcare, by 2015, that number had more than halved although the country’s shift to universal healthcare has not been without its difficulties.”
She says in the report that just days before his budget speech, Mkhize presented Parliament with the national Health Department’s latest annual performance plan in which it indicates that the final NHI Act is likely to come into effect before March 2020. The NHI Fund itself, a centralised pool of funds for purchasing services from the private and public health sectors, will be established a year later, after which it will begin buying a comprehensive package of services in selected districts. By March 2022, this pot of money will also be used to buy services from regional and tertiary hospitals.
Lopez Gonzalez writes that the bundle of things everyone will be entitled to – the basic package of services – will be developed ahead of a similar bundle designed to govern what kind of hospital services will be included. These services could also become the basis of a basic medical aid option proposed by the Competition Commission as part of its four-year investigation into the private healthcare sector. But that, as well as what medical aids will look like under the NHI, remains to be seen until the NHI Bill is tabled in Parliament and made public.
She writes in the report that in the version Motsoaledi, released in 2018, medical aids can co-exist with the NHI, but it is unclear whether they would be able to offer the same services as the NHI, or just top-up services.
Lopez Gonzalez writes that about a dozen pieces of legislation, including the Medical Schemes Act, will have to be amended to allow for the NHI. A controversial draft amendment to laws governing medical aids has already been released. The next phase of this legislative overhaul is expected to take place this year as the department drafts proposed amendments to the National Health Act.
She writes, meanwhile, about the Progressive Healthcare Forum, once a WhatsApp group of 250 nurses, doctors, academics and government officials — many of whom had first met in their 20s and 30s as anti-apartheid activists. More than 20 years later, they are now heads of departments, business people, union representatives, leading professors or serving on provincial Aids councils or in national research bodies and have already successfully lobbied for the Presidential Health Summit that took place in October 2018. A resulting social compact on health is now expected in the coming weeks, Mkhize has announced. Many forum members also sit on advisory committees within the government.
Lopez Gonzalez writes in the report that the Progressive Health Forum admits it doesn’t know how to fix South Africa’s system, but it thinks it might know where to start. It has suggested seven areas to start with, including better prioritising of funding and programmes as well as reviewing how well statutory bodies like the Health Professions Council of South Africa are working.
She writes that almost half of the forum’s priority areas – strengthening leadership, community engagement and governance as well as undoing years-long provincial health hiring freezes – were echoed in Mkhize’s speech, saying that it seems the new health minister could be a better listener than most.
Lopez Gonzalez writes in the report that this positive interactions with the forum could bode positively for the NHI discussion in which so many details – details that will speak to the values and character of the country – still need to be fleshed out.
Legalbrief Policy Watch report
Mkize’s policy statement and budget report
The Times report
Business Day report
Business Day report
The Times report
Report on the Daily Maverick site