Developing the legal framework for the National Health Insurance (NHI) policy is likely to take twice longer than by the 2022 deadline government has planned, the annual Hospital Association of SA conference was told. In addition to amending 11 existing healthcare Acts, the government would probably need to craft two entirely new pieces of NHI-related legislation.
It will require such a complex set of legislative reforms, it will be impossible to achieve by 2022, said Werksmans Attorneys’ director of healthcare and life science practice, Neil Kirby.
The report says the NHI aims to provide quality healthcare services to everyone, which is free at the point of delivery, and to narrow the gap between the care currently available to the rich and poor. The government’s latest policy on NHI is set out in a White Paper released by Health Minister Aaron Motsoaledi in June, which says the enabling legislative framework for NHI is to be developed between 2017 and 2022.
In addition to amending 11 existing healthcare Acts, the government would probably need to craft two entirely new pieces of NHI-related legislation, said Kirby. This would likely involve an NHI Act stipulating who would belong to the scheme and the role of providers, and an NHI Fund Act to deal with the financing mechanisms, he said. Amendments would probably be needed to the Consumer Protection Act and the Labour Relations Act as well. Once the acts had been promulgated, they would require enabling regulations to bring them into effect, Kirby said.
“This is gargantuan, paradigm-shifting stuff. (This) is an incredible burden on Parliament, which has to deal with numerous issues: this is not an issue that necessarily takes precedence over other legislative processes,” he warned. “This cannot be rushed, but the slower it is, the more jittery everyone becomes.”
The report says this year, NHI was the key talking point at the conference as the White Paper has created a climate of uncertainty for private healthcare providers and funders.
Econex director Mariné Erasmus said patients would get a better deal far sooner if healthcare experts turned their attention to fixing the public sector’s management issues instead of debating the funding reforms required for NHI. She sketched a picture of the massive health burden facing South Africa, arguing that the country’s poor outcomes were due to bad governance rather than a shortage of money. South Africa spent a greater proportion of GDP on public healthcare than Thailand did, yet Thailand had better health outcomes, she said.
“We may require additional funding, but for now it is a great distraction. We should be focusing on delivering better services – the real solution we need is likely to be less costly and produce better outcomes.”
According to an Econex analysis, the top wealthiest 40% of South Africans citizens are paying 85% of healthcare funding nationally but Erasmus is quoted as saying: “… in (South Africa) the poor aren’t getting what the wealthy are paying for. The problem can’t then only be one of funding.”
Laura Lopez Gonzalez, Mail & Guardian health news editor, writing in a Bhekisisa report, says that the answer to this riddle may, in part, lie in a recent report by the oversight body, the Office of Health Standards Compliance (OHSC). Between 2014 and 2015, the office’s inspectors conducted more than 600 appraisals of public clinics and hospitals across the country. Two out of every three facilities failed inspections.
Conditions were shocking. In one hospital, OHSC staff found sedated patients heaped onto the floor. Inspectors also documented instances in which health workers concealed expired medicines. In some cases, hospitals were found with medication that had expired three years prior.
Throwing money at problems like these won’t change them, cautions Erasmus. “Why do (public health) facilities fail? The staff in the (private and public sectors) are the same, they work in the same sector, train in the same institutions, their patients have the same diseases… The only thing that I can think of is that leadership is problematic.
“One structural issue remains unaddressed: One of governance, management and accountability. If we focus on changing that… we may actually deliver better care since most of the funding seems to be there,” argues Erasmus, who gave input into the NHI white paper.
“But we’re focusing on a problem (funding) that is largely already solved. The public sector does not look the way it does due to a lack of funding. Structural problems need structural answers.” And the warning from actuary and University of Cape Town senior lecturer Shivani Ranchod is that one of the many harsh truths South Africa will have to face on the road to universal quality healthcare is that the country may not be able to blame the shockingly dirty toilets and collapsing ceilings of the public sector on funding alone.
Lopez Gonzalez writes meanwhile, that heads of some of the country’s largest hospital groups and medical aid schemes pledged their support for the NHI at the Hasa meeting. “We cannot build a sustainable society and economy without ensuring the health of our nation. We recognise that given our shameful past in South Africa, we have created an incredibly unequal society and nowhere it that more evident than in the arena of healthcare. There is an enormous divide between the haves and have-nots and that gap is growing,” said Netcare CEO Richard Friedland.
Supporting access to quality healthcare is a no-brainer, according Ranchod. Deciding on how far you’ll go is another story: “Of course we’re all committed to universal healthcare and the NHI because we care about human beings because it makes sense… because no one wants to see a neonatal intensive care unit without incubators.
“But to make a substantial change to any system is almost impossible to do without some sort of pain. We have to think about what is it as an individual and as institutions about what we are willing to give up for the system to change…whether we’re talking about land reform, employment equity or fees must fall.”
Ranchod argues that the necessary legislative changes should be through open, iterative processes that allow for conversation. “We have to get our processes right to engage in an open, honest way. We have to do something because our system is not good enough. South Africans deserve better.”
The UK’s healthcare system past could be South Africa’s future, Lopez Gonzalez writes in a further Bhekisisa report.
She says the universal healthcare system, known as the National Health Service (NHS), had a problem: By the early 2000s, a growing number of elderly patients were waiting up to three years for sight-saving cataract services in the early 2000s. But the government-funded healthcare scheme didn’t have enough beds. It did, however, have plenty of parking. And, Lopez Gonzalez writes, through co-operating with the NHS, Netcare, which entered the UK market 15 years ago, helped to drastically shorten the cataract waiting lists. “All we needed was a parking lot and a connection to three-phase electricity,” remembers Friedland.
The group operates more than 50 private hospitals in the country, but 43% of its patients come from the NHS through the service’s electronic “choose and book” appointment system: Patients elect where to go for care, and the NHS pays private providers like Netcare a nationally-set rate for service.
To shorten the cataract surgery waiting lists, Netcare’s flatbed trucks travelled UK highways carrying a kitted-out trailer for cataract operations. Two trailers each were dedicated to operating theatres, pre-operating wards and examination rooms. Netcare offloaded these trucks into 30 NHS parking lots around the UK where they became mobile cataract clinics as part of an NHS tender.
As the lorries cruised around six days a week and 50 weeks each year, pensioners tracked their progress online, mapping out when the trailers would be in their area and booking appointments.
Lopez Gonzalez writes that ultimately, Netcare’s cataract caravans had performed more than 40,000 surgeries over five years. Patients were sent home the same day, and many had spent just 10 minutes under the knife as surgeons slashed operating time. She writes that Netcare’s director of strategy and healthcare policy Melanie Da Costa, appearing before the Competition Commission Health Market Inquiry in 2016, said that: “Eventually the doctors were doing 20 to 24 surgeries per day in these theatres, and they were finishing at lunchtime and going home.”
Lopez Gonzalez writes that under South Africa’s NHI, the government will use public hospitals and clinics to provide healthcare, in addition to buying services from accredited, private providers for standard rates – much like the UK’s NHS. By doing this, the NHI will become the largest buyer of healthcare services in the country.
But, she says, the practicalities of this are still developing, and the heads of private hospital and insurance groups like Netcare and Discovery are already thinking about what private healthcare might look like in a post-NHI world – and how they may have to change to be a part of it.
The private sector could start by following Netcare’s lead in the UK, tackling waiting lists for cataracts or hip and knee surgeries, especially in rural areas, she quotes Mediclinic Southern Africa CEO Koert Pretorius as saying. He says a percentage of these procedures could be done at below cost prices if private hospitals could get medicines and even prosthetic limbs procured at state tender prices.
Preliminary Hasa research shows that South Africa has about 525 private hospitals and most of these are independently run or, in other words, are not part of large groups. Pretorius says these facilities could help manage nearby clinics and even school health programmes under the NHI.
The country has screened more than 3.5m learners since Health Minister Aaron Motsoaledi resuscitated school health programmes in 2014. One in three children were found to have at least one condition relating to their eyesight, hearing or teeth, the minister has said. But NHI special advisor to the national health department Vishal Brijlal admits no one knows how many of these children ever received care.
Lopez Gonzalez quotes Discovery CEO Jonathan Health as saying that this is a gap private medical aid administrators could help to mend. He says: “(The NHI) seeks to purchase services from a wide range of providers … that’s about procurement, about understanding cost-effectiveness and the cost and quality of services, analysing data and purchasing effectively.
“I’m not exaggerating when I say that the medical aid scheme administrators of this country stand out in the world for their skills, systems, data analysis capacity and their health economics capabilities. You talk today about the need to urgently look at the school health programme… I can say to you within weeks, or a couple of months at most, the private funding and delivery side could arrange those services.”
But he says a lack of trust between the public and private health sectors has stalled collaborations and both parties are to blame. “If we had a government that was willing to say let’s do 20,000 cataracts over the next (number) of months, that could be up and running in a few months. If that trust deficit could be bridged, we could benefit real people.”
And, says Lopez Gonzalez, trust isn’t the only thing that will have to change under the NHI. In 2012, Netcare tried to recreate its success in the UK with mobile cataract services in the field of breast cancer with a mobile mammography unit in the Free State. Four years later, not a single patient had stepped through the van’s doors – a fact Da Costa blamed on inflexible regulations.
“We had written at least eight letters to the health professions council before we got a response and we have just had multiple, multiple requests for data, presentations, etc. To cut a long story short, we have now donated this trailer to the provincial department of health,” she told the Competition Commission in 2016.