Apartheid built healthcare inequalities. It is up to the National Health Insurance (NHI) to dismantle them, writes South Africa’s Health Minister Dr Aaron Motsoaledi in the Sunday Times.
“Like birth, revolution is characterised by blood and pain. In a revolution or any radical change, there are two contesting forces – one fighting for change and the other for the status quo.
“It is understandable that the beneficiaries of the current order will fight tooth and nail to stop the revolution – and National Health Insurance is a revolution in the provision of health.
“The battle over the implementation of universal health coverage, a plan endorsed by the World Health Organisation (WHO), is not happening only in our country. In the US, for instance, Obamacare, the US version of universal health coverage, is under attack by the new administration of President Donald Trump.
“We have our own Trumps in South Africa. Those who are beneficiaries of a system that benefits the minority and excludes the majority oppose the NHI on ideological grounds. They do not want equity with regard to healthcare provision. They argue that the state should leave private healthcare alone and rather sort out the mess in public health facilities. They argue that the poor management and incompetence that characterise the public healthcare sector should not be exported into a private sector that works well.
“It is true that the public healthcare system faces serious problems, but this is not a uniquely South African phenomenon. The UN and the WHO have identified the extreme inequities between the wealthy and the poor around the whole world as the cause of these problems. They prescribe universal health coverage as the remedy. The outgoing director-general of the WHO described it as an equaliser between rich and poor.
“But critics of the public care system deliberately choose to ignore the link between cause and effect. To them the problems faced by public healthcare are because of the sheer stupidity of those running it. They ignore the fact that the state of public healthcare is not an accident of history. It is a product of these inequities.
“Over the years, the public health system has been systematically stripped of resources – both human and financial – as these were directed towards the private sector. This was achieved by pooling funds to access good-quality care for a select few South Africans in the form of medical aid. With medical aid, huge amounts were siphoned from the public purse through huge medical-aid subsidies camouflaged as a condition of employment. It was also achieved through very generous tax rebates and credits directed at the few South Africans who were able to join a medical aid.
“These are the resources propping up the private sector, without which it would not be sustainable. This has the effect of compromising the efficiency, effectiveness and quality of the public health sector, because naturally human beings follow resources. So it is logical that the majority of skilled health professionals followed the resources in the private sector, leaving the public sector all the poorer.
“This subtle and stealthy re-allocation of resources to the haves started in 1967 with the proclamation of the first medical scheme. It started as a whites-only system and was later extended to a few blacks, which is where we are today. Ironically, 1967 was the year that public healthcare demonstrated its supremacy when it delivered the world’s first heart transplant, where the recipient did not have to be a have or a have-not: it did not matter, he was just a patient.
“Unfortunately, 50 years down the line, due to this movement of funds, we wake up with 4.4% of GDP supporting the health needs of 16% of the population on one hand, and 4.1% of GDP spent on a whopping 84% of the population on the other.
“Blaming the public healthcare system for poor performance under these conditions is no different from giving blacks an inferior education for 50 years – with most of the resources pumped into white education – and then turning around and blaming blacks for poor educational outcomes.
“Democracy in itself cannot reverse this because it only afforded us equality before the law, not equality with regard to resources. This analogy of the healthcare system with Bantu education is lost on many people because discrimination in this case is based not on colour and race but on money, and a few blacks have been co-opted to have access to private healthcare.
“NHI is designed to do away with any form of discrimination, subtle or obvious, regardless of colour, creed, or social or economic status. It has been rubbished as too expensive, a plan that will collapse the quality of healthcare in private and public hospitals. Over and over again, we are told we should rather focus on ensuring public hospitals are well equipped and have adequate staff, and leave private healthcare alone. The issue of NHI being too expensive is a fallacious argument. It is also morally bankrupt.
“Actually the system that is more expensive is the current one that allocates 4.4% of the GDP to the healthcare needs of 16% of the population. No other country does such an illogical thing.
“Because they are aware of the moral bankruptcy of their argument, opponents of NHI try to hide behind the interests of the poor to advance their argument. They argue that the labour movement would not accept NHI because this would affect their members’ medical-aid benefits.
“Nothing could be further from the truth. In fact, Cosatu, the biggest labour federation with more than 2m members, is on record saying we are moving too slowly on implementing NHI. They understand that the current situation is not sustainable. Medical inflation is more than double the rate of inflation every year but the benefits in medical-aid schemes are shrinking.
“But as we argue for social justice in the provision of healthcare, we should also explode the myth that NHI wants to do away with the private healthcare system. NHI is a funding model that will ensure all South Africans have access to health in both private and public health facilities without regard to economic status.
“Why should this be viewed as a bad thing? It is possible that those who see private hospitals as exclusively reserved for the rich may fear that poor people will ‘invade’ their space. But how do we justify the status quo?
“It is time that we isolate those who want to perpetuate inequalities brought about by apartheid planning. It is time that we urge all progressive forces to join hands and push for the rapid implementation of NHI.”
South Africa should rely on the expertise and strengths of its private healthcare system for a successful rollout of its planned national health insurance (NHI) scheme. Fin24 reports that this is according to Nathaniel Otoo, former CEO of the Ghanaian National Health Insurance Authority (NHIA), who, at the Board of Healthcare Funders’ (BHF’s) national conference in Cape Town, shared some of Ghana’s challenges with implementation of universal healthcare. Universal healthcare is one of the Millennium Development Goals and countries around the world are currently grappling with the challenge to realise this by 2030.
The report says Otoo stressed the importance of private sector involvement in the quest for universal healthcare in his country. “The private sector must play a role from the onset, as it is an engine of growth that often excels in innovation, financial management, risk taking and entrepreneurship and customer care.”
He said in implementing universal healthcare in South Africa, the country could effectively leverage these private sector strengths to ensure a successful NHI implementation. “If well planned and conceived, the private sector could be a reliable partner for regulation, governance, health service provision, quality improvement, financial intermediation, information systems support, commodity supply chains, and most importantly customer care.”
There are still challenges that prevent universal health from being fully implemented in Ghana though, the report says, such as the financial sustainability of the model, poor regulation in the health sector, inequitable distribution and poor quality of services.
“With over 200 hospitals in the country, run mostly by the government through the Ministry of Health and the Ghana Health Services, corruption and maladministration in the distribution of funds for expanding and sustaining the NHIS poses a major challenge,” he said.
Otoo said in Ghana, the NHIS was established in response to very limited access to healthcare as a result of a fee payment system called “cash and carry” which came into effect in the 1980s. “By the early 2000s, only about 20% of the population could access healthcare in Ghana and this was a significant reason for launching the NHIS.”
The report says Ghana has a population of about 27.4m and the country still has some way to go before achieving universal healthcare, with only 41% of the population currently covered by NHIS.
The discussion on universal healthcare comes as South Africa is embarking on its own NHI implementation, the report says. Cabinet recently approved the NHI White Paper and it will soon be gazetted as a national policy document. The proposed system however faces a number of challenges, such as uncertainty about funding and the future role of medical schemes and private healthcare providers.
Government hopes that the number of private medical schemes and the options they provide will decrease under the proposed NHI plan. Fin24 reports that this is according to Malebona Matsoso, director general at the Department of Health, who outlined to the conference some of the elements of the NHI which includes plans for the public and private healthcare sector.
Matsoso said risk-pooling and cross-subsidisation will be critical elements to finance universal healthcare under the NHI. This funding system should aim to spread the financial risk of illness across the broader population and collect large pools of prepaid funds that people can draw on to cover their healthcare costs when they need it.
Government will also look at introducing a single service benefits framework to the private healthcare industry as well as a new set of prescribed minimum benefits that are more closely aligned to common care pathways under the NHI. The number of medical schemes in the private sector will also have to come down and they will have to provide fewer options per scheme, Matsoso is quoted in the report as saying.
Barry Childs, CEO at Insight Actuaries and Consultants, said in a presentation that regulations need to be relaxed so that medical aids can be allowed to pool common benefits and have better cross-subsidies across different risk categories. “This will most likely result in fewer scheme options. But currently, regulation requires that each risk pool within a medical scheme must be self-sustaining and no pooling across risk categories are allowed.”
He said the proliferation in the open medical scheme market can be ascribed to this limiting regulation of not allowing risk-pooling.
The Special Investigations Unit (SIU) has, meanwhile, teamed up with the private healthcare industry to create a forum to help detect and prevent corruption and abuse in preparation for the NHI. Fraud, waste and abuse in healthcare remain challenges in the well-funded private healthcare sector, which faces risks from both patients and healthcare providers, with the industry losing billions every year. Business Day reports that these issues were discussed at the conference.
SIU head Andy Mothibi said the unit had been in talks with various associations in private healthcare about the creation of a joint forum that would result in law enforcement agencies and funders collaborating to prevent criminal activity. Data generated by the BHF suggest that about 7% of all medical aid claims are fraudulent. It is estimated fraud costs the private sector R22bn a year – compared with about R24bn in irregular expenditure recorded for provincial health departments in 2009-13.
Mothibi said the SIU would be signing a memorandum of understanding with stakeholders including the Council of Medical Schemes, the BHF and the Health Professions Council of SA to come up with strategies the forum would deploy. Prevention was key in fighting fraud and waste and the forum would collaborate to mitigate risk under NHI. “Our view is that this space (healthcare funding) deserves attention,” Mothibi is quoted in the report as saying.
Gregory Pratt, senior clinical adviser at Medscheme’s forensic unit, said fraud and abuse posed a material threat to the affordability and sustainability of medical schemes, and to any national insurance scheme. There was an entitlement factor among doctors who sometimes charged triple the amount for patients who suffered a condition covered under the prescribed minimum benefits, Pratt said.
He cited a psychologist charging R4.3m in 102 days, pharmacies in Soweto claiming more than R100m in three years and more than R5m being paid to a radiographer in one year, as examples of how practitioners abused the system. The enforcement of codes of ethics was critical at this point because fraud, waste and abuse would seep into NHI.