The Marmite NHI

Organisation: Position: Deadline Date: Location:

John Bercow, the speaker of the UK parliament, was recently referred to by a reporter as “the Marmite speaker”, writes Donald Dinnie, consultant at Natmed Medical Defence.

The expression was developed, originating in the UK, using Marmite as an adjective to mean you either love it or hate it (or them) – but cannot be indifferent to it.

The National Health Insurance Bill is like Marmite. People either love it or hate it.

There has been no indifferent response to it.

For a piece of legislation that has been so long in coming and so much talked about, it is surprisingly limited in its detail. The meat of the legislation and key to its success lies to a large extent in the contents and execution of some 28 areas in which regulations will be made. And in ancillary and related legislation.

Regulations are required, for example, regarding the relationship between the Fund and various categories of health establishments, healthcare service providers and suppliers, the payment mechanisms therefore, the budgeting of the fund, the accreditation of healthcare service providers and health establishments or suppliers, the registration of users of the Fund, the relationship between public and private health establishments and the optional contracting in of private healthcare service providers, the relationship with the Fund and medical schemes, the fees payable to the Fund, the practices and procedures to be followed by healthcare service providers, health establishment and suppliers in relation to the Fund, the scope and nature of prescribed healthcare services and programmes, and the manner and extent to which they must be funded.

The purpose of the legislation is to establish and maintain a National Health Insurance Fund, funded through mandatory prepayment, which aims to achieve sustainable and affordable universal access to quality healthcare services by serving as a single purchaser and single payor of healthcare services. The goal of this single purchaser and payor is to ensure the equitable and fair distribution and use of healthcare services, and to ensure the sustainability of funding for healthcare services within the country.

The chief source of income for the fund includes:

General tax revenue, which includes the shifting of funds from the provincial equitable share and conditional grounds into the Fund;
Reallocation of funding for medical scheme tax credits to various medical schemes. This will mean that current users of medical schemes will lose the tax benefits of contributions, reducing the affordability of medical schemes and driving those persons out of the medical schemes market.
Reduction in medical scheme membership, which is likely to have a negative effect on the financial sustainability of medical schemes; and
An employer and employee payroll tax and a surcharge on personal income tax, all of which is to be accomplished via a money bill.

Under the circumstances, individual taxpayers stand exposed to triple taxation for the use of public healthcare by way of the general tax revenue – which they are already paying – plus a payroll tax, plus a surcharge on personal income tax.

The key to the success of the legislation is ensuring the delivery of quality personal healthcare services. Under the existing system, the problem with quality of service has been fairly acknowledged by the Department of Health as a concern and a point of focus. The legislation talks about the progressive realisation of the right of access to quality personal healthcare services and making progress towards achieving Universal Healthcare Coverage. Sustainable, equitable, appropriate, efficient and effective public funding for private healthcare services is only achieved once a public trust in the public healthcare services is established. Currently, there is a trust deficit, which requires serious attention and work.

Public healthcare already receives a relatively large amount of the National Budget. Generating more funds for National Healthcare isn’t an answer in itself to achieving quality personal healthcare services. Efficient application, control and management of those funds are needed.

Currently, very few public health facilities meet the standards of the Office of the Health Compliance.

Poor quality of healthcare services is a major factor in driving medico-legal litigation. Pushing more users into the public healthcare system from the private healthcare system will add to the delivery strains on the public healthcare system and, without significant improvement in quality, will increase in number and quantum the medico-legal claims; thereby requiring more funding for the costs of dealing with these claims and settlements or judgments.

It becomes a vicious circle where normal funds are required to be allocated to resolution of medical malpractice claims, which means that those funds are not available for the improvement of delivery of healthcare services, which in turn means more claims and so on.

There are a number of projects around the country, both National and Provincial, which are aimed at dealing with the scourge of medical malpractice claims against State Healthcare. That is, dealing with the results of sub-standard care; and equally focused and meaningful programmes are required at the delivery end of healthcare services.

There is also an appreciation by the Department of Health that the legislation is part of a process aimed at achieving universal healthcare. It can’t be a flick of a switch and instantaneous conversion to quality, universal and healthcare for all in the country.

In this regard, there does need to be clarity as soon as possible as to what healthcare services would be offered by the State, and what opportunities there are for the provision of complementary cover both by way of medical aids or medical schemes. Where the Fund is not in a position to provide comprehensive healthcare services as contemplated, medical schemes will have the opportunity to provide complementary cover – but certainty and clarity is required in this regard to enable medical schemes to plan or operate their businesses.

Issued by Vanessa Rogers at Textbox Conceptual for Natmed Medical Defence

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