While everyone wants the NHI to work effectively, the numerous challenges ahead will require collaboration with stakeholders and additional consideration given to workable reforms, suggested delegates at a recent Health Funders Association symposium.
They also discussed quality of care concerns as well as the potential for increased medico-legal litigation due to overworked staff, among other aspects, reports Daily Maverick.
Dr Paula Armstrong, senior director at FTI Consulting, who focuses on policy and regulatory framework with a special interest in healthcare policy, said South Africans have poor healthcare outcomes compared with other countries with relatively similar socio-economic status and economic development, like Lebanon, Tunisia, Egypt and Columbia, while higher levels of disability-adjusted life years (DALYs) point to worse healthcare outcomes.
She cited a DALY graph from 2016 that included countries with highly developed economies, like Canada, the UK, US and Germany, the BRICS countries and middle-income countries.
“It is somewhat dated from 2016, but is likely to be the same. It was certainly similar in 2019 (…) and relative to all of those countries, South Africans DALYs are higher. South Africans are sicker than anybody on this chart. This is what we are dealing with, what we have to solve, and what the NHI seeks to solve,” she said.
Armstrong also noted the National Income Dynamics Study, conducted every two years by the University of Cape Town, which showed the proportion of households that are either in chronic poverty (more than two years), transient poverty (temporary, measured below the poverty line), or were vulnerable, middle class or elite.
“Over about nine years, chronic poverty and transient poverty increased in 2010, which seems to be the impact of the financial crisis around that time. We don’t have any data post-Covid on this, but I can tell you it’s going to be a terrible picture post-Covid,” she said.
“Even though it is improving, more than 50% of households are still measured at below the poverty line in South Africa. So, given the correlation between poverty and poor healthcare outcomes, this is a problem we have to solve, and this is the objective of universal health coverage in South Africa.”
Navigating challenges and opportunities
Dr Simon Strachan, chairperson of the South African Private Practitioners Forum (SAPPF), said what was needed was a comprehensive approach to reform.
“We know the inequalities in South African healthcare … we came through the public sector, it taught us what we know. We understand it has to move and we want to be part of that process,” he said.
“The one thing that is very clear about healthcare professions is (that) no matter the circumstance, we’re still going to be there. We still have a duty to our patients. So we don’t want to feel as if we have … to manipulate it to work in an environment that is not conducive to our livelihoods or offering the best quality and access to our patients.”
Bill’s effects on patients, practitioners
SAPPF’s concerns are quality of healthcare, access to healthcare, contracting with healthcare practitioners, treatment protocols, governance, medico-legal litigation and corruption.
“It will very likely be a primary healthcare service that is affordable to the country. But if you improve primary healthcare services, you are going to uncover more patients who need secondary and tertiary care,” Strachan said.
“Therefore, you’re going to need more hospital services. If that logic is true, what this creates is the hospicentric system, because what’s not included in the Bill is any contracting for ambulatory specialist services. It’s all supposed to happen in the hospital. That’s a huge problem.”
The Bill also makes no mention of physiotherapists, occupational therapists and other rehabilitative facilities.
“Where do they fit in all of this?” he said.
Cost and care
An accredited primary healthcare provider or health establishment providing primary healthcare services must be reimbursed by the fund in accordance with the prescribed capitation strategy, according to the Bill.
“At the GP level it will be by risk-adjusted capitation. It’s not necessarily the best way to fund healthcare, especially at community level, where you will be looking for continuity of care and quality,” he said.
Strachan raised concerns about the “Powers of Fund” section of the Bill. It states that the fund may enter into a contact for the procurement and supply of specific healthcare services, medicines, health goods and health-related products with an accredited health service provider, health establishment or supplier, and must negotiate the lowest possible price without compromising the interests of users or violating the provisions of the Act.
“We obviously want to deliver healthcare as economically as we can, (…) we have no problem that there should be treatment protocols and guidelines, but cost is a part of the decision-making process when determining benefits and treatment guidelines.
“If you’re saying it’s at the lowest cost, can I ensure the patient I have in front of me will get the best medical care I can offer? If I’ve made a diagnosis and look at the formula list and there is only that available … when I know there is far better available.”
There were also concerns around medico-legal litigation, and Strachan noted that mistakes occur when practitioners are hungry, angry, late or tired.
“You are going to have a workforce that will be overworked and we know the situation in the country already so we need to guard against this.”
He said the public and private sectors must collaborate effectively, with strong governance, adequate funding and efficient administration, to achieve successful universal healthcare.
“We believe that we are one national health asset, and how we approach this is with the absolute belief that there will be a well-governed, well-funded, well-administered private sector, which has to work in parallel with the state for universal healthcare to work in South Africa.”
Meanwhile, experts at the symposium suggested that as more legal challenges against the NHI unfold, they are likely to consolidated, another Daily Maverick report says.
There are already six legal challenges in the works – from Solidarity, the Health Funders’ Association, the South African Medical Association, the Board of Healthcare Funders (BHF), the South African Health Professionals Collaboration, and the DA.
However, that Elsabe Klinck, managing director at Elsabe Klinck and Associates, anticipates that as additional cases are filed, they will be consolidated.
“That might delay things in the beginning, because you’ll have more sets of advocates who will need to co-ordinate their diaries and so on, but then we can have a single ruling,” Klinck said, adding that one of the positive, unintended spin-offs of the NHI debacle has been the resulting unity from the private healthcare sector.
“A lot of the legal practitioners who would normally fiercely compete for your business are all now on the same page and we would encourage sharing (of information),” she told delegates.
‘Highly unrealistic’ costing
Armstrong flagged that an NHI white paper published in 2017 had pegged the total cost of the NHI in 2025 at R256bn – the same figure quoted in the 2015 white paper on the NHI. In fact, she said, the costing quoted can be traced back as far as 2011, “so it is way out of date and anchored in highly unrealistic assumptions”.
“From an economic perspective, there hasn’t been a lot of, or any, development in the thinking around what the cost will be. Of course, it depends on what will be included in the benefits package, and we don’t know this yet from a policy perspective or an economic policy perspective,” she said.
Klinck said that in the two cases already filed by the Board of Healthcare Funders and trade union Solidarity, it was important to note who was being sued in each case.
“The BHF is suing the President and the Minister of Health, while Solidarity is suing the Minister of Health, the President, the DG, the Minister of Finance and National Treasury. This means there are two cases with two different approaches,” she said.
The BHF has asked for the President’s signing of the Act to be set aside so that the NHI Act is declared of no force and effect. The BHF has also asked for the record of decision-making – that is, what led to the President signing NHI, and what legal opinions from the state attorney were considered.
Klinck said this was a clever approach because it meant the government would have to release legal opinions from the State Attorney, and the President would have to show that he actually weighed up the information before signing the NHI Act.
Medical aid schemes
Shortly after President Cyril Ramaphosa signed the Act, BHF managing director Dr Katlego Mothudi highlighted issues around Section 33 of the Act, which says that once the NHI fund is fully implemented, medical aid schemes will no longer be allowed to provide similar services.
“There are a few issues. One is that participation in medical aid schemes is voluntary. We think if someone is willing to do something voluntarily and you forbid them to do it, you are infringing on their rights. You have a right to spend your hard-earned money in the manner you think is appropriate,” he said.
Mothudi also said that schemes currently afforded members better healthcare than that available in the public sector.
“If you’re going to ask them (medical schemes) not to provide these services, you are denying their members access to healthcare services, which goes against the Constitution,” he said.
Solidarity has indicated it is “vehemently opposed to the NHI and is strongly in favour of a private market approach, offering a choice to private service providers and the public, as well as being in favour of an improved public healthcare system”.
“The Solidarity case is calling for the whole Act to be declared unconstitutional and to prevent the President from bringing portions of the Act into effect,” Klinck said.
The Solidarity affidavit is significantly longer than that of the BHF as it tries to attack the vagueness of the entire NHI Act. For example, “healthcare services” are referred to throughout the Act, but Klinck says there is no indication of what will be defined as “healthcare services” or how they will be phased in.
Daily Maverick – Consolidated legal challenges to NHI Act will have more clout
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