Full implementation of the National Health System was likely to take decades, according to its deputy director-general Nicholas Crisp, who announced this week that two more chief directors of the five directorates of the NHI branch had been approved – to oversee user and service provider management, and healthcare benefits and provider payment design.
The other three directorates, of which two already have heads, are: health product procurement; digital systems; and risk identification and fraud prevention. Only the directorate for fraud prevention still needs a chief director.
The latest appointees, whose names have not been released yet, will report for work in August or September, write Mohale Moloi, Linda Pretorius and Mia Malan for Bhekisisa.
The latest news comes after the Treasury approved money to appoint 44 people in the NHI branch late last year, bringing to around 100 the total staff tally for the core office running the branch.
While the National Assembly gave the go-ahead for the Bill in June, other than the timeframes for implementing the fund being pushed out (with the first phase now to run from this year to 2026, instead of from 2017 to 2022 as was planned before) and the Minister’s decision powers being reined in, little has changed from the version previously tabled.
Under the NHI, private medical schemes will essentially cease to exist, at least as we know them now.
So, what changes in their healthcare can South Africans expect to see happening in the first year after the Bill’s become law (if approved by the National Council of Provinces)?
‘Nothing,” Crisp said in an interview on Bhekisisa’s monthly TV programme, Health Beat, in June. Full implementation, he says “will take decades”.
But within the first five years after the Bill becomes an Act, there are likely to be fewer medical schemes in the country and their benefit packages will look more or less the same, setting the groundwork for the basic package to be offered by the NHI, he added.
Sasha Stevenson, head of health at SECTION27, a public interest law centre, said the fund, essentially designed to be a system of contracting, would be “far from simple”, and legal opposition should be expected.
On the fear that patients might die in public hospitals while awaiting lifesaving treatment, Crisp said poor health service was not acceptable.
“That’s why we need to reform how we deliver healthcare. We have many resources in this country, but they’re not accessible to most people. The question we’re trying to address with (NHI) is how we achieve universal health coverage, all of us get the healthcare that we need, when we need it, where we need it, without financial hardship.”
A system was needed that “is not a duplicate of the two-tier system we have now”, he said.
When Bhekisisa referred to the corruption scandal with the Digital Vibes communications contract, he replied that corruption “is never acceptable”.
“Most of the people who work in the Health Department don’t behave in that way; the handful of people who do are doing us a disservice as a nation. With NHI, we must make sure checks and balances are in place so that these kinds of things, like corruption, don’t happen. We need to identify the risks, to try to design them out of the system, and where we can’t, flag them and then address them.
“We can minimise the risks and the amount of corruption and fraud by simplifying the system. That’s why a simplified, single model is preferable to the complicated health system we have now.”
However, as Stevenson pointed out, “the NHI is far from simple”.
“Contracting comes with a lot of risk. We can’t just deal with corruption when it happens, and should prevent it from happening in the first place.”
She added that were was not much detail in the Bill on what those checks and balances would look like, other than advisory committees “meant to advise on what kinds of benefits should be allowed, and what payment mechanisms there should be”.
“Those structures don’t include health service users and they don’t include civil society,” she said, and many healthcare workers were frustrated, believing they hadn’t been consulted.
“In South Africa we have a habit of creating policy and then expecting it to be implemented without hearing from the people who are doing the work,” she said.
“Theories on changing health systems are quite clear: nothing can just be implemented from the top and then it works. We need a process where we test things out and the implementers give feedback to policymakers. That’s going to be key in this next stage, because we want change to actually happen.”
Crisp said he didn’t disagree “that we should consult people on how we do it, but everybody can’t be talking to the national department”.
“Health workers should be talking to the provincial departments. We should be talking to the people in hospitals, in clinics, GPs in their practices. But my biggest concern is the public. Because I haven’t found one person who actually understands their medical aid now, or how the public sector does, or doesn’t, accommodate them.”
Medical schemes banned
In its current form, the NHI Bill says medical aids, as they are today, will effectively be banned, and will only be able to cover complementary services, or those that aren’t covered by the NHI.
But, “It’s difficult to know what the complaints will be, because we don’t know what the fund is going to cover and we don’t know what those complementary services will be”, said Stevenson.
If the Bill were to become law tomorrow, said Crisp, “You won’t feel anything in the first year. The system won’t change in a short time; it will take a couple of years before we see the first steps. Full implementation, which is what people … are unhappy about in section 33, will take decades. (Section 33 outlines what the role of medical schemes will be once the NHI is running).”
Having 76 medical schemes, he added, was not sustainable. “There are big ones, and some are very small, with small risk pools. I see a realignment of medical schemes, where we end up with fewer, offering fewer packages (so, less complicated choices) and one compulsory package, in which everybody knows what they’re getting for a set price, as negotiated and fixed between the state, the Council for Medical Schemes, the Competition Commission and the medical aids.
“That’s what I’d hope to see in the next five years.”
Stevenson said the big challenge for the department in the next decade would be to make sure public health facilities offer good enough quality so that they can be contracted by the fund, and “that’s not private health facilities that can meet the norms and standards”.
She added that there was a significant chance cases would be brought (to the court), which would stall parts of the NHI’s roll-out.
See more from MedicalBrief archives:
A ‘Crisp’ rendition of SA’s NHI
Medical schemes’ NHI transition will take ‘years to decades’ – Crisp
Complex private health system more complicated than state’s – Crisp