South Africa’s National Health Insurance (NHI) is not being modelled on the UK’s National Health Service (NHS), and reaction to Health Minister Joe Phaahla’s recent fact-finding visit to that country was “inappropriate and emotive”.
There was no one country on which SA could model its NHI, deputy director-general for NHI Professor Nicholas Crisp told Chris Bateman, writing for MedicalBrief, in response to a hard-hitting column in BizNews in which columnist Ivo Vegter slammed as “foolhardy” attempts to build the NHI by modelling it on the UK’s NHS.
Vegter berated Phaahla for the “belated” NHI fact-finding mission to the UK, questioning how any “profound discoveries” would be subsumed into an NHI Bill conceived 13 years ago and legislated for four years ago.
Vegter opines: “It doesn’t take a junket to the UK to learn some salient points from the NHS. Perhaps the key lesson is that the budget for the NHS exceeds £180m per year, to serve a population of 68m. Scaled to South Africa’s population of 61m, that works out to R3.4trn, and the NHS isn’t even the most expensive universal healthcare system in Europe: France, Germany and Sweden all spend even more.”
To provide perspective, Vegter compares this with South Africa’s annual GDP of around R4.6trn. While he says Phaahla’s funding proposals range “from vague to non-existent”, the intention “appears to be to devote no more than 8.5% of SA’s GDP – the amount government spends on public healthcare at present, plus the lesser amount private individuals pay towards medical aids – to the NHI.”
“That adds up to about R395bn, which is less than one eighth of what the UK spends on its NHS. It’s foolhardy to try to build a national healthcare system in a developing country with limited resources like South Africa, by modelling it on a far more costly system in the rich world and which is visibly failing,” he adds.
Vegter says that even with the “staggering cost” of the UK’s NHS, it is beset with problems.
“Its performance has been in steady decline for years, long before the shock of the pandemic plunged the NHS into crisis. Key workers, including frontline nurses and ambulance personnel, are striking for better conditions and pay,” he adds.
UK comparison exposes ignorance
However, Crisp denies outright that SA is modelling its NHI on the UK, saying the UK is a very different society to South Africa. He also takes issue with Vegter’s assumptions and comparisons.
“For a start their employment methods would not comply with SA labour requirements – and the NHS is very different to an NHI. It’s best to look at similar GDP per capita bands to us. This kind of UK comparison exposes the author’s ignorance of health systems and is emotive.”
He says Canada and Taiwan are the only two countries in the world with true single-payer systems covering their entire population.
While Crisp believes it’s “inappropriate” to comment on the challenges unique to the UK system, he says Brexit created a sudden staffing imbalance and the rapidly ageing population structure resulted in elderly care issues dominating health needs. The UK delivery platform had simply not responded fast enough.
He cited Thailand and Columbia has having similar GDP per capita to South Africa ($7 066 for the former and $6 104 for the latter – with SA’s at $7 055. SA’s GINI coefficient stands at 63 and Colombia’s at 54.20.
“So, there is no one country that we can model on, and we should not try to do so. We look at the broad system structures across a wider comparison and for lessons on what worked and what did not work,” he adds.
While many countries had single-payer systems, they did not all work in the same way. The systems all worked to reduce co-payments and other forms of costs for patients. While reducing costs was the overall goal, the systems did not always cover the same services. In some countries, patients still paid some out-of-pocket costs. In others, they might need to find supplemental health insurance plans to cover what the system did not.
Adds Crisp: “Not all single-payer systems are national systems. Many large countries rely on the regional governments of states or provinces to administer the healthcare system and pay providers. These governments often get the funds they need from the national government.”.
He says countries that have single-payer health systems (or similar systems) include:
- Canada – uses regional control with national grant programmes to fund the system.
- The United Kingdom has regional flexibility with national funding in its healthcare system.
- France has a mostly national administration and funding in the system it created.
- Australia allows for regional flexibility and uses national funding.
- Norway gives regional leaders flexibility and uses national funding.
- Denmark uses national grant programs to give funds to regional leaders for flexibility.
- Sweden gives regions the flexibility to distribute funds through mostly regional funding.
Maverick column ‘over-simplified’
Says Crisp: “Countries range from being very complex to simple when you compare their payment systems. For example, the Singapore federal government pays the healthcare providers. England has local clinical commissioning groups that take national funding and distribute the payments. More complex systems in countries like Germany and the Netherlands are often thought to be single payer. Many private health insurance companies exist in these countries, so they are really multi-payer systems. The funds are disbursed among competing healthcare insurance companies that pay doctors and hospitals. These companies may be non-profit (like in Germany) or for-profit (like in the Netherlands).”
He emphasised that single-payer health insurance and universal health coverage were not the same thing.
“The latter means that all people in a country have access to healthcare. But the term universal health coverage doesn't address how healthcare costs are paid. Our research has aimed at how to address inequity and prevent financial catastrophe for people accessing care. We have chosen a single payer model, which is primarily tax funded. This is what middle income countries have mostly done.”
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