NHI — Exciting health reforms possible if we move beyond all the political sclerosis

22 Oct 2023

It is often enlightening to ask how and why certain services differ in the ways they do between the private and public healthcare sectors. By too rigidly focusing on the NHI Bill, argues Spotlight Editor Marcus Low, government risks losing sight of the many other interesting answers to this and other important questions about healthcare reform in South Africa.

It is often enlightening for us at Spotlight to ask how and why certain services differ in the ways they do between the private and public healthcare sectors.

Take something as simple as needing medical help when you have a flu that just won’t go away. As a private-sector patient, I’d call my GP’s office and make an appointment. Providing I get there on time, chances are I would at most be asked to wait for 10 or 20 minutes in a comfortable waiting room. By contrast, at many public healthcare facilities, you are not able to make an appointment, and often have to wait for long hours in a poorly ventilated and overcrowded waiting area and will likely end up seeing a nurse rather than a GP.

Some aspects of such differences are understandable, albeit deeply problematic. The shortage of doctors is much more acute in the public sector than in the private sector. There is a moral imperative to address this imbalance, but as previously argued, the current NHI plans are just one way to address it.

Why some public healthcare facilities still do not use appointment systems is harder to explain. Even if some users prefer to queue rather than to have appointments, it is odd that all facilities do not at least have hybrid systems with some appointments and some queueing. Having appointment systems is not rocket science and doesn’t have to cost millions.

NHI protesters There is a moral imperative to address the imbalance between the private and public healthcare sectors, but the current National Health Insurance plans are just one way of doing so. (Photo: Rosetta Msimango / Spotlight)

There are, of course, other examples. As a private healthcare user, it is relatively trivial for me to get a six-month chronic medication script from my GP and to arrange for the medicines to be delivered to my home. Though there has been significant progress in this direction in the public sector, many people still find it hard to get scripts and collect their medicines.

Of course, differences in available resources are a large part of what is going on here, but it is not the whole story. As a private healthcare user, my needs, my preferences, and my time are generally respected in a way that seems rare in the public sector. To be clear, there are many committed healthcare workers in the public sector who show exemplary respect for their patients, but at a systemic level, as in the decision not to have appointment systems or not to allow for extended medicine refills, people’s time and needs are being disregarded.

Apart from the risk of corruption and mismanagement, much of the middle-class resistance to NHI may well have to do with the fear that people who can now access private healthcare services will become subject to precisely this kind of systemic indifference to their needs. And indeed, while the rhetoric around NHI has often been about ideals like the need for greater social solidarity, we haven’t really seen a vision presented of NHI as offering better, more respectful, and more personalised healthcare.

But, with a bit of flexibility, this could change.

NHI Systemic level issues like a lack of appointment systems and difficulty for some patients to get extended medication scripts and refills in the public sector are some of the ways that patient’s needs and time are being disregarded. (Photo: Rosetta Msimango / Spotlight)

Consider annual checkups. Rather than asking public sector patients to go to overcrowded clinics with long queues for tests, why not give public sector users the option of getting their basic screening tests for HIV, TB, hypertension, and diabetes done at private sector pharmacies along the lines of Discovery Health’s Annual Health Checkup. Of course, data systems will have to be developed to support this and it will have to be budgeted for, but the extra convenience will no doubt make a big difference for many and could help with early detection of these diseases. (We previously wrote about the idea of such an expanded annual checkup programme here.)

Read more in Daily Maverick: There are paths to quality universal healthcare besides NHI

Getting the state to pay for such checkups at private sector pharmacies is not exactly NHI as set out in the bill, but the idea certainly shares some DNA. In this, as with using public funds to pay for public sector cancer patients to go to private hospitals, there are things we can try that are of the same universe as NHI, but not from the straight jacket of the NHI Bill and all the inflexible thinking that surrounds it.

To be fair, there are at least some exceptions that show such innovation is possible. Maybe most notably, these days many public sector patients can collect their chronic medicines at private pharmacies or other pickup points. Though still a work in progress, the evolution of the public sector medicines distribution system shows that we need not wait for the NHI Bill before taking steps to make things easier and more convenient for users.

In addition, with the NHI pilot projects we have seen at least some awareness that there is a need to try new things and learn from them. Unfortunately, on the whole the NHI pilot projects didn’t meaningfully pilot the key aspects of NHI, and where they did, as with GP contracting, it didn’t go well. And here one gets to the rub. From the outside one gets the impression that those who wanted to run pilots we could actually learn from lost out to those who consider the pilots just another step toward building political support for NHI.

As for the NHI Bill itself, the fact that the ANC and much of the portfolio committee on health, has been intent on reducing almost all discussion on the Bill to a simple for or against shows a clear disdain for meaningful engagement. Indeed, whatever its merits, the ANC’s version of NHI has become fundamentally associated with an overdose of ideology and an absence of curiosity and critical thinking.

But we don’t have to buy into the ANC’s sclerotic thinking. We need not believe the myth that our only choice is between the status quo and the specific future set out in the NHI Bill. Neither do we have to be afraid to ask why the public sector can’t be more like the private sector, or why all clinics can’t have appointment systems. There are many possible ways to reform and improve our healthcare system. Some will be affordable, some won’t. Either way, it would be foolish to simply turn our backs and pretend they are not there. DM

Marcus Low is the editor of Spotlight.

This article was produced by Spotlight – in-depth, public interest health journalism.

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