To have or not to have an NHI

While there seems to be widespread recognition that our current health service is inequitable and that access to care must be extended to all, commentary on the NHI Bill has generally been negative, even hostile.

A more constructive minority feel, with justification, that while the motivation behind the NHI is good, pushing ahead with it now will destroy an already critically ill health system. There are excellent examples in Daily Maverick pieces by Ferial Haffajee, Judith February and Mark Heywood; Anneliese Burgess’ article in Vrye Weekblad; and critical comments by Professor Alex van den Heever.

Common themes that run through these contributions include contextual issues concerning corruption, poor governance and accountability at all levels of the state and a mercenary private health sector urgently in need of regulation; crises of quality and sustainability in both private and public healthcare delivery systems; and critical defects within the bill itself.

The controversy around the NHI Bill must be viewed against the background of South Africa’s profound economic, social and political crisis — a crisis characterised by failure of the democratic state under the paralysed ruling party to improve the living and working conditions of the majority and to reduce the dangerous structural inequalities inherited from (and sustained beyond) apartheid; a crumbling, dysfunctional public health sector after more than two decades of crippling public-sector austerity under neoliberalism; an unsustainable and unregulated private health sector; and rampant, deeply entrenched corruption.

While key state institutions are broken or captured, powerful vested interests resist attempts to stop the looting of national resources and tax evasion, and to hold accountable those responsible.

Our national health crisis is a major part of all this. It is characterised by an enormous quadruple burden of disease, arising from severe structural inequality in access to the goods, services and social conditions that we all need to be healthy. These are known as the social determinants of health (SDH), and include decent housing, household food security, water and sanitation, personal safety and security, good education, decent jobs, and adequate income.

Large numbers of people lack adequate access to the SDH. They live and work in conditions that are incompatible with good health: unsafe physical environments, social disintegration, violent crime and deep distrust of state institutions. Then, when they get sick they frequently encounter a fragmented, highly inequitable health service where quality health care is least accessible to those who need it most. As a nation, we cannot allow this to continue.

Dealing effectively with the health crisis requires concurrent concerted action in both these areas. First, we must address the SDH. These lie outside the ambit of the health sector; addressing them requires concerted action by other state sectors. International evidence suggests that addressing SDH effectively will lead to a substantial (about 50%) reduction in the burden of disease.

Second, we must build an equitable, unified and sustainable health system that delivers good-quality health care to all according to need rather than means (an important distinction that lies at the heart of much of the debate). Despite its flaws, the NHI is the only concrete plan in town that has the potential to achieve this through its stated objective of Universal Health Coverage (UHC), drawing on all available healthcare resources, many of which are sequestrated in the private sector beyond the reach of the majority.

Many countries around the world are striving to implement UHC; it has become central to the global strategy to promote health equity and is included in the Sustainable Development Goals.

But the concept of UHC is open to contestation and the term is used to cover a range of financing mechanisms and health system designs. Much of this debate centres on disputes between those who favour voluntary membership-based prepayment insurance models that discriminate against the poor and least healthy, and those who advocate universal mandatory prepayment systems where the wealthy, younger and healthier people cross-subsidise those who are less well off, older and less healthy, in a spirit of social solidarity — the model underpinning the NHI.

There is compelling evidence that, to realise its objectives of universality, equity and (particularly in the South African context) social solidarity, the road to UHC must address the needs of the entire population and the whole health system from the start.

Experience, especially in Latin America, shows that piecemeal “transitional” arrangements that set up various population categories with differing risk profiles and funding channels lead to the creation of groups with vested interests in the status quo who resist subsequent attempts to move towards unified systems.

Indeed, this is the situation we confront today, where the main resistance and most vociferous criticism comes from groups with vested interests in the highly profitable private sector. To make progress towards UHC, a single-payer system with mandatory prepayment is essential.

The NHI Bill can rightly be criticised in a number of aspects. It is written as if the context is irrelevant. Building a good health system requires a high degree of societal coherence, a functioning state with trusted institutions and an ethical private sector. We lack all three.

Society is torn apart by inequality, persistent spatial apartheid, exclusion from the economy, lack of jobs, and so on. The state is hamstrung by factional battles within the ruling party and an incoherent opposition. And, as the Competition Commission’s Health Market Inquiry shows, and Nicholas Crisp, a senior health manager and adviser to the Minister on NHI recently said to Daily Maverick, many of the operations of the private sector, especially over-servicing, represent “massive, institutionalised, organised fraud”.

A stark example of over-servicing is the fact that 74% of babies born in the private sector — to the healthiest mothers — are delivered by Caesarean section (at an average cost of R39,000), while the rate in the public sector is 28%, and the global average is 21%. While the bill includes mechanisms to prevent and deal with corruption and fraud, there is no convincing reason to believe that these will be effective, particularly since all members of the NHIF Board will be appointed by, and then be accountable to, the Minister.

Furthermore, there is a real danger that, ironically, the NHI could aggravate urban-rural inequality. Reimbursement of service providers, both public and private, depends on their accreditation by the Office of Health Standards Compliance (OHSC). The most recent report of the OHSC reveals that only five of the 696 facilities inspected met set criteria for accreditation. Unless there is massive investment in, and capacity building of, the public sector, it is likely that few public facilities, especially in rural districts, will receive accreditation while private, urban-based facilities are more likely to succeed.

The bill proposes that contracting for services at the district level will be undertaken by Contracting Units for Primary Health Care (CUPs). Unless substantial capacity is developed and mechanisms for monitoring — including by local health committees — established, the potential for dysfunctionality and fraud is great.

There is widespread recognition that the weakest components of our health system are at the community and primary (clinics and health centres) levels of care. Moreover, poor and rural people depend very significantly on these services. Investing in community-based health workers can not only save lives, but also reduce costs of healthcare, and provide much-needed employment to rural women and stimulate local economies. We contend that this approach is more likely to succeed in job creation than the president’s forthcoming investment conference.

Much of the hysteria around the NHI centres on its “unaffordability”. The often-touted figure of R256-billion as extra expenditure completely misrepresents the actual cost, as clearly explained by Dr Nicholas Crisp in his interview with Steven Grootes on SAfm Sunrise on 19 August (podcast available on the SAfm website). With the current expenditure on the public health sector at R221-billion, the additional cost is of the order of R30-billion — an eminently affordable increase.

As a nation, we cannot let the health crisis continue. The current state of affairs in our health system is unsustainable and morally unacceptable: the public sector, on which most of the population depend, is under-resourced, badly managed and dysfunctional in many areas. The private sector, where resources are concentrated, is unaccountable, lacks proper regulation and is increasingly unaffordable and unsustainable.

The NHI, with all of its faults and lack of clarity, provides a basis for a unified and equitable health system. None of its detractors have produced a viable, realistic alternative.

Moving forward will be fraught with setbacks and arguments and it won’t be easy. But we must do what is necessary to make it work.

“No society can legitimately call itself civilised if a sick person is denied [healthcare] because of lack of means. Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”

— Aneurin Bevan, British Health Minster from 1945 to 1951, who introduced that country’s National Health Service. DM