What SA’s Covid-19 experience tells us about NHI

What lessons then, if any, should we take from the Covid-19 response as we continue to debate the NHI Bill and how an NHI system might work? We put this question to three public health experts.

What Covid-19 revealed about health systems

The impact Covid-19 has had on NHI is an interesting question, but more relevant perhaps is asking what the pandemic has taught us about our healthcare system, argues Professor Alex van den Heever, chair in the field of Social Security Systems Administration and Management Studies at the Wits School of Governance. 

Van den Heever says the pandemic has shown that the centralisation of power often creates what he calls a “single gatekeeper” for activities, such as distribution and procurement. “If you have all your eggs in one basket, and this is what we learned from the Covid-19 experience, is that if they mess up, they mess it up for everybody. That’s the problem with poor centralised designs — that you give too much power to a centralised structure, [and] if they fail, it fails for everybody,” he says. 

Procurement corruption and NHI

Speaking on the corruption that was revealed by the Special Investigating Unit (SIU) involving procurement of personal protective equipment (PPE), Van den Heever says that this shows how pre-existing provincial public healthcare systems are deeply corrupt across the board, which is cause for concern given the centralised structure of NHI.

Adding to this, Sasha Stevenson, Head of Health at Section27, says that these PPE disasters highlighted the risks when procurement is not transparent and there is no accountability. “These were not new risks. In fact, the Auditor-General has been warning about poor financial and supply chain management and a lack of accountability in health for years,” she says. 

These procurement issues, however bad, cannot solely be blamed on the health sector, says Nicholas Crisp, who has been working to establish the government’s NHI office. “The procurement in the healthcare sector is not controlled by the Department exclusively, this corruption is everywhere, all the departments. There are issues around the procurement policies and requirements that are laid down by the Treasury, not by the National Department of Health. We know, and the Treasury knows, that it was a mistake to reduce the requirements for the procurement of PPE, because it opened doors that allowed this to happen.”

Crisp says that the plans for procurement under NHI are far better than the current or emergency procurement regulations.

Centralised procurement

For procurement under NHI to be effective, Stevenson says that strong governance systems must be established from the start and transparency must be guaranteed. This transparency must carry over to all transactions of the NHI fund, details relating to the benefits package, as well as details concerning procurement.

“Covid-19 highlighted, once again, the vast inequities in the health system. A health system that can only cater to some, will fail all. For NHI to work we need strong leadership and governance, we need transparency, and we need equity,” says Stevenson.

The NHI proposals as they stand, notes Van den Heever, involve a lot of centralisation of procurement in a corporate governance framework that allows for political appointments all the way through. “There are three areas that are high-risk areas vulnerable to corruption in public organisations. One is the power of appointment, the second is procurement and the third is licensing. All those three elements will actually fall under centralised control within the NHI framework with governing party control over the organisation. Remember, a political party is a private organisation and has no place directly running public entities,” he says.

“The only difference between what we have now and what is envisaged in the NHI, is that they’re proposing to consolidate that authority at a national level and then make it a purchaser of everything. So it’s a massive increase in the concentration of power,” he says. 

With regard to weak provincial healthcare systems, Crisp says that Covid-19 has shown the need for cohesion between national and provincial health departments to be dramatically improved and that the national department must provide stronger leadership. “In the public sector, giving money to the provinces and telling them to give health a little here and there and not having a succinct and coherent national budget is terrible,” he says. 

Public and private sector cooperation

Despite the findings of widespread corruption, not everything that the pandemic has revealed in South Africa has been bad. Stevenson says that the government’s centralised vaccine procurement and allocation plans could be a good opportunity to showcase the benefits of a functioning NHI. “If implemented, these plans are a good opportunity to demonstrate the benefits, for public health, for cost and for equity, of a health system that treats people according to need rather than according to wealth,” she says. 

“Similar opportunities presented during Covid-19, such as standardising testing cost or hospitalisation protocols across the public and private sectors, were not taken up. The vaccine programme is a chance to learn from the shortcomings of the ‘business as usual approach’ to health service provision, and I hope that the department will stick to its guns,” she says.

Covid-19 was a wake-up call, says Crisp, that highlighted known deficiencies that suddenly became priorities. “We’ve proven we can fix A, B, C, D and E, we’ve proven that we can talk to the private sector. There’s a whole lot of stuff that is better than it was before Covid-19,” says Crisp.

Residents in Kagiso on the West Rand show up to give input on the NHI Bill. (Photo: Rosetta Msimango / Spotlight)