The Mercury
June 03, 2009 Edition 1
Anso Thom

HARDLY a day goes by without South Africa’s beleaguered health services hitting the headlines. Many of the stories speak of neglect and poor health care.

Only recently, The Mercury reported that state clinics and hospitals misdiagnosed a boy with suspected meningitis on four occasions. Neo Alberts, 16, was brought to a Joburg clinic twice in two weeks after complaining of severe headache, vomiting and a stiff neck – classic symptoms of suspected meningitis.

He was sent home with nose drops, penicillin and a sick note. When he was taken to Chris Hani-Baragwanath Hospital, paramedics and a doctor reportedly accused him of taking drugs. It was only when it was too late that the doctor told his parents he had “severe meningitis” and he was put on a drip. Neo died soon afterwards. In Cape Town, asthma sufferer Bevan Gaffley was reportedly refused proper treatment at the Delft Day Hospital.

According to his family, they begged staff for hours to assist him, but to no avail. His mother later found him slumped in a chair, his eyes rolled back in his head, allegedly still waiting to see a doctor. The young man is now on life support in Somerset Hospital’s intensive care unit. And on Friday, thousands of doctors took to the streets to voice their unhappiness with the state of our health-care system.

They were not only protesting against the very low salaries for young doctors who have to attend to an inhumane number of patients every day, but also, among other things, the poor state of affairs at the institutions where they work, where equipment is often dysfunctional and basic supplies are out of stock.

While all this is going on, a team of people asked by the ANC to come up with a National Health Insurance (NHI) plan has been meeting behind closed doors, drafting a proposal they believe will ultimately pump more money into the buckling health system. And this weekend, the leader of this ANC task team and CEO of the Human Sciences Research Council, Olive Shisana, will present the grand plan to a high-level ANC meeting.

The NHI was a key ANC election promise and the party vowed to implement it within five years, despite the economic downturn. Top ANC brass recently promised it would be in place within a year. While pooling the country’s scarce health resources is essential to improve health services for most, there is a fierce battle about how this should be done and funded.

Goal

Those on the left are arguing for the effective nationalisation of private health, while medical schemes are keen to remain part of the health system and administer parts of the NHI. Insiders have confirmed the task team is dominated by unionists who believe the goal is a scheme that will ultimately get rid of medical schemes. This would mean that those wealthy enough could pay cash for expensive health care from a much reduced private sector.

A confidential NHI draft distributed in February proposes universal coverage that is free at the point of service and covers all “medically necessary” interventions. It says the NHI should be a state-administered, single health insurance system, and that funding for the NHI should be sourced from general taxes and compulsory contributions by all employers and employees.

Tax rebates for medical aid contributions will fall away, making medical scheme contributions unaffordable for those who want such cover over and above that provided by the NHI, particularly those at the low income end. There is widespread agreement that inequities in the health system, which have resulted in the private sector monopolising resources disproportionately, need to be addressed. However, this must be done in a manner that does not destroy the functioning private sector and cause more skilled health professionals to leave the country.

It is widely accepted that former health minister Barbara Hogan’s firmness that the current NHI proposal be subjected to proper processes and public scrutiny led to pressure from the unions that she be removed from the health portfolio. It will be one of new Health Minister Aaron Motsoaledi’s first big tests to see if he will be resolute that the ANC proposal is subjected to the same processes Hogan insisted on.

While some in the ANC are keen to see an NHI plan in place by September, health economists and other experts have cautioned against moving too fast. Many respected experts in their field, at first part of the task team, left after they realised their voices were not being heard. It is important for these people to be drawn back into the process. Fundamentally South Africa needs an NHI of some form. Those in the know have pointed out that it is possible and affordable, but that it is critical that the country first invests in our public hospitals, the backbone of any NHI plan.

We need to keep building up the funds dedicated to the public sector and consider the establishment of a national emergency insurance fund, which will see everyone in trauma and emergency situations treated at the nearest health facility, irrespective of whether it is public or private sector. Our public hospitals are struggling to cope. The HIV/Aids epidemic is flooding wards, we have a critical shortage of nurses and underfunding is seeing a cut in beds, malfunctioning equipment and a constant shortage of drugs and other supplies.

The funding of systems and solutions to uplift the hospitals is critical as it will move the institutions from crisis mode to service providers that the public feel confident in and want to utilise. South Africa’s health sector has much going for it and it has the potential to be a phenomenal service, but hastily adding an NHI plan which would only add to the burden is not the solution.

Once hospitals are able to offer an excellent service, it would make sense to move to some form of NHI at a rapid pace. However, the process being used to implement NHI and the pace at which it is being done could remove any hope of getting it right. Others have added their shopping lists of matters to be addressed before the NHI can begin to be introduced.

These include:
o    Addressing the human resources problems;

o    Addressing infrastructure problems, especially in terms of hospitals;

o    Establishing an effective procurement and supply chain;

o    Implementing a proper IT system;

o    Putting proper monitoring and evaluation systems in place, in order to understand the disease burden;

o    Finding an effective system through which to collect revenue;

o    Ensuring that the proposed system meets constitutional obligations;

o    Addressing issues of accessibility to NHI, especially for people who do not have identity documents or who are not permanent residents.

Countries such as Norway, Singapore, Ireland and Canada that have achieved full NHI systems share several key characteristics: high per-capita expenditures on health care, high employment levels and low levels of income inequality, and an adequate supply of human and physical health-care resources.

Criteria

South Africa does not meet most of these criteria at present. The private sector argues that South Africa must follow a path to NHI through gradual expansion of employment based health insurance coverage. However, others point to the failure of many countries, particularly in Latin America, to achieve universal coverage through this approach. Experience in Mexico, Chile and many other countries has shown that developing a two tiered social health insurance (covering only the employed) has heightened health system inequities and proved an obstacle to moving to universal coverage.

A growing number of countries, such as Ghana, are implementing universal NHI from the outset, with the government paying the contributions out of tax funds for those unable to pay. The elimination of medical schemes will not accelerate the implementation of an NHI. Medical scheme premiums are private money and eliminating them will not shift that money to the NHI system.

Elimination will also not automatically shift doctors and nurses back to the public health system – some believe that private doctors will either exit the system or work for cash. Migration to the public sector will only occur in large numbers if remuneration and working conditions are improved. Ultimately, politicians and those tasked with devising an NHI plan can fiddle around the fringes – ignoring the elephant in the room – but until the government properly finances the public health system which has been systematically underfunded for years, an NHI remains a potentially good idea on paper. – Health-e News

This is the first in a series of articles on this topic to be published in the The Mercury over the coming weeks.