Sunday Times
June 13, 2009
Rowan Philip

South Africa’s private hospitals are to be thrown open to the poor — and the country’s wealthier people will have to pay more for a service that will include state hospitals.

An ANC task team, headed by Dr Olive Shisana, CEO of the Human Sciences Research Council, is to unveil a policy document on a national health insurance plan within the next month.

It aims to replace South Africa’s dual system of public and private care within five years.

The Sunday Times understands that the plan involves doing away with medical aid tax breaks, and compelling every employer and employee to pay monthly fees to a central fund — likely to reach R100-billion.

In terms of the plan, every South African will have to be registered with a primary healthcare “gatekeeper”, to keep costs down.

Taxpayers and medical scheme members already, in effect, spend an average of R560 each month to subsidise healthcare for the poor.

But, as Shisana conceded in an interview with the Sunday Times this week, the public health sector is stretched to the point that it requires a share of the resources of the private sector as well.

Shisana said redressing “chronic inequality” was behind the move. She slammed the current system as an “apartheid health system” in which (private) institutions are still white” while critical staff and equipment shortages in the public sector kept the average life expectancy of South Africans below 50.

She said it was “ridiculous” that only 40% of the country’s doctors were available to treat 85% of the population, and — although no private doctor would be “forced” to work under the national health insurance system — she hoped that many of the country’s 27000 private sector doctors would be accredited to the new system.

“Any South African should be able to use any health facility, once the plan is in place,” she said.

South Africa has 216 private hospitals, with 28000 beds, and 342 public hospitals, with about 100000 beds.

Despite fierce public rumours this week that South Africans could in future be banned from buying health insurance for services covered by the new system, Shisana indicated that “choice” would remain a feature of the new system.

Alex van den Heever, a health economist and former participant on the task team, said the world’s healthiest societies lived in countries with national health insurance systems. However, he said, almost all were industrialised countries with very low unemployment, and that any fast roll-out of such a system in South Africa would be “disastrous for private and public healthcare”.

Shisana refused to confirm the proposals contained in the current draft , saying there would be “ample time for public debate and consultation with stakeholders” after its release.

However, an early draft of the proposal by the task team says that:

o    All South Africans must register with the “gatekeeper” primary healthcare provider nearest their home , who will refer serious problems to specialists at accredited hospitals;

o    “Zero tolerance” will be shown to accredited private hospitals which show “differential treatment between national health insurance patients and fee-paying private patients”;

o    All people in formal employment and their employers must pay an extra health insurance payroll tax, and make “mandatory monthly contributions” to the fund. Low-income earners and the poor are exempt;
o    All tax deductions for medical schemes must be “removed”, and added to the health insurance coffers — although the treasury opposes this;

o    All accredited private sector GPs are to be paid the same fees, based on the number of patients on their books — irrespective of how often a patient is treated by them. Infants, pensioners and pregnant patients will rate higher fees; and

o    With “resistance” from medical schemes and their members expected, wealthier South Africans are to be “sensitised” with an information campaign about inequities, in the hope that they will agree to “support the worse-off and sick sectors of society”.

Systems must be set up to prevent fraud, as well as “undesirable behaviour” among doctors, including “cream-skimming low-risk patients and refusing to treat high risk patients”.

Sources associated with the task team told the Sunday Times that Shisana’s five-year goal was “idealistic” and that a 15-year timetable for the roll-out was a more realistic goal.