NEHAWU
National Education Health & Allied Workers Union

1. Introduction
In response to the South African Department of Health (DoH)’s proposal to introduce Social Health Insurance (SHI), NEHAWU convened a seminar on National Health Insurance. The seminar was held on 29-30 August 2007 in Braamforntein, at the Parktonian Hotel. A number of delegates from health organisations, health sector trade unions which included the South African Medical Association (SAMA), Democratic Nursing Organisation of South Africa (DENOSA), and National Union of Mineworkers, academics and the Department of the Health attended the seminar.  

2. Aim and Objectives
The aim of the seminar was to engage all key stakeholders to develop concrete proposals and identify appropriate responses to the DoH SHI proposal.

Objectives:
•    To stimulate discussions among stakeholders around NHI and consequently identify areas of research in order to support the campaign with proven data
•    To mobilise key stakeholders towards NHI campaign

The seminar was addressed by key speakers from leading organisations such African National Congress, Minister Geraldine Fraser Moleketi, South African Communist Party (SACP) and received informative presentations from the Director-General of the Department of Health, the Director of the AIDS Law Project, the Council of the Medical Schemes and the South African Communist Party.

Based on the current situation of the South African Health system which is characterised by inefficiency in health care delivery and inequalities in terms of access to health care, the representatives were determined that the implementation of the National Health Insurance (NHI) would  address such challenges facing SA health system.  

Informed by the presentations, the representatives of the organisation that attended the seminar reached the following conclusions:

• That there is an emerging and widely shared consensus on the need for a developmental state that can decisively intervene in the current health crisis, the biggest burden of which is carried by the working class. It is believed that one of the fundamental tasks of the developmental state is to build a strong public sector.
• The crisis afflicting the health system in our country is a result of a combination of the persistent legacy of Apartheid, the compounding impact of GEAR on public health infrastructure, staffing and funding, the on-going attempts to phase-in a Social Health Insurance system, without any fundamental transformation in the provision and funding of the health system.
• That South Africa needs to build a unified national health system, founded on a well resourced, effective and expanding public health sector. Therefore; National Health Insurance represents an important pillar for building a unified national health system providing universal access to health care to all, in line with South African constitution.

Thus, it was agreed that there is a need to step up our efforts to realise our demand for NHI in South Africa and there was a concern among the participants that to this day, there has been no movement towards an NHI in the existing ANC policy favouring the NHI. Instead, piecemeal reforms in a form of social health insurance and health charter are being advanced. Both these reforms use market-driven mechanisms to provide health care. Therefore, there is a need for a fundamental restructuring in the manner in which the health care system is funded and operated in South Africa. 

It was also noted that with the current health care resources (private and public) at its disposal amounting to more than 8% of GDP (more than R135-billion in 2006), South Africa can afford health care for all. There was a concern that two-thirds of these resources currently serve a minority of the population (less than 7 million), through a profit-driven private health industry. Yet, the public health care system which serves the majority performs poorly compared with many countries on major health indicators such as life expectancy, infant mortality.

3.    Broadly Agreed Perspective on the NHI

1. NHI is not voluntary but it must be state mandated.
2. NHI must be state administered. This raises questions on whether Medical Scheme contributions should be discontinued or should it continue to include Medical Scheme contributions. How it is state administered raises options if this should be located in a state agency or in the National Department of Health.
3. NHI should be universal and not for targeted groups only, such as for those who cannot make any financial contribution. This would discourage the choice to opt out of the NHI for hose who can afford to pay for services elsewhere.
4. NHI must be free at the point of service delivery.
5. To exclude luxurious/cosmetic services
6. To adhere to SA constitution to make health care accessible to all people irrespective of where they come from and their economic status. However, it was mentioned that foreigners need to be encouraged to have insurance when they come to SA.
7. To improve infrastructure, e.g. enhance technology and improve governance
8. NHI should also be contributory. The employed to make contributions – maybe those that earn low wages to make discounted contributions.

How this money is collected should be discussed but the following options to fund NHI were highlighted as below:

• Deductions from the pay-roll
• Dedicated progressive tax to fund health care. It must be a progressive tax, proportional to earnings. How to collect it must be decided.
• Increasing tax
• Donor funding
• Compulsory contributions
• All tax forms

4. Areas of Further Work
It was highlighted that a range of areas on which more work, consultation and education amongst our members and other organisations is still required in order to support our vision of an NHI. This includes:
•    The research gaps around particular areas such as the funding, pooling, provision and purchasing in the delivery of the NHI.
•    Outlining the implications and options of the transitional process towards the achievement of the NHI around the funding, pooling, provision and purchasing.

4.1. Issues to cover:
•    State administration – what kind of state administration?
•    Resources required to administer NHI e.g. HR, skills
•    Universality – who are we covering?
•    The NHI package. Should it include home based care and life time care? Should it cover luxury items?
•    The costing of the NHI system?

5. THE WAY-FORWARD

Participants agreed to:

• To build a broad coalition around a campaign calling for the NHI. Therefore, to jointly outline steps towards a public launch of a campaign and a development of a programme of action.
• To engage with the ANC Social Transformation Committee of the ANC ahead of the December National Conference in Limpopo.
• To engage COSATU and all its affiliates and the SACP – which has recently adopted its Red October Campaign, to focus on the health care system.
• Through our structures, both for our members and the public at large, to build a nation-wide education campaign around the NHI, as part of our task to popularise the NHI in a simplified and understandable language for our members and the public as a whole.