Politics, Sci-Tech

NHI: Not quite here yet, but it is coming

By Stephen Grootes 12 August 2011

Finally, we have some details on how the National Health Insurance scheme will work, enough to get a working draft of the whole thing going. Health minister Aaron Motsoaledi has unveiled the NHI Green Paper, after it went through a process almost as secretive as that of government’s land reform programme. Sensitive it is, and expensive it's going to be. STEPHEN GROOTES takes a look.

At 59 pages, it is not overly long for a document that aims at completely reconfiguring a country’s health system. Especially one as fragmented, abused and stuffed up as South Africa’s is. And there is something badly missing: The costing, the final “how it will actually be paid for” part. The most important figure really. It’s worth quoting the entire paragraph that contains as close as the whole thing comes:

“To achieve universal coverage, pooling of funds requires that payments for healthcare are made in advance of an illness, and these payments are pooled and used to fund health services for the population. The funds can be from a combination of sources (e.g. the fiscus, employers and individuals). The precise combination of these sources is the subject of continuing technical work and will be further clarified in the next six months in parallel (with) the public consultation”.

Right, so it will cost us more, but we don’t know how and we don’t how much. We do have some broad brush strokes though. At the moment government has budgeted around R110 billion for its health spending in 2012/13. The NHI would see that go from R125 billion next year, to R255 billion in 2025. You could almost build a couple of power stations with that. But it’s actually quite a climb-down. When the ANC first gave us public figures (at last year’s national general council) they came to a total of R374 billion by 2025. Someone has obviously done some serious trimming.

But none of this squares with finance minister Pravin Gordhan, who had been brought to the announcement, presumably to reassure everyone. He says he doesn’t want to see the tax burden rise. Hear, hear. But how can it not? As we all know, you cannot build more power stations without some serious cash. Health systems are the same. At the moment, Motsoaledi says we are spending 8.5% of our GDP on health, and if government’s current growth predictions are correct, we’ll end up spending 6.2% of our GDP on health. There’s a massive caveat though.

That’s only if you and I give up our privately-funded medical aids. If we don’t, then the amount spent on health as a percentage of GDP will just grow.

Right, now to the “if”. Yes, you will be allowed to continue using your Discovery card, it will nestle in your wallet next to your NHI card. Yes, you can go the Milpark if you want to. And yes, if you do that, you will still have to pay your NHI contribution. So yes, at this stage, it would appear to just be another tax for something you don’t use. A bit like the money you currently pay for police (and ADT) and education (and St John’s) and the roads (and any tyre repair chain you care to name) and SABC (and DStv).

But there is a strong case for the NHI as well, and we mustn’t ignore it. Motsoaledi gets almost emotional when he talks about equity, about how so many of our people have virtually no healthcare whatsoever. And about how that is unsustainable. That is true. It’s yet another variation on the tune that so many of our people have nothing, and the rest of us hide behind our ever-rising walls and live a completely different existence.

The scheme would see contributions gathered by Sars and fed directly into the NHI system itself. The scheme would be “an autonomous, public entity reporting to the minister of health and Parliament.”. It would be managed by a CEO “who will report directly to the minister of health”. There is also talk of “drawing in” the expertise that currently exists in managing health schemes to get this system off the ground.

Once facilities are accredited they will be able to provide services to the scheme and will be “reimbursed on the basis of the payment levels determined by the NHI”. This could be the start of major spats. Those “levels” will make or break any private healthcare company. There is also likely to be huge temptation for those with sticky fingers. While there is currently a private-public hospital in Port Alfred, the scope for more of these could be determined on how these levels are reached.

Motsoaledi sees five types of hospitals being included in the system from your local district institution to your specialised facility. There’s a big focus on getting people out of hospitals and into clinics. He’s quite open about how horrified he was to discover the minor ailments people present at the Chris Hani Baragwanath hospital, literally stubbed toes that should be dealt with by your local facility. However, I well remember hearing about this same problem more than six years ago, and it’s not something that will be dealt with quickly.

The ministry has spent some good money and time on a new computerised database system. Essentially, with a couple of clicks you can work out how many people are served by which facilities and where. There’s a great data to be gleaned from this: It can tell you how long it would take to drive to a particular spot for treatment at a government facility or where the local private GP is. Think a super-duper Google map of our health system (if you want to see something similar, spend some time on the Independent Electoral Commission website, and see how you can drill down into individual voting districts. It’s the same thing, only better). There’s a lot to be gained from it, if delivered well. In the US public hospitals were forced to publish their death rates several years ago. As a result, public pressure very quickly forced a closing of the gap between the worst and the best hospitals.

But mucking about with a health system is always risky. This particular move looks a little scary. There’s still much more maths to be done. And, of course, there are still big project-threatening questions to be asked about cost and how those will affect all of us. The reputation of the public health system is so bad, that those on medical aid will be hard-pressed to give it up. Suffering through long waits with a sick child on a hard bench would force many to re-think their futures.
Motsoaledi himself has publicly lamented over the last year or so how little investment there was in public health infrastructure in the last 10 years. There are several reasons for this. But one of them has surely got to be his predecessor but one. Manto Tshabalala-Msimang ruined our health system, and its image. Anyone who thinks about public health still thinks of her. And no one in the ANC has ever apologised for what she did, despite the fact there is still clear anger over it. If you are going to muck about with the health system, you need trust. And until someone actually publicly says what she did was wrong, trust will be sadly lacking. And until someone sits down and does their sums properly, so will the money. DM

Grootes is an EWN reporter.

Photo: Patients with HIV and tuberculosis (TB) wear masks while awaiting consultation at a clinic in Cape Town’s Khayelitsha township, February 23, 2010. REUTERS/Finbarr O’Reilly.