While they cannot exclude the possibility that the massive National Health Insurance Fund — predicted to disburse as much as R3-billion a week once it is in operation — will be impossible to “plunder”, they are trying their best to make it extremely difficult to do so, said public health consultant and manager of the National Health Insurance process in the Ministry of Health Dr Nicholas Crisp.

Crisp, with Sasha Stevenson from public interest law centre SECTION27, took part in a webinar on Sunday 15 November facilitated by editor of Maverick Citizen Mark Heywood and organised by the Health Sector Anti Corruption Forum (HSACF) that is co-ordinated by the Special Investigating Unut.

Crisp stressed that while the spectre of possible corruption and looting of the fund loomed large, it could not be allowed to deter plans to introduce the National Health Insurance, saying that the health sector was in dire and urgent need of reform.

Summarising the progress in implementing the NHI, Crisp said that the bill had been tabled in Parliament and a call had been made for written and oral submissions. “That concluded prior to Covid-19,” he said, explaining that Parliament received 30,000 written submissions and many requests for oral submissions. He said that visits to provinces for public meetings had been wrapped up before the outbreak hit the country. 

We need to make sure that the general public understands that the NHI is not a gimmick or a monster.

“Then we all went to work on Covid-19,” said Crisp, who has been working in the public health sector for 36 years. He said that after about two months he asked to be released from the Covid-19 team to again begin work on the NHI.

“A request for a new organogram has been submitted. The position of deputy director-general for the NHI has been advertised and will close on Monday (16 November). Further posts will hopefully be approved. There are 20 to 25 key positions that should be filled in the next two to three months,” he said.

He said there were many misconceptions about the NHI. 

“In its essence, it is a financing mechanism for funding health services. Ultimately the intention is for all of us to contribute to one single pool, the NHI Fund. It will be a public entity responsible to purchase health services,” he said. The fund he said, once fully operational, would receive up to R3-billion a week. 

He said the NHI Fund would be created by legislation. “We can’t go there until there is a bill. For now, the NHI is being set up as a branch inside the national Department of Health. Everything except the fund can be created here.”

He said that the outbreak of coronavirus infections in the country served as a huge wake-up call about the NHI. “During Covid the cooperation from the private sector was fantastic. People constantly asked what they could do at cost price. We must capitalise on where the goodwill is. 

“We need to make sure that the general public understands that the NHI is not a gimmick or a monster,” he said. 

Stevenson said it was clear to everybody that the way the health system functioned at present made no sense. “Reform is required. The question is the details. There are concerns over the processes, how the transitioning process will work, how the fund will be managed and how transparency will be assured.

Heywood asked Crisp: “Are you not just setting up a huge feeding scheme for tenderpreneurs? Convince us?”

Crisp said he believed the devil was in the details. “There are issues that must be debated. I do believe the NHI (as presently designed) is the right way to go. It is never impossible to plunder, but it will make it extremely difficult,” he said. 

Crisp explained that the fund was being set up in a way that it would purchase services from providers. The providers would still buy the consumables and goods. 

“It is a worry and a fear how this will be administered,” he said, adding that the digital systems would have to be secure and hard to hack and protect.

Stevenson said the healthcare system was very susceptible to corruption. “We saw the sharp issue of corruption during Covid. We need to deal with each area where there could be corruption.” 

She said that corruption was not only limited to the public sector.

I am an eternal optimist. Nothing is different anywhere else. If we leave the health sector like it is running now it will implode. You can’t just leave it like that. It has serious design flaws.

“There is fraud and abuse in medical aid claims as well. We need to look at the governance of the fund, the transparency of decisions and governance. We will need to solve corruption at each level. We can have all the technical systems in the world to deal with corruption at low levels. The way it is formulated at the moment, board members are appointed by the minister, advisory committees are all appointed by the minister, there is no space for civil society. We need to work structures in that they are less susceptible to maladministration and corruption,” she said. 

Crisp said he hoped that Parliament would take many of the suggestions made to improve the legislation seriously. “My job is to put as much of the administration in place as possible. We must be vigilant. We need accountability and transparency,” he said.

“We talk like there are only problems in the public sector. There are many problems in the private sector. I can give you legitimate case by case information on people being forced to lie to medical aids to get access to healthcare,” he said.

“We must make it simpler and far more transparent. I would like to see every transaction, as far as possible, to be placed in the public domain. I am under no illusions that this is going to be a walk in the park. You can’t squeeze a banana ripe. You must do it bit by bit. 

Responding to a question by Heywood about “terrible looseness” with which public funds are managed, Crisp said he could not suggest that the NHI would “get rid of corruption”.

“It is incumbent on us to design out corruption, fraud and maladministration. Patients steal from medical aids all the time and so do health practitioners – but the system doesn’t pick it up. You must have a system where [suspicious] amounts are flagged and bells and whistles go off. We already have that in [the NHI] system – to limit payouts to a correct amount,” he added.

He said they were in consultation with banks to learn from their systems. “But people still steal from them. You can’t completely exclude fraud and theft. We can minimise it and deal with it immediately. We can have internal and external flags and investigation. We are going to work with the Special Investigating Unit for fraud and corruption to be reported immediately and to investigate if payments should be allowed.

Stevenson said corruption happened everywhere. Consequence management had been sorely absent in the health system for a long time. “We need the political will to change the way public funds are dealt with,” she said.

“I am an eternal optimist,” Crisp said. “Nothing is different anywhere else. If we leave the health sector like it is running now it will implode. You can’t just leave it like that. It has serious design flaws,” he said. 

“Do you step back and say [the health system] will still be sick when I die? Or do you step back and say it is not ok. That is the point of departure,” he said.

“What do we do to fix the situation? You are welcome to differ. I have decided that I want to be part of the solution. We will do everything we can to block the corruption, stealing and fraud. I also watch the Zondo Commission. You can’t just say it will happen and do nothing. 

Stevenson said the best thing that citizens could do was to get involved in opportunities for public participation. She said civil society should advocate for these opportunities. “We must do what we can to take action.”

“But can ordinary people be the guardians of a national health system?” Heywood asked.

“They have not been empowered,” Stevenson said. “We as civil society have been trying to take it on. We talk to people about the NHI. There has been a lot of spin about it. People are looking for change, but any time something changes it is attributed to the NHI. We need better information and also allow for public participation. We can’t do that alone. We need more real information on what the NHI will look like.”

Crisp agreed, saying that he did not think that the public was even close to understanding the NHI.

“The information in the public domain is horribly wrong and skewed. There are fights between those with vested interests. Since 1984, nothing has changed in the public health system. I got a report from Butterworth hospital the other day and I wanted to cry. It is the same as what I have battled with in 1984. We need a communications manager dedicated to the NHI. We must design and have proper communication plans,” said Crisp. DM/MC

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