Having read through the Bill that was published late last week, I am now certain that the National Health Insurance is a profoundly terrible solution for a problem we do not have; which is to say that if we actually did have real challenges concerning access to healthcare, the NHI would have been a grossly inadequate and just downright bad proposition.
Believe it or not, South Africa, in theory and in practice, actually has universal health coverage. The National Health Act, in its current form and shape, guarantees access to healthcare for all; it provides free primary healthcare for every citizen, sets conditions for free health services in district and tertiary hospitals, stipulates strict conditions under which a patient may not be turned away, even when presenting at a private hospital, and defines the framework for a means test to bill those who can afford in the public sector setting what is termed “Kuthiwa ukukhokhela i-file”, an amount that ranges from R42 to R65.
To appreciate the openness and coverage of our access to healthcare, you only need to visit our wards and theatres, and count the number of foreign nationals that are admitted in our public hospitals. While it might be a mission for a foreign-born child to find space in our public schools, this is definitely not the case with healthcare. Heck, part of the reason South Africa is ranked number one on the continent as a preferred destination for medical tourism is precisely because of our accessibility.
So it really baffles me how we ever got to this point where for almost a decade we have been led down a path in a search for a solution to a problem we don’t have. When we are told we have found the panacea, it turns out to be really bad and we are now glad that we actually don’t have the problem.
Our real problem is the quality of the healthcare to which we are being granted such generous universal access.
We are granted access to a progressively collapsing public healthcare system, which is under-staffed, under resourced and has debilitating infrastructure. We have access to a healthcare system that does not qualify to be called a system, lacks standardisation of processes and procedures, has poor quality assurance across the board, and is riddled with financial mismanagement and procurement irregularities that amount to unaccounted billions and massive fruitless expenditure. We have a problem of poor leadership and gross incapacitation from national, to province, to district. We further have a private health sector that is extremely overpriced, disproportionately resourced, largely unregulated and heavily distorts the doctor-to-patient ratios in our country.
That is our problem!
The National Health Insurance Bill does not even vaguely deal with these real challenges that cripple our healthcare system. Instead, it babbles on about pooling of funds, co-funding, and all other “entrance fee” issues which aren’t really the problem in South Africa. We don’t have a problem of entrance.
We need a bill that enforces the necessity to establish a highly skilled and multisectoral co-ordinating body to provide oversight and efficiency assurance for the Hospital Revitalisation Programme, which is aimed at improving existing infrastructure and building new health facilities. In addition to infrastructure development, the programme is targeted at dealing with health technology and organisational development and management. Concerted attention to these three thematic areas, within this programme, will deliver significant improvements in the quality of public healthcare. Currently millions of rand, within this programme, are returned to Treasury at the end of every financial year due to poor budget utilisation as a result of sub-optimal programme management systems.
We need a human capital development strategy that is geared towards producing more healthcare professionals, especially doctors; improves the scope and capabilities assigned to nurses, maximises the production capacity of the current medical schools, and build at least one new medical school in each province to train all healthcare professionals, and not hide behind this virtual medical school we are told we have in Limpopo, but don’t really have. This strategy must also introduce and enforce mandatory public service hours for all doctors as a licence condition to practice in South Africa in order to counter the doctor-to-patient ratio distortions created by the private sector.
We need a healthcare service delivery model that is value-based, as proposed by Prof Michael Porters from the Institute for Strategy and Competitiveness at Harvard Business School. Value-based healthcare is characterised by a healthcare system that is organised into Integrated Practice Units; measures outcomes and costs per patient; offers bundled payments for care cycles; provides integrated care delivery across separate facilities; expands excellent services across geography, and adopts a robust workflow digitalisation programme and process standardisation. The thrust of this model is to bring the sophistication provided by higher-level hospitals close to the entry-level care centres and thus shorten every patient’s stay in the healthcare value chain, while providing improved and better value.
Last, but certainly not least, we need strict measures to cap costs in private healthcare. The private sector increases prices, year on year, at a ridiculous rate that is often close to double the inflation rate. While they hide on the supply-demand dynamic, the competition commission has found this not to be entirely true. This must be controlled. We also need a stronger Office of Health Standards Compliance. We currently do not have objective reporting mechanisms for the quality of services in the private sector. It is often assumed that just because the hospitals are clean and efficient, the care must be premium, which might not be the case.
We really do not need the NHI, certainly not its current form and shape. The only time we need the NHI is when Minister Aaron Motsoaledi is looking for a PR exercise that will deflect attention from his incompetency, which has brought public healthcare to its knees. The unfortunate part is that he is quite a compelling communicator, and will have everyone in the room eating out of his dirty hands and even confuse some really smart people into believing that he is actually working hard and we are close to finding the magic pill.
Look, to be fair, he might be working hard, but he has definitely been working on the wrong thing for the last 10 years. DM
Dr Bandile Hadebe is a Former President of JUDASA (Junior Doctors Association of SA) and the current National Head for Strategy for Progressive Youth in Business.