Defend Truth


SA’s looming NHI will have to contend with a historically unhealthy state of affairs


Dr Xolisile G Ngumbela is a senior researcher at the School of Public Management, Governance and Public Policy, College of Business and Economics, University of Johannesburg. He writes in his personal capacity.

The challenges facing South Africa’s fragile health system are threatening to catapult communities into chaos.

Neglect and a lack of resources, particularly in the rural Eastern Cape, has resulted in a number of difficulties in the area of healthcare expenses, healthcare services, and medico-legal issues. The nation lavishly finances the care of a small percentage of the population and many healthcare professionals solely treat a small number of wealthy patients. Far fewer are available to care for the rest of the population.

Our Constitution states that everyone has the right to access healthcare. The National Department of Health has recognised that it is past due for the nation to transition to universal health coverage to guarantee access to high-quality healthcare for all citizens, regardless of their financial situation. However, the introduction of the National Health Insurance plan in South Africa is not alone an answer to the challenges that are bedevilling South Africa. Anecdotal data and research from all over the world indicate that there will be difficulties in implementing the NHI plan. In South African public hospitals, these issues would include issues like rising incidence of illness and a lack of staff to oversee the project. The roadmap for the scheme, even at this stage, appears to lack clarity so conspicuously that even health workers themselves have no idea of the plan’s goal.

Legacy of underservice

At our transition to democracy, South Africa should have dealt decisively with a bureaucratic, fragmented health policy that delivered service along apartheid lines, rather than need and access. A clear political commitment to ensuring equity in resource allocation was promised, and while the country is trying to put its house in order, we are not out of the woods yet.
To begin transforming the health sector, government had to begin by correcting past ills through viable clear-cut means. Several factors are currently hampering its efforts. The concept of a National Health Insurance has the potential to profoundly alter the South African health sector, replacing the two-tiered system that is currently in existence with one that is more integrated, equitable, and cost-effective. But although the White Paper outlines the NHI’s ultimate objectives, there hasn’t been much progress made in articulating the practical steps that must be undertaken right away. Government has not been able to effectively and coherently communicate what NHI means, what range of health services will be provided, what the financial contributions will be, how the quality of services will be assured, and what role health providers and workers will play in the public and private sectors.

Providers and users of health services are crucial NHI partners, and there is anxiety among stakeholders as a result. There is an urgent need to finalise an NHI implementation roadmap that outlines a time-bound framework for how NHI will be implemented, including the essential activities and tangible deliverables, as well as how and by whom these activities will be performed.

Currently, the flaws in the NHI implementation plan provide significant obstacles that will prevent progress on the NHI, including the challenges associated with concentrating funding into a national NHI Fund. This is especially so given the current provincialised health financing system which faces difficulties due to the lack of skills in rural provinces.

Cost control

Nonetheless, the NHI’s benefits would include lower overall healthcare costs. Through bargaining and regulation, the government would be in a position to keep medical care costs under control. Additionally, there may be a reduction in administrative expenses since doctors would just have to deal with one government entity. The promotion of Primary Healthcare may also assist to eliminate educational obstacles relating to health. Children who have undiagnosed and untreated health problems cannot benefit fully from education. To remove obstacles to learning, the NHI should ideally increase access to testing and healthcare options.

Above all, the system should encourage equality. Rather than a person’s capacity to pay expensive medical costs, access to healthcare should be based on need. Every citizen should be able to obtain the same level of care with lower total health expenses and standardised services.

The implementation of an NHI may help us boost the economy. South Africa might have a healthier workforce if the NHI can offer preventative care. Increased preventative care would also lessen the need for trips to the emergency room, which would lower the price of medical care. Worth noting too is that NHI can strengthen social security if it is properly planned and implemented — an area in which our government seems to frequently fail. Future social problems like crime and welfare dependency may be avoided with improved access to healthcare. An NHI should also provide assistance to vulnerable populations who have been neglected in the current inequitable healthcare system, such as the elderly or low-income women.

Primary healthcare doubts

There are some perennial problems. Current national health expenditure seems to prioritise tertiary services rather than primary healthcare, despite the obvious necessity to decentralise services into district health systems to counteract apartheid-era discrimination which saw white people and people living in urban areas getting the lion’s share of quality services.
Poor management is another contentious issue: delivering seamless, quality service to citizens requires solid partnerships and skilled managers free of cadre bias. But defective and deficient policy implementation reigns.

How will this history affect a proposed NHI built on the idealistic notion that everybody must have a share in good health? It can only work if it is well-managed, with resources in rich supply.

Healthcare systems run mainly on one of four models: direct or out-of-pocket payments; general taxation; voluntary or private health insurance and social health insurance. South Africa features a mix of these models, with all of them depending on an efficient system.

Our unique problem is a large and impoverished rural population, which faces the greatest challenge to accessible healthcare. This is due to several factors:

  • A lack of qualified personnel;
  • A concentration of skilled workers in urban areas;
  • Over-burdened public sector healthcare staff; and
  • Poaching of healthcare workers by international players who can afford to pay higher wages.

South Africa also operates under the illusion of choice. Patients are “free” to choose between public and private healthcare — with the latter run very efficiently — but such luxury is beyond the budget of the majority, owing to escalating poverty and a continued credit crunch.

The result is a reverse-apartheid scenario in which economics dictates quality of life.

Eradicating problems at district or local level is key. Non-negotiable factors influencing how we will cope over the next decade include commitment from national, provincial and local authorities, strict control over finance and staff resources, and on-the-ground authority to make community-focused decisions.

Government must take heed of the red flags plaguing health systems: fragmentation of services, interprofessional communication problems, lax attitudes of personnel with respect to community involvement, a lack of planning and evaluation, and a poor referral system.

They also must listen to health academics and experts who work with the data — and the people. These professionals have repeatedly told government that service fragmentation, lack of qualified staff and cash-flow issues should be swiftly dealt with with a resultant rapid improvement in healthcare delivery.

The solutions and resources are there — but those in power must have the will to utilise them.

Given the number of challenges in the current situation, when will NHI be implemented? I’m not sure. Government hopes the National Health Insurance Bill will be put into effect within the next financial year, at most. Reform, though, may take decades, according to authorities who speak behind closed doors.

Make sure you are financially stable in the interim in case you or a loved one needs medical attention. You can pay for the services you require during a hospital stay if you have a trustworthy health insurance provider. To gain some certainty in these unpredictable times, it may be worth requesting a quote today. DM


Comments - Please in order to comment.

  • Miles Japhet says:

    The problem is mismanagement and corruption in the public health sector.
    Naive socialist ideas about equality resulting in a push for an NHI will simply result in a flight of skills, lower taxes and an even less affordable and functioning healthcare system.
    The key reward of achieving economic success is the ability to choose. Education and health choice being primary motivators for people to invest in their education and take many years to do this.
    Apartheid ended 30 years ago – there is no longer any excuse other than ANC mismanagement and bankrupt ideology for the shocking sites of public health. Address the cause.

  • Rod H MacLeod says:

    “Non-negotiable factors influencing how we will cope over the next decade include commitment from national, provincial and local authorities, strict control over finance and staff resources, and on-the-ground authority to make community-focused decisions.”
    Xoli, this has NEVER occurred in South Africa under the ANC. What factors have changed that inspire your belief that this will now happen within an NHI roll-out?

Please peer review 3 community comments before your comment can be posted

MavericKids vol 3

How can a child learn to read if they don't have a book?

81% of South African children aged 10 can't read for meaning. You can help by pre-ordering a copy of MavericKids.

For every copy sold we will donate a copy to Gift of The Givers for children in need of reading support.