Health is a universally recognised right, and the socioeconomic status of an individual must never be used as a criteria that influences a person’s health status and wellbeing. A human life is a human life – it starts and ends there. And it is for this fundamental reason that South Africa’s healthcare system is about to go through big and lasting changes.
With the presidential assent of the National Health Insurance (NHI) Act in May 2024, the country is taking a bold step towards making healthcare fairer, more affordable and accessible for everyone – whether you live in a city or a rural village, whether you’re rich or poor and whether you are employed or not. All these factors should not matter when a person needs healthcare, for health and wellbeing are key contributors to every person living a socially, economically and even culturally fulfilling life.
But what will this actually mean for ordinary South Africans? We need to actively talk about these things and occupy the public space that is often dominated, unfairly so, by those who drive a purposely negative narrative on the matter of universal health coverage. They do so primarily because they have vested and often undeclared interests in ensuring that the status quo remains to the benefit of the few. Of course, the profits that make their pockets heavy ensure that many of our people’s healthcare needs remain unaddressed.
These naysayers are quick to profess their “undying love” for universal health coverage (UHC). However, many label and define UHC incorrectly as a clinical care concept, and fall very short when the consensus requires that rhetoric to manifest into tangible actions that meaningfully improve the health and wellbeing of our people through reforms that make healthcare affordable and accessible for all.
Making healthcare more affordable
At this very moment healthcare in South Africa is divided into two starkly different systems: public and private. The public system serves the majority of the population, but for decades has remained underfunded and highly stretched. The population numbers are growing, there is an increasingly declining public budget and we experience “migration” of key healthcare professionals into the private sphere where fee-for-service dominates. It is obvious that the private system has better resources, but we cannot hide our heads in the sand and ignore the fact that it is expensive and only a small portion of people can afford it – even those on medical schemes are battling to afford the premiums.
The protagonists of the private sector continue to lobby for half-sided solutions, such as low-cost benefit options, as a solution to this. This is a false solution in two key ways. First, it purports to retain a divide that ensures that those who earn low incomes get a watered-down set of benefits, yet they are more likely to have a higher need for healthcare services. Second, there is a vested interest to “grow the medical schemes population”, with an undeclared interest to keep reaping surpluses that are not in any way beneficial to those they cover. Of course, this approach will also need medical tax credits to be viable, which will further deplete the fiscus.
How many of the people who currently have medical scheme cover have had to make the difficult choice to leave out their elderly parents, because the premium shoots up and becomes unaffordable? How many people are told “sorry, your benefits have been exhausted” and, while they keep paying the premium, they are unable to use the service (unless they pay out of pocket) or they must use a state facility? Even for prescribed minimum benefits (PMBs) some people struggle to get them paid for – either because they accessed services from a provider who is not in the scheme’s network or the scheme’s approved tariff rate for the particular PMB is lower than what the provider charges. Let us not even start talking about the providers that are contracted onto scheme networks but still demand upfront payments from users.
The rot runs deep, but for some the (feeble) argument remains: “Fix the public sector first, leave the private sector alone.”
The idea behind the NHI is to bring everyone into one integrated system that provides healthcare based on healthcare needs, not on how much money you have or what you can afford. Under this system, people will no longer have to pay out of pocket when they go to a clinic or hospital. That is a life-changing reform, especially for individuals and families who are presently purposely forced to delay getting care because they simply can’t afford it.
However, making healthcare “free” at the point of use doesn’t mean it will be free to provide. The system must be managed properly – if money is wasted or stolen the reform could fall short of its promises. This is what the regulations published by the minister of health seek to address – to introduce robust and proactive governance and oversight structures for ensuring cost-effective and sound management of resources allocated for personal healthcare services needed by the people. All the people, not just a privileged few.
Affordability also means we must change the way we pay providers, and we must not shy away from making sure that the providers are held accountable for the health outcomes of those they treat. The state, through the fund entity, must ensure that appropriate and fair legislative and administrative interventions are implemented to regulate healthcare tariffs, obviously not to the detriment of providers. Payment must be fair and reflect costs incurred to render a quality service, but this does not mean providers must randomly choose the tariff and impose it on users. There must be rationality to the tariff. Transparency is a key requirement – patients, and the NHI Fund, must know what costs they will incur for a particular service, and there must be adequate financial risk protection. No one must become poor (or poorer) just because they need to access a healthcare service.
Healthcare that is fair for everyone
In a fair healthcare system, everyone should get the care they need, no matter where they live or how much they earn. But today, access to affordable and quality care depends a lot on your location and income. Urban areas have better hospitals and more doctors, dentists and other healthcare professionals. Rural areas often struggle with understaffed clinics and limited services.
With NHI the state’s plan aims to correct that. It wants to give all South Africans equal access to the same standard of care. That’s a huge goal – and a necessary one. The naysayers are quick to argue that this must not be done, because the government always fails, by implication saying the state must just let things deteriorate. Which is nothing short of an irresponsible and off-the-cuff response from those benefiting from the lopsided system we are currently grappling with. We must recognise that indeed the reform is complex and it will take time, resources and the commitment to improve services in the places that need it most – but we must not cower under the pressure of the naysayers.
Getting more healthcare professionals where we need them most
One of the biggest problems in our health system is the shortage and uneven distribution of health workers, such as doctors and nurses. Most doctors, especially specialists, work in private hospitals in cities – even those receiving salaries from the state continue to earn private-sector incomes through the system called Remunerated Work Outside the Public Service. There is an urgent and moral need to review this unethical system to assess whether it addresses our health system equity concerns. Meanwhile, rural areas and public clinics often don’t have enough staff.
The success of the NHI depends on changing this. We need to encourage more health workers to serve in rural and poorer areas, and make sure they’re supported when they do so. That means fair pay, good working conditions and career opportunities – things that make it possible for them to stay and make a difference. And the NHI Fund, through innovative provider accreditation and contracting processes, must consider mechanisms that would allow for providers to be directed into areas where there is the greatest need for targeted healthcare services. There is no way we can achieve meaningful universal health coverage if the needed professionals are all conglomerating in urban centres when the need is elsewhere.
What comes next?
We must reaffirm our commitment to humanity, to the values espoused in our much-vaunted Constitution, especially in the Bill of Rights. This requires a deliberate reconnect with our Ubuntu, a philosophy and way of life that highlights the importance of mutual care, respect and collective identity. This is because the changes to our health system are about more than policy – they’re about each and every one of our people’s lives. They’re about making sure a grandmother in a rural village can get the same quality care as a child in a fancy, security-gated residential estate in a Johannesburg suburb. They’re about making sure no one has to choose between putting food on the table and seeing a healthcare provider for needed care.
But we must all know that this vision will only become reality if government leaders, health workers, civil society and communities work together. We need transparency, accountability and, most importantly, action. And we need truth, not the lies that are peddled against the NHI so that a limited few can keep reaping profits from a dysfunctional, poorly performing system.
South Africa’s healthcare future is being rewritten. It is a story of hope and commitment to the health and wellbeing of everyone. And that is NHI. DM
This opinion piece is written in Moremi Nkosi’s personal capacity.