I am a proponent of an integrated health system for all South Africans, which I call a national health system, and I have advocated for this since the late 2000s. I left the chair of the South African Medical Association in January 2009 because of disagreements on this very subject. South Africa’s main challenge is extreme inefficiencies in its health system, in both the public and the private sector. When one considers the total health expenditure of South Africa, its citizens deserve better outcomes.
The first step towards creating an efficient national health system is to fix the current problems in the public and the private sector. Wasteful expenditure, exorbitant administration costs, corruption, overpricing and overpaying in the private sector are, among other considerations, the problems that must be addressed. The private sector is further afflicted by inadequate benefit structures, bias towards hospitalisation, and overservicing. Poor capital expenditure investment, inadequate infrastructure, substandard human resources, corruption, incompetence and harmful outsourcing are serious problems that must be fixed in the public sector.
The creation of a new fund, the NHI, is not a sustainable solution to any of the above problems. What is needed is a concerted effort to fix the problems in the public and the private sector. Instead of a new fund, we must amend the Medical Schemes Act to ensure universal health coverage for new members with no co-payments for essential care, limit administration costs to less than 5%, guarantee a certain level of care to members, and secure payment to willing service providers at pre-agreed tariffs.
We have a crisis of unemployed young healthcare professionals. The mooted NHI system will destroy the livelihoods of the many independent healthcare professionals now serving the people of South Africa
We must also implement some of the recommendations of the government-initiated health market inquiry report. Administering medical schemes should be a member service, not a business. A common IT platform and a national health database must belong to the nation, not to a new business, regardless of whether it is privately or publicly owned. Both of these must be used for planning and provisioning, and not trading, purposes. Members should be able to receive health services from both public and private providers.
To fix the public sector, we need to amend the constitution and make health planning and management the exclusive responsibility of the national government. The provinces and local governments must become delivery sites. Some medical services and critical hospitals must be under national control. Professional health education and training must be under the authority of the national department of health, which applies international training and education standards.
Reopening nursing colleges is also essential to fixing problems in the medical sector. We must return to line-item budgeting, restore or grant institutional autonomy to certain health facilities, and assign local health services providers both management powers and adequate budgets. We must curb administration costs to less than 10% initially and less than 5% in the medium term. We must criminalise political interference in health management and apply meritocratic principles to appointments, without sacrificing the transformation agenda.
Other required fixes are insourcing important functions and ensuring access to new technologies to enable institutions to collect fees from patients who need to pay for services. Such people would include those on medical aid and foreign tourists, including medical tourists. We must compel all public servants — including cabinet members, parliamentarians, members of the judiciary, and especially public health workers — to use the public health system.
A sound national health system needs a functional and efficient public healthcare system. The first step is to fix the public sector and medical services offered privately through medical aids. For parliament to create a second health financing system does not make sense when the real problems lie in service institutions and how the system is leveraged to generate super profits. What is required is reform of the medical schemes — the preferred option — or a new funding mechanism to replace the Medical Schemes Act.
Having two coexisting funding acts makes no sense, unless the intention is to create a new fund that officials can exploit, and from which they can derive undue benefits, when they themselves receive the funding for their care from the existing medical aids.
It is unfortunate that the government is bringing uncertainty to a right enshrined in section 27 of the constitution. Given that South Africa has limited resources, the right thing to do would be to pool the monies for medical services in a single fund from the day the act becomes law, and not some mooted date in the future, as envisaged by section 33 of the NHI Act. If such a fund is not for all of us from the day of inception, it is not national. I have come to accept that apartheid has been replaced by “SA-partheid”. This means a new type of apartheid administered and perpetuated by the previously disenfranchised.
What we need is a pathway to one nation and one health system for all. The concept of NHI may be a pathway to that future, but what is being proposed now, through the legislation the president signed on May 15, is not and will delay even further the promises of section 27.
We have a crisis of unemployed young healthcare professionals. The mooted NHI system will destroy the livelihoods of the many independent healthcare professionals now serving the people of South Africa. In addition, the NHI will be completely under ministerial control, and current structures with more than 57 years of experience in medical services funding, such the Council for Medical Schemes, will have no role in its governance.
The NHI will also duplicate the functions of existing professional statutory bodies such as the South African Nursing Council, the South African Pharmacy Council, and the Health Professions Council of South Africa.
Let us remember that the road to hell is paved with good intentions. South Africa needs a national health system, but the NHI is not it.
• Letlape is health spokesperson for ActionSA
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