"One country, one healthcare system" was a theme at Ramaphosa's summit, which tried to brainstorm solutions to some of the country's most pressing health problems including medicine shortages and corruption. (David Harrison)

The National Health Insurance: Who's in, who's out and how much will it cost

Laura Lopez Gonzalez
The NHI was the centre of this weekend’s presidential health summit. Now the pressure is mounting for Treasury to figure out how to fund it.

NEWS ANALYSIS

The health system is in crisis, government officials admit. Now, they have just weeks to produce an initial plan on how to fix it ahead of introducing a National Health Insurance (NHI), Deputy President David Mabuza revealed this weekend.

With its namesake, President Cyril Ramaphosa was absent from this weekend’s presidential health summit. The gathering drew more than 100 representatives from civil society, government, unions, academia and the private sector. Prior to the event, that was held in Boksburg, each delegate received a 21-page concept note outlining challenges within the health system — this included corruption and how the NHI will incorporate the private sector. 

Solutions proposed during the meeting will now form the basis for wider consultation ahead of a public plan to turn the health system. The strategy is slated to be released in less than two months — by 10 December.

“We intend to develop a compact among all key stakeholders, including government, health providers, academics, health system users, labour, the private sector and civil society,” Mabuza explained.

The Deputy President presided over the summit alongside Health Minister Aaron Motsoaledi.

“This compact will provide guidance and assist in the implementation of critical tasks, such as updating the quality improvement plans for all our health facilities…[and] the development of a human resource operational plan to allow us to correct the deficiencies in the system.”

Mabuza also reiterated Ramaphosa’s previous statements that the government would prioritise the filling of posts and that provinces had been told to safeguard service delivery amid tight budgets. These assurances come after at least three years of austerity budgets in many provinces, including some like the North West and Eastern Cape that have reported freezing posts.

He also promised that National Treasury will soon deliver a long-awaited proposal on the financing of the NHI Fund, but did not give a specific timeline. How the NHI will be funded, is perhaps the biggest question in South Africa’ move towards universal healthcare.

A 2017 version of the NHI Bill projected the universal health scheme would cost R256-billion by 2025 — a figure based on outdated statistics.

The Office of the Presidency is expected to establish a “war room” to help coordinate the shift to an NHI. While Treasury continues to review financing models, the Presidency is re-costing the health system to provide more realistic figures on the NHI’s true price tag, including calculating health costs based on district health profiles, Mabuza said.

“We admit that we have a crisis”, Minister of Science and Technology Mmamoloko Kubayi-Ngubane said. “We must own the problems”.

Read the concept note for the summit

The newly released NHI Bill proposes a centralised NHI fund to finance the new dispensation and to analyse data on how health services are being used and how cost-effective they are.

The Bill proposes that this body be accountable to the health minister and a board, which reports to Parliament. But there are widespread fears that the fund will be a target for corruption.

At the summit, the executive director of the public interest law organisation  Section27 Mark Heywood argued: “We can’t be talking about new statutory institutions when the existing institutions within the health system are corrupt and mismanaged.

”There is dysfunction when acting on reports [of graft]. We need punishment,” he said.

Motsoaledi said he agreed but that current mechanisms to tackle corruption — including the auditor general — were “post-mortems”, working retroactively after funds had been syphoned off. Instead, he advocated for new bodies, such as a mooted NHI anti-corruption office, to prevent fraud before it started.

Meanwhile, the Special Investigating Unit (SIU) head advocate Andy Mothibi revealed his team is prioritising investigations into fraud within the high-risk health sector.

“We want independent investigations that are turned around quickly and submit and identify findings appropriately. Once those findings come out, there’s this worry that there is no action,” he explained.

Mothibi’s remarks come just months after Section27 obtained the SIU’s report into corruption in the Gauteng health department under form MEC Brian Hlongwa. Delivered to former President Jacob Zuma in March 2017, the report revealed R1.2-billion in the embattled body was lost to graft under Hlongwa’s watch.

He currently serves as the ANC’s chief whip in Gauteng provincial legislature and was recently appointed to the party’s provincial executive committee (PEC) — its highest-ranking body. Also elected to the PEC this year was former health MEC Qedani Mahlangu, who presided over the Life Esidimeni tragedy in which at least 144 mental health patients lost their lives after being transferred largely to unlicensed community organisations.

The SIU hopes to establish a new health anti-corruption forum that will include civil society representation from groups such as Section27.

Mothibi said: “We would like to make sure that space is known for taking actions. Prosecutions, civil litigations, disciplinary actions... have to follow.”

Watch the summit's closing, including a review of key issues addressed

Watch the closing of the Presidential Health Summit.

Posted by Bhekisisa Centre for Health Journalism on Saturday, October 20, 2018

Heywood emphasised that corruption also occurred in the private sector. An air of mutual distrust between the public and private sectors has been palpable since the NHI was proposed.  Cosatu has been the most vocal in its disdain for a private sector some accuse of commodifying health and putting profits over patients.

But some in the private sector remain wary of perceived ineptness and corruption within the public sector.

For years, many South Africans wondered whether they’d be allowed to keep their medical aid cover under the NHI. At the summit, Mabuza gave the clearest and highest ranking indication of what the future holds for private medical schemes — and their role providing supplementary cover under the NHI.

"We need one health system of all our people… in which health services are provided by both the private and public services according to improved standards of care, and that does not negate the existence of private health schemes for those who desire [them],” he said.

Netcare hospital group CEO Richard Friedland presented research by Insight Actuaries that estimated large private hospitals alone could cater for an extra 7.7-million people under the NHI. Smaller, independent facilities, the analysis argued, could provide an additional 8 000 beds and serve 14-million people if brought into the fold.

A promising pact between public and private may be sealed, but each will have to tread carefully in courting the other.

“We all recognised that irrespective of what the private sector can bring to the party, public sector delivery remains the bedrock of healthcare delivery. There are significant challenges in service delivery and capacity,” Friedland said.

He explained: “The question that we face is how can we manfully partner with the public sector in a way that’s not seen as patriarchal or patronising."

“Most importantly, how do we achieve this in a practical way that is not seen as privatisation through the back door and that our social partners and unions don’t believe this is an attempt by the private sector to potentially privatise the public sector.”

To bridge this, Heywood proposed the development of a public-private charter that would outline values to guide the next phase in private-public healthcare partnerships. It remains to be seen whether this idea will be adopted.

Meanwhile, the national health department and medical aids are working to try to align the basic services they provide by March, national department deputy director general Yogan Pillay recently said at the Global Symposium on Health Systems Research in Liverpool, England.

The department is also working with the international nonprofit the Clinton Health Access Initiative to develop a core range of services to be covered by the NHI, Pillay explained. This will start with mapping the services, procedures and even drugs that are currently offered in the public sector.

Unions and civil society have made it clear, Pillay said: “The NHI will have to maintain or add to services that already exist.”.

But if other countries experiences with universal healthcare is anything to go by, the process to decide on what’s in and what’s out of the NHI will be contentious and based on a mix of economics, medicine and even emotions as the government tries to please a range of sectors including a diverse civil society and balance competing agendas.

The road to the NHI won’t be without arguments — key to managing this will be how transparent government is when it makes decisions that will give the scheme its final form.

“We will confront many challenges along the way. At times, we will disagree”, Mabuza said.

“[But] the path we have chosen is irreversible. We are at the point of no return.” 

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National Health Insurance (NHI)