Special Reports:

National Health Insurance

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The National Health Insurance (NHI), for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa. The scheme will do this by creating a fund that the government will use to buy healthcare services at set fees from accredited public and private health providers. The NHI has not yet been legislated — the health department is hoping to have the NHI Bill approved by parliament by the end of 2022.

Motsoaledi frenzy over NHI


His reasoning has come in for much criticism, but the minister has no wish to continue the debate.

Online comments, emails and opinion pieces have been pouring in from readers since Bhekisisa’s publication of the health minister’s response to a letter from the chief executive officer of the South African Private Practitioners’ Forum. 

In his letter, “NHI: Let’s talk about this revolution”, which was published on February 7, Chris Archer accused Health Minister Aaron Motsoaledi of being “disingenuous” and using “anecdotal information” to exaggerate and distort “the facts concerning the private [health] sector”. 

Archer said Motsoaledi is doing “little to assist the process of dialogue between the health department and the private sector about the issue of costs”. With regard to the NHI, he blamed the minister for “painting a picture and creating an aura of hope that simply cannot be”, in light of resource constraints. 

Motsoaledi responded with his own letter, “Physician, don’t fool yourself – Motsoaledi replies to NHI criticism”, which we published along with Archer’s. The minister accused Archer of deliberately using incorrect numbers for his assumption that the NHI is unaffordable and impractical, and said the doctor was spreading “myths and serious misconceptions”. 

“Archer compares the health costs of the United States, the United Kingdom, Australia and South Africa, but what he fails to point out is that the GDP [gross domestic product] of the US is $16-trillion (21.9% of the global economy), that of the UK is $2-trillion and Australia’s $961-billion (2.1% of the global economy), whereas South Africa’s GDP is only $576-billion (0.5% of the global economy),” Motsoaledi said. “The total per capita expenditure on health in the US is $51 000, that of the UK is $36 000, and in Australia it is $41 000. In South Africa it is $11 000. In simple terms, the American and Australian economies are 95 and 21 times the size of South Africa’s economy respectively.”

Last week we published Archer’s “right of reply” to Motsoaledi’s letter on the M&G’s comments and analysis pages. Today we publish some of the many reader responses we received – many of which were critical of Motsoaledi’s figures and calculations. 

Motsoaledi’s spokesperson, Joe Maila, said the minister has declined to respond any further to this issue.

The healthcare numbers speak differently

  • The good doctor has confused gross domestic product (GDP) per capita and spending on sickness care. The American GDP is $51 000 per capita per annum and sickness care is 17.9% of that, according to a World Bank table. An American thus spends nearly the whole of a South African’s GDP of $11 000 on healthcare. It’s no wonder that United States President Barack Obama has tried to do something about that. As Dr Aaron Motsaoledi says, it’s unaffordable. The rest of the world spends between 4% and 10% of GDP on sicknesscare. We, with Argentina and Brazil, are on the high side at 8.5%, comparable with the United Kingdom and Australia.  We also have an already unaffordable private sickness care system, and its costs are escalating at well over the inflation rate every year. That is not sustainable. More medical aids will reduce services, charge more and eventually go under as fewer and fewer people can pay. But in its current form, a national health insurance will not work either. If only two or three public hospitals could pass an audit, how will more of the same help – Paul Fanner
  • We do have universal healthcare; it is just badly managed. The NHI won’t make nurses do their jobs, for example. – Toni Benoni
  • This fellow may be pretty good at fixing sore throats but he seems to be as innumerate as the rest of his party. He says the per capita health spend in the UK is $36 000 or R396 000 – that is per head! Anyone with a dumbed-down maths literacy pass, even at 30%, would see how ludicrous that is. The actual figure for their National Health Service (googled several years ago) is R36 000 per head per year. Our maths lit graduate could multiply our population number (55-million) by that number and see that to provide the same service would cost the South African taxpayer nearly R2-trillion, more than twice what [Finance Minister] Pravin [Gordhan] collects in tax, in total, every year at present. – Moor
  • “The total per capita expenditure on health in the US is $51 000, that of the UK is $36 000, and in Australia it is $41 000. In South Africa it is $11 000.” So the per capita expenditure for South Africa is R121 000. In fact all the numbers and calculations in the “article” are incorrect. – Daterly
  • The NHI and e-tolls have many parallels and are doomed to fail because they rely on the buy-in by skilled taxpayers. These citizens do not trust the management or the ?government. – MSP2
  • I like Motsoaledi but, in one area at least, he’s being disingenuous: medical aids have been in trouble over the past decade because of changes made to the law by the ANC government – it was obvious when they made the changes that medical aids would end up in trouble because of their actions. Now he’s saying that “medical aids are in trouble, anyway”. Sorry, but that’s plain dishonest. – Teresa Williams
  • Minister of health, this is an excellent reply to an uninformed individual. I attended the minister’s presentation at the University of the Witwatersrand: the minister was not only passionate about the NHI but he was also practical in his approach. I think it is time that, as academics, we should not misinform the public to score points just so we can discredit the minister. – Zvikomborero Nyakudzi

Simply apply Economics 101 to NHI dilemma

Greg Ash

It seems that our health minister is so deeply committed to socialist thinking that he has forgotten Economics 101. His rebuttal of Dr Archer’s argument about the unaffordability of his National Health Insurance (NHI) plans is to argue that the reason that the systems in the United States, Britain and elsewhere cost so much is because they have bigger economies and so can afford to spend more.

Unfortunately, the constraint we have of how much we can afford to spend because of our low gross domestic product (GDP) (or more accurately, low GDP per capita) has no effect on how much healthcare costs. An x-ray machine costs what it costs no matter how little money you have to pay for it. Same for a hip replacement prosthesis, a vial of penicillin and, even to some extent, nurses’ salaries (we are losing our nurses abroad and to non-nursing occupations because they can earn more elsewhere). The international market simply does not care whether we are poor. 

Dr Archer is correct: South Africa’s private healthcare is the cheapest full-service, top-quality healthcare system in the world. This system is too expensive for the government to provide it free to all (it would cost R600-billion a year and we do not have the doctors, nurses or hospitals available).

The sooner the honourable minister realises that he needs to cut his coat according to his cloth the better. We need universal general practitioner (GP) outpatient care now, and can later build to full-service care. The cheapest and fastest way to do this is for the government simply to pay GPs a fee-for-service [as opposed to a salary] to do this. Government trying to be the supplier, and not just the funder of healthcare, will result in just one more service delivery failure.

Dr Greg Ash is a private practice doctor. He is a member of the Association of Plastic and Reconstructive Surgeons of Southern Africa and the South African Private Practitioners Forum. He has a part-time position at the Nelson R Mandela medical school at the University of Kwazulu-Natal.

Prickly: Health Minister Aaron Motsoaledi’s NHI views elicit mixed opinions. 

Spare us the name-dropping demagoguery, minister

Neal Goldwyer

When he is not playing the revolutionary, Health Minister Aaron Motsoaledi likens his crusade to implement “universal health” to, variously, United States President Barack Obama’s Patient Protection and Affordable Care Act (2010), Britain’s National Health Service (1948), and the World Health Organisation’s (WHO) Alma-Ata Conference on Primary Health Care (1978). All three are historical milestones, but I fear the minister is just name-dropping to sound important. 

Ironically, the issues that Obamacare is only now resolving in the US were dealt with in South Africa long ago in the Medical Schemes Act (2000). The social protection aspects the Act established may still be missing sustainability regulations, but these are easy holes to patch. 

In 2013 Pravin Gordhan said that major policy initiatives such as National Health Insurance (NHI) schemes would be affordable only if growth reaches 5% a year and government revenue doubled. Similarly, NHI proposals for South Africa failed in 1946, not from the rise of the National Party in 1948, but because of economic conditions at the haemorrhaging seams of a post-war British Empire. No more work went into the Beveridge Report underpinning Britain’s “revolutionary” NHS than into the National Health Service Commission Report proposing the same for South Africa. (Beveridge’s report runs to 300 pages; the NHSC’s to 12 000; the NHI Green Paper gazetted in 2011 to 59).

It is revealing when Motsoaledi (mis)quotes the WHO’s definition of health (from its 1946 founding constitution): “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. Beginning with “health is not just the absence of disease”, this inversion reveals his, and not the WHO’s, rejection of curative services. Promoting prevention at the expense of surgery is foolhardy. Africa has the world’s highest concentration of surgical disease. 

Talking about Alma-Ata [a 1978 WHO declaration that identified primary healthcare as the key to the attainment of the goal of health for all – Motsoaledi referred to this in his letter], without mentioning the WHO’s Italy conference in 1979 is incomplete. Primary healthcare was meant to release the developing world from donor aid. HIV and Aids would prove this premature. Even in 1979 primary healthcare was reconsidered and replaced by a selective, affordable subset of interventions defined by the acronym Gobi (growth monitoring, oral rehydration, breastfeeding, immunisation).  

There is no war. There is no revolution. Just hectoring demagoguery favoured by those spoiling for a fight.

Neal Goldwyer is a research consultant at Health Man, a privately owned healthcare consultancy for the management and administration of specialist and healthcare networks.

Specialists are abusing private care

Humphrey Zokufa

Dr Chris Archer’s letter, which lambasts the health minister and the proposed National Health Insurance (NHI) system, demonstrates the miscommunications and misunderstandings that exist within the health sector.

“Universal coverage” is at the core of the National Health Service in the United Kingdom and most of the health systems in Western Europe, which are ranked highest in the world for efficiencies, quality and outcomes. Because healthcare in these areas is seen as a social good and not commoditised, these systems are based on risk cross-subsidisation – where the young and healthy subsidise the elderly and ill – and income cross-subsidisation – where people with higher incomes pay more and those with lower incomes pay less. Primary care with robust referral systems is the norm in most cases. This is unlike the United States, where healthcare is commoditised and costs relative to efficiencies are ranked among the lowest in the world.

Healthcare spend in our public sector is about R120-billion a year on around 42-million people. Spend in the private sector is about R103-billion on 8.5-million people. Health expenditure in the private sector is roughly six times that of the public sector, and there is no real evidence to demonstrate that outcomes are better in the private sector.

The spread of human resources follows the same pattern. For example, there are three dental practitioners for every 100 000 people in the public health sector and 63 for every 100 000 in the private sector. Given the quadruple burden of disease facing the public sector, it is imperative that the spread of human resources is addressed.

The Board of Healthcare Funders (BHF) and its members have long stated their support for a process to realise affordable, universal healthcare coverage for all South Africans. Its submission to the NHI green paper stresses the need for a system overhaul to achieve this.

The BHF submission calls for reform that entrenches primary and preventative care rather than the current hospi-centric approach, which in 2010 contributed significantly to the R2.5-billion deficit that schemes faced. This approach, coupled with the lack of formal tariffs, threatens scheme sustainability and drives the increase in co-pays that members are experiencing.

BHF agrees with Health Minister Aaron Motsoaledi that “medical aid schemes are already in serious financial trouble”. The 2012 Registrar’s report says the hospi-centric approach is costing medical scheme members about R42-billion in hospital expenditure and R24-billion on medical specialists a year.

The absence of tariffs has exacerbated incidences of opportunistic charging by some specialists, especially for the prescribed minimum benefits (PMBs) that schemes must pay for in full.

A BHF-commissioned analysis, for example, shows that the 10 largest anaesthetist practices charge significantly more for a PMB condition than for a non-PMB condition. These results are damning given that an anaesthetist’s work is the same for both conditions.

The private healthcare sector is a national asset, rich in expertise and experience, and it would be a pity if Archer and the South African Private Practitioners Forum could not contribute meaningfully to the move toward universal coverage.

Dr Humphrey Zokufa is the chief executive of the Board of Healthcare Funders, a membership organisation for medical schemes in South Africa, Botswana, Namibia, Zimbabwe and Lesotho.

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Mia Malan is the founder and editor-in-chief of Bhekisisa. She has worked in newsrooms in Johannesburg, Nairobi and Washington, DC, winning more than 30 awards for her radio, print and television work.