Does free healthcare guarantee equal access?

Gareth Stokes, FAnews Online Editor

We’re more than 100 days into President Jacob Zuma’s first term and South Africa’s medical aid stakeholders are still waiting for government to publish its comprehensive National Health Insurance (NHI) policy document. Val Beaumont, executive director of

Consider, for example a recent article by Ano Thom, published on Health-e.org.za. Thom addresses some of the concerns and opinions espoused since the NHI debate began, leading with: “An ANC task team headed by the former Director-General of Health, Dr Olive Shisana, and heavily laden with trade unionists is trying to convince the ANC and government to hastily implement an NHI plan that many believe spells disaster for the buckling public health system.” The task team’s report, leaked in February 2009, is viewed by many as the cornerstone of government’s eventual policy.

Beware of building on a flawed foundation

Thom’s article contains a number of damning allegations, including that the previous Minister of Health, Barbara Hogan, was removed from her portfolio after pressure from trade unions. In March 2009 the Department of Health, under Hogan, proposed a staggered NHI implementation. Steps included releasing a white paper in 2009/10, completing draft legislation by March 2010, promulgating the legislation in 2011 and completing the administrative structure by March 2012. The phased implementation of the system would begin once the administrative structures were in place. The article also recounts how ‘insiders’ told the author that the unionists believed their goal was “to get rid of medical aids and force all citizens into public health.” Problem is nobody has run the numbers to see whether the proposal is financially feasible.

Economist and Dean of Research at the University of the Western Cape, Professor Renfrew Christie, told Thom the proposal was “A rich country solution! Sweden has a tiny population, superb civil servants and was totally healthy when they did it. The UK was used to war time draconian measures and had a superb civil service and buy-in across most classes in 1947 after the war and was a richer country without pandemics.” This view was also expressed in The Mail & Guardian Online, in a piece titled A Legacy of Incoherence. This publication questions government’s ability to implement and manage a massive pool of public funds given its administrative performance to date.

“It is in this context of system failure that the government is seeking, hastily and without public debate and scrutiny, to introduce a national health insurance scheme,” says M&G Online. They ask how South Africa hopes to succeed when Britain and Scandinavia struggled despite having “functioning hospitals, efficient state bureaucracies and buy-in across the social spectrum when they introduced NHI.”

No guarantees for the poorest of the poor

There are also growing concerns about government’s ability to extend healthcare services to all South Africans in whichever form NHI is implemented. In Dynamic Health Care Decisions and Child Health in South Africa (ERSA Working Paper No. 142), Olufunke Alaba and Steven Koch conclude that “income levels remain a key determinant in the decision to seek medical help.” They claim the existing public health policy exacerbates health inequality among young children. In other words “sick children in poor households are less likely to receive medical treatment than those from more well-off households.” Why is conclusion important?

It addresses, in part, the concerns with the functioning of the existing public health infrastructure in the larger NHI framework. Regardless of what the health theorists claim, a functioning public healthcare sector is crucial for the proposed social healthcare intervention to succeed. This means any failings in the current system still have to be adequately addressed. Government should thus strive to elevate service at public hospitals and clinics to an exemplary level while the NHI debate rages. South Africa’s public healthcare (even in the NHI model) will have to address issues of accessibility for the very poor, the aged and infirm and isolated communities.

Private medical schemes vendetta gathers steam

With NHI in the wings a number of reports are condemning private medical aid schemes. A couple of weeks ago the Sunday Times launched a blistering attack on the sector, alleging that more than 50% of medical schemes members would typically exhaust the funds available for day to day medical expenses by mid-year. More recently, Patrick Matshidze, acting chief executive and registrar of the Council for Medical Schemes (CMS), told members of Parliament that levels of solvency among the country’s 119 schemes were dropping sharply. “We’re beginning to see medical schemes facing problems,” he said.

Matshidze told Parliament that the average solvency level had dropped from 39.1% in 2005 to 36.6% in the latest year of assessment. “18 open medical schemes have failed to meet with the prescribed level of solvency,” said Matshidze, adding that some of these schemes were “on their death bed!” The CMS requires all private medical schemes to maintain a solvency level greater than 25%. You may recall that Discovery Health, the country’s largest private medical scheme, ran foul of this provision a couple of years ago. Will these ‘revelations’ influence Parliamentarians when they’re asked to ‘vote’ on the future of medical schemes as outlined in the NHI policy document later this year? We’ll have to wait and see.

To date the most surprising aspect of the NHI debate is the uneasy silence from the country’s major private medical schemes and private hospital groups. Comments are few and far between – and extremely conciliatory. Dr Jonathan Broomberg, head of strategy and risk management at Discovery Health is typical of their stance. “South Africa has a world class private healthcare system. We must guard against any proposals that will damage this system, and focus on how the private sector can assist in achieving the objective of improving health outcomes for all South Africans.”

Editor’s thoughts:
Food, health and security can all be found on the base level of Maslow’s Hierarchy of Needs Pyramid. These are the bare essentials for an acceptable quality of life – and a government that ensures its citizens enjoy these benefits will rule in perpetuity. Should we be debating healthcare issues before government’s official NHI proposal is published? Add your comment below, or send it to gareth@fanews.co.za