Can the NHI cure the public system failings and private system inequality?

A fierce debate about the future of public and private healthcare in South Africa has been ignited by the recent publishing of the final health market inquiry report and the National Health Insurance (NHI) bill, which is under consideration by Parliament.

Umunyana Rugege, executive director of civil society group Section27 told a recent forum at the Gordon Institute of Business Science that a single vision is needed to allow for greater equality in healthcare services.

“While the National Health Act envisages a united healthcare system, the current circumstances reflect the inequality in the country,” she said.

The right to access healthcare is guaranteed in Section 27 of the Constitution, and the State has obligations to enable the advancement of access, even where the private sector is concerned, she explained.

“There is incomplete and inadequate regulation of the private healthcare sector, and patients are disempowered: They lack knowledge and understanding. Despite the public system’s failings and corruption, there is still a need to address inequality in the private system,” Rugege said.

Access, pricing, quality and information are all key patient concerns.

Dr Ntuthuko Bhengu, panelist of the health market inquiry and health sector specialist argued that the Constitution “asks us to be mindful of access, and we can’t talk access if medical services are of out of reach of ordinary South Africans.”

health market inquiry – Findings and recommendations

Dr Eric Buch, professor of health policy and management and former Dean of the Faculty of Health Sciences at the University of Pretoria said it is in the private sector’s own self-interest, as well as the interest of the country, to implement the recommendations of the health market inquiry “as quickly as possible.”

“There has long been a lack of faith that the private sector offers good value for money.

We know we don’t get good value for the money invested in the public healthcare sector; but we are also not getting good value for money in the private sector due to a lack of integrated care and pricing. There are structural problems in both the public and private sector,” he said.

“The supply side of healthcare is not regulated at all and there are no incentives to guide what should be done in the interests of patients,” Dr Bhengu added.

Rugege said the health market inquiry’s recommendation to establish a supply-side regulator to investigate licencing and pricing should be implemented as soon as possible.

Forums should be established where industry players and doctors can share information and set prices for prescribed minimum benefits so as to not be anti-competitive, she added.

“There should be a standardised package of prescribed minimum benefits on all medical aids to enable the public to compare the schemes and benefit options, which will empower them to make their own decisions based on quality and value for money.”

NHI - New healthcare business models and mind shifts

“We have a major problem with equity in South Africa, and there are ways of changing the healthcare model to allow for greater volumes. While the NHI is more likely to lead to greater equality, neither solution is perfect,” Dr Jane Goudge, professor and director of the Centre for Health Policy at the University of the Witwatersrand said.

A greater reliance on community-based care and health extension workers would enable the system to deal with larger volumes of patients and be more cost effective, but would require a mindshift, she explained.

Dr Buch said under the purist interpretation of the current NHI model, the private sector would have to provide services to the single purchaser (government). However, there is currently “very little detail around the legislative framework and regulations and no detailed implementation plans.”

Rugege said while Section27’s role was to engage with government and private sector stakeholders to create a vision of a unified healthcare system, “It is not possible to buy into the current NHI vision as it is so vague and lacks detail.”

Dr Buch explained that the issue of healthcare system governance is important in the context of the current debate: “The NHI could have said more about the failure of government to govern the healthcare sector. While the private sector has a lot to answer for, the government has to move decisively to play its role in governing healthcare.”

The right to access healthcare is guaranteed in Section 27 of the Constitution, and the State has obligations to enable the advancement of access, even where the private sector is concerned

He said it was not axiomatic that a new universal healthcare system would automatically remove individuals’ ability to choose to pay for private healthcare.

“There are many iterations of national health systems all over the world that are asking the same questions as the NHI and the health market inquiry,” he explained.

It is problematic that South Africa is not training a sufficient number of healthcare professionals to create a pipeline to allow for expanded access to services, Dr Buch added.

He cited the example of Ethiopia, which had intentionally trained additional doctors and healthcare professionals to ensure there was capacity to deliver access to healthcare services.

In conclusion, Dr Buch cautioned that it is necessary to look at the potential adverse consequences of policy change and how to deal with these implications.

“We live in a participatory democracy; our role is to engage to make things better,” Rugege argued.

Read: The success of NHI depends on planning

“The private sector is not without obligations and has a role in delivering on the Bill of Rights. The NHI has opened a debate to enable greater equality in healthcare services, now what we need are concrete solutions,” she said.


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