'National Death Insurance': Healthcare in ICU, says new report


The South African government wants to implement a policy of National Health Insurance (NHI) to ensure every South African has decent healthcare. This is a noble goal, but it is unlikely that the government will be able to make it a reality.

All South Africans will be compelled to belong to the NHI system, without the right to opt out. At the same time, people will have to pay into the system even if they choose to pay contributions to a medical aid, too. All health revenues will be paid into a central fund, from which all health disbursements will be paid.

The state will decide on all aspects of healthcare, and private healthcare will thus effectively have been nationalised, with all that that entails.

Yet the South African government has shown itself to be poor at running a wide range of entities, from South African Airways (SAA) and Eskom to the education system – the list is long – and there is no reason to think it will manage to run the entire healthcare system effectively.

Healthcare in ICU

A new report from the IRR, titled South Africa’s National 'Death' Insurance Scheme, lays bare the extent of the crisis in SA's public health system.

Throwing more money at this profoundly deficient public health system, and effectively nationalising private healthcare, will not improve health outcomes.

On the contrary, the report exposes the appalling scale of deficiency, mismanagement, negligence and corruption in the sector which the government intends to be at the very core of its proposed NHI system.

Big problems, high cost

Although many dedicated people are working to make public healthcare work, the problems run deep and come at a high cost to South Africans.

Despite this, the government seems determined to push ahead with NHI.

The bulk of the report is devoted to a collation of more than 100 media reports on negligence, corruption, and mismanagement in our public health sector between April 2017 and August 2018.

Some incidents, such as the Life Esidimeni tragedy – which saw more than 100 people die because of government mismanagement of the public healthcare system – are well known.

But this shameful episode is matched by many other incidents in which, due to negligence, mismanagement, or corruption, people received sub-standard medical care and, in extreme cases, were disabled or even lost their lives. Many of these incidents have not received widespread coverage (and it is possible that yet more incidents have not been reported on at all).


Examples include a 13-year-old boy losing both feet, his left hand, and four fingers on his right hand, following complications after appendix surgery. He was not taken to a high-care ward after his operation as the lift was not working. The amputations followed an infection that affected his circulation.

Elsewhere a botched birth resulted in a baby suffering from quadriplegic cerebral palsy; while another case involved a woman having to return to hospital a week after her caesarean section because of abdominal pain. It turned out a swab had been left in her abdomen, and her placenta had not been removed.

A toddler was left brain damaged, allegedly because of the slow response of nursing staff to her choking on her own vomit after intestinal surgery. Meanwhile a baby lost an arm after an intravenous drip had been incorrectly inserted, leading to complications and, ultimately, amputation.

A study of health standards found that only five out of the 696 hospitals and clinics inspected complied with the standards set out by the Department of Health in order to achieve an 80% pass mark.     

READ: Everyone will be covered by NHI by 2025 - Ramaphosa

In one instance, patient files were stored in a space too small to accommodate them and often damaged by damp when it rained. This is significant, considering another case where a woman had her bladder stitched to her womb during a caesarean operation - but the doctors were not held to account because vital information was missing from her file.

A man was discharged despite a part of an ankle wound still being open. He required further surgery four months later, and will likely have to wear an ankle brace for the rest of his life.

A staff nurse mistreated a bedridden patient, ridiculing her for being unable to sit up to have her diaper changed, and did not draw the bed curtains to give the woman privacy. The patient died the following day, reportedly receiving "very little assistance".

Then there was the unexplained discovery of a 61-year-old man’s body in a hospital ceiling 13 days after he disappeared following an operation.

And there is not a single full-time oncologist working at any of KwaZulu-Natal’s state hospitals.

Effective economic solutions

South Africa needs to be innovative in working to provide quality healthcare for all, but disabling excellence in the private healthcare system will not be the answer.

Throwing more money at public healthcare is pointless if systemic problems are not addressed.

Greater access to private healthcare should go hand in hand with improving the public healthcare system, which can only be achieved through merit-based appointments, strict accountability for poor performance, and effective action against corruption and wasteful spending.

Furthermore, access to private healthcare can be expanded by allowing low-cost medical schemes and primary health insurance policies.

Poor households should be helped to join these schemes or buy these policies through tax-funded health vouchers.

To help spread risks, medical scheme membership and/or health insurance cover should be mandatory for all employees, with premiums for lower-paid employees buttressed by employer contributions for which businesses would garner tax credits.

Medical schemes and health insurers would then have to compete for the custom of South Africans, which would encourage innovation and help to hold down costs.

The report recommends increased public-private partnerships, regulations to allow the private sector to establish more day hospitals and the like, and that private universities and hospitals be permitted to train doctors, specialists, and other health providers, as public training institutions cannot meet the scale of need.

Marius Roodt and Mailies Fleming authored the IRR's report 'South Africa's National Death Insurance Scheme'. The full report can be read here.

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