The South African health system has been imploding on its citizens for years now. The more obvious, needless, loss of life (HIV, infant and maternal mortality etc) in the public health services is now matched in the private sector by their own financial catastrophe. Medical schemes now assume extensive risk with no congruent obligation for the healthy to contribute during their well youth; their liquidity is limited by large, legislated reserves of idle money.
Within the middle class, the aging population’s health care needs are no longer assured by a life time of retirement planning, and an extensive out of pocket spend equal to half the national health budget drains household budgets in an impossible to predict horror of financial burden. The upward spiral of private sector costs, and the downward spiral of public sector quality cannot be sustained. The proposed intervention from public health experts has been on the table for a decade, and government’s triumph over the pharmaceutical industry in making medicine available and affordable, now needs to be duplicated across the health system as a whole.
Horror headlines ("NHI will cost us R125bn in the first year" when the national health budget this year WAS R113bn) conveniently gloss over South Africa’s 8.5% of its GDP spend on health –a figure 3.5% higher than the WHO recommendation, and still higher than the average upper income country spend of 7.7% GDP. A 2005 health spend analysis warrants a cool-headed read: R47.5bn on public health (for 38million people); R54bn on medical schemes (for about 10million) and a whopping R16bn in out of pocket spend by citizens in either medical aid top up, or cash payment.[i] The Green Paper on NHI offers an - almost too courteous - explanation of why things have to change. Technically frustrating, it is however a call to all stakeholders to demonstrate the extensive and creative political will required to find an economically possible, and socially just substitute.
The responsibilities cut both ways: before even considering NHI, government needs to remedy crucial aspects of existing health legislation. Competition’s Commission (ie business) rulings have no place in health care –a sick person or their family will pay any price to avoid illness or death – and government has an obligation to regulate once again an ethically acceptable tariff. Similarly, legislation could make medical schemes immediately more affordable, and offload millions from public service dependence, by obliging every economically active individual to have medical aid cover. Congruent to government’s obliging provision of minimum benefits, and removing risk-rating, goes the responsibility to make this economically possible with a broad risk-base. The young and healthy need to start paying towards a healthy lifetime now.
Public-private partnerships to strengthen health care management, broaden the patient base, and act as strong gate-keepers (medical schemes are extremely well practiced) within strict referral pathways need to be nurtured and implemented without fear or favour. A more engaged and dynamic national conversation must be driven by a factual and un-emotive campaign (the political point-scoring is in full swing) to explain why we cannot afford NOT to implement the NHI.
20 August 2011
Susanna Coleman is a Public Health Optometrist, specialising in eye care advocacy, development and communications.
[i]Shield Report 2007, p.20