NHI is no public health panacea

The public health system has been racked by one scandal after another. More than 144 state mental health patients died in the Life Esidimeni tragedy, over 200 people perished in the recent listeriosis outbreak and the lack of oncology services in KwaZulu-Natal has left countless patients without lifesaving treatment.

Yet Health Minister Aaron Motsoaledi is adamant there is no crisis. In a hastily convened media conference on Tuesday, he assured the nation that the health system — while hugely overloaded, with long waiting times and diminishing quality in some places — was not collapsing. The public sector was providing 4.2-million people with HIV medication, treating 300,000 tuberculosis patients and dispensing chronic medicines to 2.2-million patients at sites away from hospitals to reduce overcrowding, he said. These achievements, he said, were not the hallmark of a collapsed system.

His selective use of statistics is a classic case of a politician under fire trying to present the glass as half full. He told only part of the story of the public health system and ignored the desperate reality facing far too many citizens. His words and numbers of the great successes in treatment were of little comfort to all failing to get the care they need: if the province in which you happen to live has no oncologists and your child with cancer is sent home to die, what use to you are these numbers?

The key statistic that indicates how well a health system is providing care is its institutional mortality rate, which reflects deaths among women during and shortly after childbirth. It stood at 140 in 2014, according to the most recent Saving Mothers report from the National Committee on Confidential Enquiries into Maternal Deaths, double the sustainable development goal target of 70 per 100,000 live births. The report found more than half these deaths could have been prevented if women had received better care.

There is more bad news in the latest inspection report from the Office of Health Standards Compliance: only five of the 696 facilities it inspected in 2016-17 scored 80% or more, its threshold for compliance with its norms and standards. While these inspections do not measure clinical outcomes such as hospitalacquired infections or mortality rates, they nevertheless provide a useful lens through which to view the state of hospitals and clinics. The inspections were repeated in facilities that scored less than 50. The office found that many hospitals, clinics and community health centres had deteriorated over time.

Clearly not every public healthcare institution is failing and many do sterling work, but far too many do not make the grade. Far too many patients get too little, too late, or nothing at all.

When Motsoaledi became health minister in 2009, he was frank about the problems confronting the sector. He inherited a 10-point plan crafted by the Development Bank of Southern Africa that included overhauling the health sector’s management, improving the quality of public health services and introducing universal healthcare cover under the banner of National Health Insurance (NHI). He consistently emphasised the need to improve the quality of public healthcare services in order to implement NHI, recognising it could not be bolted onto a broken system. Over time his narrative has shifted and he increasingly emphasises the importance of introducing NHI, implying it is the solution for all that ails the public sector.

But NHI will not stop the corruption, fraud and mismanagement that have riven far too many provincial health departments, evidenced by five of them receiving qualified audits in 2016-17. He rightly emphasises that the Constitution stops him from interfering in provincial matters, because it delegates the power to design policy to the national department and gives the responsibility for service delivery to the provinces and municipalities. Clearly this is too big a problem for the minister to solve alone. But the admission that there is a crisis would be the first step to fixing it.

MANY HOSPITALS, CLINICS AND COMMUNITY HEALTH CENTRES HAD DETERIORATED OVER TIME