NHI IS NOT A LUXURY

KM: Few people can argue against the rationale and the moral argument of the NHI, but there appears to be general consensus that the country cannot afford this health plan. Is the NHI affordable?

AM: While the issue of financing the National Health Insurance is key to the successful implementation of the NHI, it is important to first outline where idea of the NHI came from. Globally, the World Health Organisation (WHO) has endorsed and accepted the principle of Universal health Coverage (UHC). The WHO documents that outline the adoption of UHC clearly stated that any country, regardless of its levels of economic development, can implement UHC. The WHO adopted UHC in September 2015 as one of the United Nations Sustainable Development Goals. Our own economic blueprint, the National Development Plan (NDP) has embraced the NHI. The Freedom Charter, which is the foundation of our country’s constitution, commits to giving people access to quality health care. Implementing the NHI is a constitutional mandate, one cannot hide behind costs when required to fulfil a constitutional mandate.

But the critical point that should be made is that South Africa runs the most expensive private health system in the world. We have a very expensive private health care in the world and there is a lot of wastage and lack of effective management in the public sector. These things have to be changed because they are not sustainable in the long term.

KM: But minister, just look at the rising budget deficit, the sluggish growth resulting in decreasing revenue. Surely there is a case to argue that certain new programs, such as the NHI, should be delayed until there is an economic recovery. Is that not a pragmatist view?

AM: Surely, you are not suggesting that the poor, those who have no money, should wait or even die as we wait for the economy to recover. NHI is a financial mechanism that will ensure that we use the resources of the country more efficiently to ensure that all South Africans have access to quality health care. People who have expressed fears about the huge costs of the NHI are making the assumption that we will just impose the NHI on the current health care system. This is a wrong assumption. Of course if we were to simply impose the NHI on the current health care system, NHI would be hugely expensive. But that is not what we are going to do.

In arguing that the NHI is unaffordable, many so called experts are basing their calculations on the exorbitant prices of health care that the private sector is charging. We will not pay those prices. We will overhaul the entire system. Under NHI, we will use the economics of scale to reduce prices of health services and medicines. We are already doing that. I will show you a slide that summarises (see the attached slide) some of the savings that we are already making.

In fact, the NDP identifies this problem, stating that for health service in the country to improve, we should address the issue of high levels of cost in the private sector and lack of quality in the public health care system.

There will be a major paradigm shift under NHI. Currently many of our people flood our hospitals. Under NHI, we will focus on prevention and primary health care. We have stated that the heart-beat of the NHI is primary health care. The clinic, which will be better equipped and better staffed to include even a medical doctor, would play a much more significant role in the delivery of health care.

KM: The issue is not really about the desirability of the NHI. The debate is really about the timing. Can this be introduced when the economy is depressed?

AM: There are two important issues associated with this question relating to the economy. The first point that should be emphasized is that NHI has real economic benefits. It is not just a cost but a real direct investment in the economy. If your population is sick, what plans of economic recovery or the planned growth through the NDP will come to naught. Can you imagine what could have happened if we had said we cannot give people ARVs (antiretroviral drugs) because they were too expensive? Hundreds of thousands of people would have died. What would have been the impact in the economy? Disaster.

The second point is that when the economy is depressed, more people struggle with their health bills. More people opt out of medical aid because they cannot afford. As more people are losing their jobs, they join the ranks of those without medical cover. They become a burden of the state. This is when we require the state needs to assist and provide health care to those who cannot afford it. While those opposing the NHI may argue that poor economic conditions should be the reason to delay the implementation of the NHI, the opposite is in fact true. During poor economic conditions, you need a health system that gives coverage to all people. In our case, that system is the NHI.

That is why many countries that implemented UHC did so during a period of economic depression. For example, England and Japan started planning for UHC after the second World War. At that time, their economies had been completely destroyed.

There is also this false argument that suggests that NHI is some luxury that can only be implemented when there is excess money. NHI is a tool that you need when things are bad, when many of your people are unable to access health care because of their economic status.

In any event, can those who always argue cost, explain why they think we must continue to run this very expensive private health care under this poor economic conditions?

KM: How do you address fears of the middle class and the rich that your plan might have a negative impact on the private health care system which appears to be working quite well, considering the number of medical tourists that South Africa attracts even from developed countries such as Britain?

AM: There is this fallacy that the NHI is about the poor. No. NHI is not just about the poor. The NHI is about giving access to everybody. Of the 23 million people employed by the state in the various levels of government and parastatals and those in formal employment in the private sector, only 8,8 million have medical aid cover. Even these 8 million, they are not completely covered because most of them exhaust their funds in the middle of the year and once they are without money, they are spewed back into the public health care system.

For me, the medical health care system is like the Biblical prodigal son who asks his father for his share of his inheritance and goes away and squander it only to return home with nothing. The private sector takes the cream from those with medical aid and once the same people have exhausted their funds, they are directed to the public hospitals. The public health care system carries the biggest burden of the country’s health needs. For instance, we treat about 300 000 people for TB and how many patients are treated by private hospitals? Zero!

And of the 4,2 million people on ARVs, 3,9 million are treated by the public health care system while only 300 000 get their treatment in the private sector. And of the 1,2 million women who fall pregnant every year, only 140 000 deliver in private health facilities while the rest deliver in the public health facilities.

KM: But minister, you cannot gloss over the issue of cost, least you will be accused of reckless spending. Where will the money to fund the NHI come from?

AM: As it is, the state pays a total of R46 billion in medical subsidy plus tax credits but this money is not available to everybody. It is only available to the 16% of the population who have medical aid. This is not sustainable and we have to change it. There is money in the system already but it is just being used by the few. This is what has to change. We want this pool of money to be available for use by everybody.

But in terms of the specific amount that would be allocated to NHI, treasury has promised to give more details about the funding model of the NHI. What is important is that NHI is not just a plan on paper, but it has been approved by the cabinet and it is now an official government program. This is very significant.

KM: Some Non-governmental Organisations have complained about the slow pace in the implementation of NHI. What are some of the real things that have been achieved under NHI?

AM: I do understand why people would want us to move with speed to implement the NHI. The currently system is failing many of our people. Despite the limited space, due to limited funds and the need to change a myriad of legislation, we have already moved to do practical things to implement the NHI. We have spent billions of rands on infrastructure in preparation of the NHI. We have already started with targeted groups such as screening of learners of learners for physical barriers to learning such as eye sight, speech and oral hygiene and hearing. But of course that can not be enough and hence I full understand the frustrations on those who feel we have not made sufficient progress on the matter.

While we understand their frustration, they must also face reality. There is no country that has ever implemented an NHI equivalent at the speed with which is now being demanded. NHI is not a sprint from one point to another but it is a lifetime ultra-marathon.