Will the NHI ac­tu­ally work?

The health min­is­ter will be met with court cases from the pri­vate health­care sec­tor while deal­ing with pres­sure from trade unions to speed up the process

Mail & Guardian - - Health - Mia Malan

The Na­tional Health In­sur­ance (NHI) scheme is com­ing, whether you like it or not. And so is the end of your med­i­cal aid in its present form. That’s if South Africa’s NHI and Med­i­cal Schemes Amend­ment Bills, which were pub­lished last week and are now open for pub­lic com­ment, are passed by Par­lia­ment in their cur­rent forms.

But the man at the helm of it all, Health Min­is­ter Aaron Mot­soaledi, may face even more strain and un­cer­tainty than those who will be de­pend­ing on the scheme. He is likely to be met with numer­ous court cases from the pri­vate health­care sec­tor. And, at the same time, he will face pres­sure from trade unions to speed up the im­ple­men­ta­tion of NHI. Trade union fed­er­a­tion Cosatu has made no se­cret of its im­pa­tience with the min­is­ter and called for his res­ig­na­tion ear­lier this month.

The NHI will be like a huge, state­funded med­i­cal scheme that buys health ser­vices from pub­lic and pri­vate health fa­cil­i­ties. The idea is to get wealth­ier peo­ple to sub­sidise poorer peo­ple, so that ev­ery­one gets ac­cess to the same qual­ity of care, re­gard­less of their in­come.

The scheme is be­ing phased in over two five-year pe­ri­ods and one fouryear pe­riod, end­ing in 2026. We’re cur­rently in the sec­ond phase (20172022), of which one of the main ob­jec­tives is to put the leg­is­la­tion in place for the NHI to be im­ple­mented. For this to hap­pen, 10 pieces of leg­is­la­tion, in ad­di­tion to the Med­i­cal Schemes Act, as well as var­i­ous pro­vin­cial health acts, need to change.

The cross-sub­sidi­s­a­tion be­tween rich and poor will be quite sig­nif­i­cant: ac­cord­ing to the Coun­cil for Med­i­cal Schemes, the body that reg­u­lates schemes, only 16% of South Africans can af­ford med­i­cal aid pre­mi­ums. The rest of the coun­try re­lies on a di­lap­i­dated pub­lic health­care sys­tem, al­though some of them also visit pri­vate doc­tors, for which they pay cash.

The min­is­ter wants the med­i­cal aid con­tri­bu­tions of the 16% to be used to­wards the NHI to help to sub­sidise the cost of care for the other 84% of the pop­u­la­tion.

The NHI will likely be funded by gen­eral taxes and pos­si­bly pay­roll de­duc­tions. De­duc­tions will in all prob­a­bil­ity be cal­cu­lated on the ba­sis of salaries, so that peo­ple who earn more pay more.

In the pe­riod up to 2026, when the NHI should be fully im­ple­mented, the min­is­ter wants med­i­cal schemes to align them­selves with what the NHI will even­tu­ally look like: the Med­i­cal Schemes Amend­ment Bill, for in­stance, re­quires med­i­cal aids to rad­i­cally change the way in which they bill mem­bers. They will no longer be able to charge ev­ery­one the same rate for the same pack­age; those who earn more will pay higher pre­mi­ums.

Med­i­cal schemes will also have to scrap co­pay­ments; they will have to pay mem­bers’ med­i­cal bills in full.

Cross-sub­sidi­s­a­tion will al­most cer­tainly change the kind of ben­e­fits that schemes of­fer their mem­bers. If med­i­cal aids’ abil­ity to raise in­come through pre­mi­ums and co­pay­ments is re­duced, they will have to ad­just what they of­fer.

But if the NHI Bill is passed, the cost of the ser­vices will be­come lower.

Pri­vate-sec­tor health pro­fes­sion­als who par­tic­i­pate in the NHI will be paid in fun­da­men­tally dif­fer­ent ways: they will only be able to charge pre­scribed NHI rates for their ser­vices. Cur­rently, doc­tors and den­tists prac­tis­ing pri­vately can charge what­ever they like, be­cause there are no set fees. For more than a decade the gov­ern­ment has tried to im­pose such rates, but, each time, the pri­vate sec­tor has in­sti­tuted court pro­ceed­ings and won.

The min­is­ter has been in­stru­men­tal in launch­ing a Com­pe­ti­tion Com­mis­sion mar­ket in­quiry into what he con­sid­ers ex­or­bi­tant pric­ing in the pri­vate health­care sec­tor. But even in this case, the pri­vate sec­tor has man­aged to drag out the an­nounce­ment of the out­come of the in­ves­ti­ga­tion for al­most three years. The in­quiry was sup­posed to have con­cluded in De­cem­ber 2015, but the re­sults are now ex­pected only in July.

Based on the pri­vate sec­tor’s past be­hav­iour, the min­is­ter can ex­pect court case af­ter court case from or­gan­i­sa­tions rep­re­sent­ing health pro­fes­sion­als for es­sen­tially forc­ing them to charge lower, pre­scribed rates. Med­i­cal schemes will also go to court to fight for their ex­is­tence. Both groups will be rep­re­sented by top lawyers and will try to post­pone the fi­nal­i­sa­tion of the bills and their con­tent for years to come.

But, even if the bills are passed un­changed, trou­ble may be brew­ing — this time from trade unions. In their present state, many state hos­pi­tals and clin­ics won’t qual­ify to be part of the NHI. Be­cause the NHI will be pay­ing fa­cil­i­ties di­rectly for their ser­vices, and not through pro­vin­cial health de­part­ments, dis­qual­i­fied fa­cil­i­ties are likely to run short of funds to pay health work­ers’ salaries.

The NHI Bill spec­i­fies that all fa­cil­i­ties that would like to be ac­cred­ited for the NHI would need to pass an in­spec­tion by the Of­fice of Health Stan­dards Com­pli­ance, an or­gan­i­sa­tion that mon­i­tors the qual­ity of health­care. The of­fice con­ducted in­spec­tions of about 700 of the coun­try’s al­most 4 000 gov­ern­ment health es­tab­lish­ments in 2016/2017. In the East­ern Cape, the prov­ince in which the high­est num­ber of fa­cil­i­ties were in­spected, al­most all clin­ics and com­mu­nity health­care cen­tres were “non­com­pli­ant” or “crit­i­cally non­com­pli­ant” with an ac­cept­able stan­dard of health­care.

Mot­soaledi has told Bhek­i­sisa that the com­pe­ti­tion be­tween pub­lic and pri­vate fa­cil­i­ties to sell their ser­vices to the NHI will be “healthy”. But how will unions re­act when pri­vate fa­cil­i­ties are co-opted at the ex­pense of gov­ern­ment hos­pi­tals and clin­ics, with unionised work­ers, whose ser­vices now won’t be used?

The Bill also says that health fa­cil­i­ties that are un­able to “en­sure the ap­pro­pri­ate num­ber and mix of health­care pro­fes­sion­als to de­liver the health­care ser­vices spec­i­fied in the Gov­ern­ment Gazette” won’t be able to ob­tain NHI ac­cred­i­ta­tion. With crit­i­cally un­der­staffed gov­ern­ment fa­cil­i­ties in many prov­inces, and South Africa’s short­age of doc­tors and nurses, it’s un­cer­tain where the re­quired num­ber of pro­fes­sion­als will be re­cruited from.

It’s a con­cern that the Bill doesn’t spec­ify what ser­vices will be of­fered by the NHI and how much the scheme will cost. The min­is­ter has re­peat­edly been asked for a bud­get, but says it’s im­pos­si­ble to es­ti­mate the cost of such a broad ser­vice. Es­ti­ma­tions have var­ied from R256­bil­lion a year in the NHI White Paper to pri­vate or­gan­i­sa­tions cal­cu­lat­ing it at R400-bil­lion.

The in­equal­ity in ac­cess to qual­ity health­care in South Africa has to be ad­dressed. It’s un­ten­able and in­hu­mane for such a sce­nario to sim­ply con­tinue. The NHI Bill is most cer­tainly an ef­fort to right numer­ous wrongs. But is it a work­able plan within a pub­lic health­care sys­tem that the min­is­ter him­self has ac­knowl­edged is dys­func­tional on so many lev­els? The NHI’s many pow­er­ful op­po­nents, and even some who want it to work, say “NO”.

Yet Mot­soaledi has warned: “If they [Par­lia­ment] don’t pass the [NHI] Act as we are propos­ing it, you can for­get about uni­ver­sal health cov­er­age. [If they don’t] we’ll make noise about the health­care sys­tem in the coun­try ev­ery year, but never get it right.”

The in­equal­ity in ac­cess to qual­ity health­care in South Africa has to be ad­dressed.

It’s un­ten­able and in­hu­mane for such a sce­nario to sim­ply con­tinue

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