Pandemic signposts path to NHI
The National Health Insurance (NHI) has become an idealistic concept known as “imaginary”. It’s become the idea onto which all South Africa’s aspirations for healthcare have been projected. The dream of a system that is fairer, less divided and more efficient. It’s even been called “pie in the sky”.
It’s clear that some version of the NHI is going to happen regardless. And its success or failure will be determined by the extent to which all South Africans contribute to it.
This dream of a single national health system could be realised if South Africa is able to articulate a common vision for all its citizens. The Covid-19 pandemic is shedding light on how best to go about building the NHI – and what to avoid.
On the positive end, it has highlighted the country’s interconnectedness and mutual dependence across sectors. The health minister has shown great leadership and collaborated closely with the scientific community.
On the negative side, the acute crisis has prompted government to work top-down through a centralised command structure.
This is not how effective systems based on primary healthcare are built. In the absence of a design approach with clear cycles of learning and feedback of evidence from the ground up, the risk is that the whole NHI system will fail to be implemented.
There are many examples of the “implementation gap” between well-intentioned policy and actual practice.
A health system is more than a complicated organisation, it is an extremely complex one. The human body itself is an appropriate image of a complex, adaptive system. It’s a biological marvel in which each part simultaneously affects every other part.
A further level of complexity arises when these changing systems are challenged by trauma or illness, and have to adapt to new environments or stressors.
The fundamental divide between the for-profit value system of the private health sector and the human rights-based approach of the public sector on the other, needs to be bridged rather than deepened, building on the intersectoral innovations the pandemic has elicited.
This Covid-19 pandemic highlights the fact that South Africa already has the technical expertise and capacity, in governance, in health economics, in health systems, in information systems and in community participation in health.
Hard and persistent work need to be planned for, like a kind of ongoing rehabilitation process, to realise the dream of one health system for all South Africans.
Reid is chair of Primary Health Care, University of Cape Town