Pres­i­dent Ramaphosa’s gov­ern­ment is push­ing through Na­tional Health In­sur­ance leg­is­la­tion de­spite op­po­si­tion and com­plaints of lack of clar­ity

The Africa Report - - CONTENTS - Crys­tal Order­son in Cape Town

Health­care in a hurr y

The sign ‘L ead­ing in­no­va­tive health­care’ greets vis­i­tors to Hos­pi­tal Street, the main en­trance for pa­tients, doc­tors, nurses and any­one us­ing the ser­vices of Groote Schuur in Cape Town, one of South Africa’s old­est hos­pi­tals. The street, lo­cated in­side the hos­pi­tal, is a busy ex­change – here pa­tients who are strong enough are walk­ing with fam­ily mem­bers, nurs­ing staff are buy­ing snacks at the lo­cal cafe and doc­tors are rush­ing to var­i­ous wards. With the econ­omy in re­ces­sion and na­tional elec­tions on the hori­zon in 2019, is­sues like Na­tional Health In­sur­ance (NHI), ed­u­ca­tion and land re­form are high on the agenda for the gov­ern­ing African Na­tional Congress (ANC) to mo­bilise its grass­roots sup­port­ers. The NHI is a health-fi­nanc­ing sys­tem that will pool funds to pro­vide ac­cess to health ser­vices for all, based on health needs and ir­re­spec­tive of so­cioe­co­nomic sta­tus. The NHI bill has been gazetted and is now open for pub­lic com­ments. Crit­ics of the scheme say the coun­try can­not af­ford uni­ver­sal health­care and that the NHI will hurt the pri­vate health­care sec­tor while do­ing lit­tle to im­prove poor ser­vice pro­vi­sion in the pub­lic sec­tor. The gov­ern­ment wants the NHI scheme to be op­er­a­tional by 2025. Groote Schuur is the hos­pi­tal where the world’s first heart trans­plant took place 51 years ago. It has long been a bea­con of health­care for mil­lions. “We have had to im­prove our stan­dards – the na­tional core stan­dards mean all hos­pi­tals will have to fol­low what we are do­ing here,” says the head of en­gi­neer­ing and deputy di­rec­tor at Groote Schuur, Den­ton Smith. He, and oth­ers like for­mer hos­pi­tal ad­min­is­tra­tor Beth Adams, is en­thu­si­as­tic about the NHI. “It will be chal­leng­ing, but it’s ex­cit­ing,” says Smith. And this is the pas­sion that is driv­ing health min­is­ter Aaron Mot­soaledi to en­sure that the NHI be­comes a re­al­ity. On the steps of par­lia­ment, Mot­soaledi told The Africa Re­port his favourite idea – from the Ger­man philoso­pher Arthur Schopen­hauer: “Health is not ev­ery­thing, but ev­ery­thing else with­out health is noth­ing. You can’t have

Half of the doc­tors serve the 16% of the pop­u­la­tion who are in­sured or can af­ford to pay

ed­u­ca­tion if peo­ple are not healthy, you can’t ex­pand the econ­omy, you can’t take ad­van­tage of free ed­u­ca­tion if you’re sick, you sim­ply can’t.” The sta­tis­tics on health­care ac­cess do not pai nt a pret t y pi c t ure and Mot­soaledi says the in­equal­ity in ac­cess to health­care is un­ac­cept­able, with half of the doc­tors serv­ing the roughly

16% of the pop­u­la­tion who are med­i­cal scheme mem­bers or who can af­ford to pay for med­i­cal ser­vices them­selves. He adds: “As far as spe­cial­ist health­care goes, 80% of spe­cial­ists are to be found in the pri­vate sec­tor and only 20% in the pub­lic sec­tor.” Out­side Hos­pi­tal Street, an un­em­ployed fa­ther of one, Mark Booy­sen, doesn’t know about the NHI de­bates and says he is alive to­day be­cause of the care he re­ceived at gov­ern­ment-funded Groote Schuur. The 54-year-old says he has been given a new lease on life be­cause of the care he’s re­ceived at the hos­pi­tal. “I had a spinal op­er­a­tion and I have been given good care. The doc­tors are help­ful and I have never paid a cent in my life.” Rag­mat Dol­lie, 82, agrees: “I know peo­ple some­times com­plain about the care they re­ceive at Groote Schuur but I have only been treated well,” she tells The Africa Re­port. There is a lot of con­fu­sion in pub­lic de­bates about how the NHI will work and how it will be funded. Ac­cord­ing to the White Pa­per on the NHI, adopted in June 2017, it will be funded through a com­bi­na­tion of cur­rent sources of gov­ern­ment health spend­ing, in­clud­ing the re­moval of the tax sub­sidy for med­i­cal schemes, and manda­tory em­ploy­erem­ployee con­tri­bu­tions. All these funds will be placed in a sin­gle pool that will be avail­able to fund all health­care in the pub­lic and pri­vate health sec­tor. The NHI is go­ing to cost the gov­ern­ment more, but it says it will im­prove ac­cess and in­cen­tivise health­care providers to op­er­ate more ef­fi­ciently. The trea­sury pre­dicts the full im­ple­men­ta­tion of the scheme will in­crease pub­lic health spend­ing from 3.9% of gross do­mes­tic prod­uct (GDP) in 2017/2018 to 6.2% of GDP by 2025/26.


The Demo­cratic Al­liance is one of the par­ties that op­pose the NHI. They feel it would create an overly bu­reau­cratic sys­tem and will only sup­port some of the coun­try’s health pri­or­i­ties. Shadow health min­is­ter Lindy Wil­son says: “We be­lieve that ma­ter­nal and child health, emer­gency ser­vices, fix­ing bro­ken, dys­func­tional and mis­man­aged hos­pi­tals, build­ing more fully op­er­a­tional clin­ics and train­ing more doc­tors and nurses are pri­or­i­ties, as these ad­dress the real needs of the ma­jor­ity of South Africans.” Wil­son says mis­man­age­ment and cor­rup­tion are rife in the health sys­tem and plough­ing money into a bro­ken sys­tem will not ad­dress the plight of the poor and vul­ner­a­ble. South African Med­i­cal As­so­ci­a­tion (SAM A) vice chairperson Mark Son­derup tells The Africa Re­port that SAMA sup­ports uni­ver­sal ac­cess to health­care but wor­ries that health min­is­ter Mot­soaledi has not an­swered the ba­sic ques­tion: “How will we do it? We can­not talk about the NHI and we need proper lead­er­ship, the proper de­bate on pol­icy.” Demo­cratic Nurs­ing Or­gan­i­sa­tion of South Africa spokesman Si­bongiseni Delih­lazo takes a sim­i­lar view: “The NHI is a big ele­phant – we need to eat it bit by bit. The pace we are eat­ing the ele­phant is very slow, and right now our mem­bers are over­worked and un­der­paid, but de­spite this we fully sup­port the NHI.” The gov­ern­ment seems to be los­ing the com­mu­ni­ca­tion bat­tle, and for many health ac­tivists, there are still too many ques­tions unan­swered: there is a lack of clar­ity about the fund­ing, how medicines will be pro­cured, in­fra­struc­ture and staffing. But with health min­is­ter Mot­soaledi’s pas­sion and the World Bank call­ing on gov­ern­ments to in­vest in health to boost the econ­omy and hu­man cap­i­tal, South Africa is on the path to ex­pand­ing ac­cess to health ser­vices with or with­out all the stake­hold­ers on the same page.

Gov­ern­ment-funded Groote Schuur is a bea­con of health­care

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