SA can learn about NHI from those who have it
● In countries that roll out universal health insurance, people still have to pay extra for health care over and above their mandatory payment towards state or private health insurance.
Wealthier people in these countries still have additional private insurance and quicker access to doctors and treatment.
And no middle-income country has used a single fund or single payment system to purchase universal health cover, as proposed in SA’s National Health Insurance (NHI) Bill.
This is according to health-care actuary Barry Childs, who analysed how other countries pay for universal health care (UHC). He presented his findings to the recent Hospital Association Conference of SA. The countries included Ghana, Kenya, Brazil, Australia, Thailand, Canada, China, France, the Netherlands and the UK.
Last month the department of health released the long-awaited NHI Bill, proposing a single fund to pay for all of SA’s health care, with all people able to access treatment on the basis of need and not their ability to pay for it.
Childs noted that the countries he studied approach the provision of and payment for health care differently, but in all cases financial contributions to the system are mandatory, as is proposed by the NHI Bill.
Mandatory contributions ensure the wealthy subsidise lower-income earners, and the healthy subsidise the sick — and they reduce the sustainability risk to insurance funds of people buying cover only when ill.
However, in contrast to SA’s proposed single NHI fund to pay for health care, most other countries with UHC that Childs studied employ a number of funds — Thailand for example has three state-run funds and Germany has 124.
A country that uses a single fund is
Ghana.
It has a relatively undeveloped state and private-sector health system, and due to “administrative challenges” it covers only 38% of the population.
“A single-payer system is not a necessary or sufficient condition for UHC,” noted
Childs.
In SA, the NHI Bill foresees medical aid schemes providing complementary cover (which has yet to be defined) when fully implemented, which the deputy director-general in the department of health, Anban Pillay, has insisted will be in 2026.
However, the minister of health, Zweli Mkhize, has said NHI would be introduced in a “phased-in and incremental approach”, suggesting medical aids have many more years ahead of them.
But in most countries with UHC, medical aid schemes continue to exist.
Childs said: “Private insurance exists meaningfully in almost every country, to cover services not provided by an NHI or equivalent, to fund co-payments, to offer wider provider choice, especially access to private providers, and to shorten waiting times.”
The rich are able to buy their way to quicker and better access to care, jumping queues and ensuring private hospital rooms or accessing services not available in the state sector.
Despite Mkhize promising the poor would have access to “essential health care” even if they couldn’t pay, UHC has not eliminated out-of-pocket spending in most of the countries Childs studied — meaning people have to make payments over and above their taxes and their insurance fund premiums.
SA has a low out-of-pocket spending rate, accounting for just 8% of all health spending.
However, Childs said this figure reflected poverty — most households live on R4,000 or less a month and cannot afford to spend anything on medical bills — as much as it did the comprehensive health-care coverage that some South Africans have.
The scope of the services offered by the NHI and what complementary cover medicals aids would offer have yet to be clarified.
Childs said in all UHC systems, there are rationing committees — known by critics of NHI as death committees — that decide what procedures and medication will be covered. This is similar to the system employed by private medical aids.
“Gatekeeping and rationing are essential,” said Childs, to avoid a situation like that in the US where Americans on average spend more than $10,000 (R150,000) a year each on medical bills.
When launching the NHI plan, Mkhize repeatedly said the fund would be free of corruption.
Childs said: “Each country considered has its own governance structures and challenges, including political complexity and risk of corruption.”
Gro Harlem Brundtland, former prime minister of Norway and former DG of the World Health Organisation, speaking at a public discussion on NHI at Charlotte Maxeke Johannesburg Academic Hospital this week, said SA’s health-care budget was big but the money was not used efficiently. The country would have to improve its systems and tackle corruption.
She said Norway established its UHC system during reconstruction after World War 2.
“All countries that have achieved UHC have relied on public financing … to build social solidarity and ensure effective coverage for the poor and the sick,” she said.
“This requires a move away from private voluntary financing, to a more efficient, equitable public financing system. UHC is critical to any country’s sustainable development.
“SA, like the US, needs to make this kind of transition; furthermore SA will have to improve the efficiency of health-care spending, strengthen procurement systems and tackle corruption,” Brundtland said.
She said it was important to challenge the view that the NHI was unaffordable for SA because of the country’s fiscal problems. Failure to invest in health care was the definition of a false economy, she said.
The former president of Chile, Ricardo Lagos, who also took part in the discussion, said Chile had established its UHC system in 1951.
He said the country had initially introduced cover for three types of diseases, expanding this gradually to the point where today 56 diseases are covered.
He said the key to Chile’s UHC success was that it had buy-in from citizens.
Brundtland and Lagos are part of The Elders, peace and justice organisation founded by President Nelson Mandela in 2007.
The NHI Bill foresees medical aid schemes providing complementary cover