Dangerous dalliance with the NHI
Finance Minister Enoch Godongwana’s February budget averted any meaningful funding heading the way of National Health Insurance (NHI).
Although he categorically rejected the NHI last year as a fiscally feasible policy, this is an election year, so we must assume that he was obliged to toe the ANC line when he stated in his budget speech that government is fully committed to NHI.
Nonetheless, outside of contradictions and fiscal feasibility, the one propaganda success that the ANC can claim is the NHI position that current public health resources are inadequate to deliver better healthcare. But this is standard fodder from socialists. Just give us plenty more of other people’s money — additional NHI tax estimates range from R200 billion to R800 billion annually — and we will produce amazing outcomes.
The number of medical personnel employed by the state has increased substantially during the past 13 years. Even with the growing population, the ratios of medical personnel per 10 000 population have risen significantly. Medical personnel in 25 out of 28 medical disciplines in the public sector experienced improvements in their ratios per 10 000 population between 2006 and 2019.
This was possible through annual increases in public health expenditure considerably above CPI and population growth over many years. Population growth is around 1,4% per annum, and the same average increase in personnel means the ratio of health sector personnel to population has been maintained. The total provincial budget over the same period increased on average by 5,8% per annum, lower than in previous years, but still in excess of the CPI.
Surely it behoves any parliamentarian faced with these indisputable and publicly available facts to question why outcomes in the public sector have not improved significantly over the past 20 years? And to question whether demanding substantially more funding via NHI will realistically improve outcomes.
This would, of course, require inquisitorial ANC parliamentarians rather than complicit and ideologically brainwashed ones to pose such questions. It is obvious that during the NHI policy process, such questions have only emanated from the opposition benches, the private health sector, civil society and business lobby groups.
Nonetheless there are a few apparent answers. The breakdown of governance and the incapacity of deployed managers have routinely been highlighted by the Office of Health Standards Compliance as the weakest outcomes across all audited metrics in the Health Department. Even where competent managers exist, their attempts to intervene with non-performing staff are often met with violent threats and intimidation from unions, undermining any possible performance correction.
When assessing the astronomical sums pilfered from government Health budgets in the department’s rampant corruption, it is simple to determine how the diversion of resources, meant to purchase medicines and materials or to maintain equipment and facilities or to fill empty posts, severely hampers service delivery.
Another form of fraud is abuse of the dual practice policy. Public sector personnel are permitted to operate a private sector practice (doctors) or to contract with private sector providers (nurses), as long as this is not done on state time. However, dysfunctional management has enabled endemic abuse of this practice, called moonlighting.
The financial incentive to spend more time in their private sector practice is obvious, yet no noticeable intervention by the department is taken to avert the problem.
It is abundantly clear that the resource argument that underpins the NHI policy is a hopeless fallacy.
Governance failures, poor management and endemic corruption are obviously the greatest threats facing the Health Department and unless dealt with, no amount of additional tax, whether in the form of NHI or otherwise, will improve public health outcomes.