‘Phambili NHI — but with care and caution’ as major problems loom

Evidence from pilot schemes points to critical fault lines in SA’s readiness for universal health care

Since the dawn of democracy in 1994, South Africa has committed to a policy of accessible health care for all people. This commitment is enshrined in our constitution under Section 27. However, 29 years later we have failed to implement this commitment and our health system is still underperforming relative to the resources available.

Health financing models play a central part in giving direction to the efforts to achieve universal health care (UHC). Evidence from across the globe suggests that countries with well-functioning national health insurance systems and strong economies with a wide tax base, which can spend more on health care, have made greater advances in achieving UHC.

The National Health Insurance (NHI) Bill represents South Africa’s strategy to achieve UHC. While the bill has been adopted by the National Assembly it is not a fait accompli, as it has to be passed by the National Council of Provinces before being signed off by the president.

As South Africans we need to learn from experiences in resource-constrained countries rather than emulate health financing models of countries such as Taiwan, Australia and South Korea — systems that are not without fault.

An important case in point is Ghana, which implemented its National Health Insurance Scheme (NHIS) in 2003. Evidence 15 years later, in 2018, suggests that although the NHIS improved access to health-care services and provided greater financial protection to the vulnerable, there were many challenges.

The first challenge was that less than half the population (40%) subscribed to the NHIS over this period. Further challenges included poor-quality health care, corruption and ineffective governance. These have resulted in wastage, despite the fact that the scheme was relatively well funded. The scheme has also faced political interference and poor stakeholder participation, including by health professionals working on the front lines of health reform implementation.

In South Africa, NHI was piloted in 10 health districts across the country during 2012-17. The evidence from these pilots points to at least five critical fault lines in the public health system’s readiness to implement NHI. These include shortages in — and the maldistribution of — specialised human resources; a lack of equipment and poorly maintained infrastructure; poor supervision and management practices; and health information systems that lack quality, coverage and standardisation and do not sufficiently support reimbursement and resource management.

Because of these problems, there were few improvements in the quality of health care provided. This shows that the public health system in South Africa is not yet strong and resilient enough to fully implement the proposed NHI.

There are many parts of the bill that remain vague and should be urgently clarified if we are to build public support for this policy. For example, the bill does not clarify the set of benefits to be funded under the NHI, the nature of referral networks, or what arrangements will be implemented for contracting and reimbursement arrangements.

Potential consequences of NHI’s full implementation include the possible mass emigration of health-care professionals

A national health technology assessment system must be established to ensure that evidence-based choices are made in regard to the benefits to be funded under NHI. For example, providing a much smaller set of benefits focused on health promotion and prevention in primary health-care settings may be the best approach as it has important longer-term economic spin-offs in averting disease and the accompanying costs of care.

Also, it remains unclear why the government is not better leveraging the substantial technical know-how and strong health information systems in the private medical schemes industry to facilitate the successful implementation of NHI.

It is also necessary to warn against potential unintended consequences of NHI’s full implementation. These include: the possible mass emigration of health-care professionals because of a lack of confidence in the capacity of the government and its financial ability to ensure the success of the service; corruption involving skimming resources from the NHI Fund; poor governance and a lack of accountability constraining NHI’s ability to realise its envisaged remit; large numbers of South Africans switching to using only private health-care services, which could put present levels of quality of care under pressure and may see informal payments being charged at private facilities; and the risk of moral hazard resulting in an expansion in the demand for health-care services that exceeds the financial capacity of the fund.

The most pressing questions regarding NHI are the “why, how and when” of its implementation. A reassessment of the health system’s readiness to fully implement it should be conducted as a matter of priority, including revisiting the costing around the affordability of the financing model.

Caution is also necessary as an expansive NHI that is not affordable will be difficult if not impossible to roll back, with substantial implications for the delivery of other government services due to the necessary reallocation of budgetary resources and an increasing tax burden on South Africans.

Rather than exclaim “phambili NHI, phambili”, the echo should be “phambili NHI, but together and with care and caution”. The bill itself refers to such a gradual, progressive and programmatic implementation of NHI.