As the deadline approaches for comment on
the NHI Bill to be submitted to the Department of Health, criticism is mounting
with health sector experts warning that it could further destabilise an already
severely challenged system to the detriment of both patients and providers. In
the past few weeks, concerning issues have been discussed at summits,
congresses and specially convened meetings aimed at getting input from
different stakeholders.

Last week, the Institute of Race Relations (IRR)
added its voice to the fray with a detailed critique on the NHI proposals
contained in a report What’s
Wrong with the Golden Promise of the NHI?

It argues that while South Africa’s deeply
deficient public health service is in desperate need of reform, the ‘main
purpose of the National Health Insurance is not to improve health services
but rather to drive the private sector out of the healthcare sphere’.

The National Health Insurance system ‘will
help achieve this by putting an end to the medical schemes that primarily fund
private medicine and are essential to its survival’, writes author of the
report, IRR Head of Policy Research Dr Anthea Jeffery.

People who now pay for private healthcare
will instead pay increased taxes to help fund the NHI, which (says health
minister Dr Aaron Motsoaledi) will be ‘like a giant state-run medical aid’. The
NHI will thus require ‘a massive reorganisation’ of the current ‘two-tier’
health system, with its public and private components. When it becomes fully
operative, all health revenues will be paid into a single NHI Fund, which in
turn will pay for all the health services provided to patients by both public
and private practitioners and health facilities.

“Pervasive state control is intrinsic to
the NHI idea. Under the NHI, the state will decide on all aspects of healthcare
– from the healthcare services to be covered to the fees to be paid to doctors
and other providers, the medicines to be prescribed, the blood tests to be
allowed, the medical equipment to be used, the new health technologies to be
permitted, and the prices to be paid for every item, from aspirins and
antiretrovirals (ARVs) to sutures and CAT scanners,” the report warns.

“Pervasive regulation will also stifle
innovation, reduce efficiency, and promote corruption. The present private
healthcare sector will effectively be nationalised, giving the government a
monopoly over healthcare. This could be just as inefficient and vulnerable to
‘capture’ by a small elite as the state’s monopoly over electricity (via Eskom)
has proved. The NHI’s beguiling promises are likely to prove false. Despite
steep tax increases to help fund the system, the NHI will lack essential
financial and human resources. People will thus wait weeks, months, and even
years for treatment. They will seldom get speedy help when they need it most:
when children fall ill, or breadwinners are injured, or babies need to be
delivered, or the elderly have strokes, or the chronically ill require
medication. The treatment choices which currently exist will be removed – and
people will find that they have no option but to rely on the state’s medical
aid, irrespective of how badly it works,” Dr Jeffrey writes.

Similar views have been expressed by well-known
health economist, Prof Alex van den Heever, Chair of Social Security Systems
Administration and Management Studies at Wits on several occasions – the latest
being at an NHI Crisis Summit presented by trade union, Solidarity.

In his presentation, he particularly
referred to the continuation of the “patronage governance model” in which the
Minister of Health and his department will be responsible for both the
appointments of those who will be in control of the NHI Fund and the
procurement of services and products, leading to a possible situation where
political actors can effectively appoint people and direct procurement to serve
their own private interests.

“When we examine the NHI Bill closely,
there is not a single proposal aimed at changing the structural features of the
current private and public systems to improve service delivery and most
importantly accountability. It merrily proposes the establishment of a fund
with the same patronage model of governance that has resulted in the
deterioration of the system over the past few years. Why would you do that if
your interests are actually to provide universal health coverage – that is
plainly NOT the purpose of NHI – its fundamental purpose is to establish
another “capturable” organisation,” Prof Van den Heever noted.

“The current NHI document leaves every
problem intact and it promises nothing for the time to 2026 [when government
envisions full implementation of the NHI] that anything will change. It doesn’t
make any promise that government would deliver. Therefore, we are retaining the
same trends and tendencies that we see in the system today and by 2026 the people
responsible for this decision will be retired on big packages and say it is
somebody else’s problem with nobody responsible for creating the mess to be
held to account,” Prof Van den Heever warned.

Referring to failures in the private sector
as highlighted by the Health Market Inquiry’s provisional findings and
recommendations report, Prof Van den Heever said these could have been
corrected a long time ago if government was prepared to listen and implement
steps to correct the market imbalances in the medical scheme, hospital and
private practice environments.

He also blasted suggestions in the NHI
proposals that the NHI Fund will substitute medical scheme coverage with mandatory
contributions to the fund expected from all who use the system through
taxation, which will effectively push people who already have medical aid
coverage into an already overburdened system.

“This is not the same than the universal
coverage models in other countries,  which is aimed at bringing a group of people
who are income-compromised or risk-compromised because of poorer health status
into some kind of protective framework. With the proposed NHI model, you take a
non-vulnerable group of people with adequate incomes and destroy the system
they are operating in to incorporate them into a public system that is
operating disastrously,” Prof Van den Heever stated.

“We need to look at another strategy and
confront government on its plans, which if implemented in its current will put
the private system in peril. If not, we will end up with no viable system in
South Africa. We will have a decline in coverage in the private sector with
people unable to go to a viable public system, where those running the system
can be held accountable for structural failures and the consequent misconduct
within the framework.

“There is not going to be an NHI Fund that
will cover all of us. It will never exist and the fundamental reason for this
is that NHI is an aspirational proposal which does not fundamentally relate to
the capabilities in the country to fund it and create the institutional framework
needed to make it work,” Prof Van den Heever concluded.