Can the National Health Insurance solve South Africa’s national health crisis?

by Louis Reynolds & David Sanders | Amandla! Issue No. 66 | October 2019

“Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community. No society can legitimately call itself civilised if a sick person is denied [health care] because of lack of means. ”
Aneurin Bevan, British Health Minster from 1945 to 1951, who introduced the National Health Service.

South Africa needs a National Health Service that gives everyone free access to good quality health care according to need rather than means. To make this happen we must protect the National Health Insurance from corporate capture and ensure that it is implemented with complete transparency and accountability.

South Africa has a profound national health crisis. The crisis has 2 aspects. Firstly, the majority of the people have insufficient access to the causes of good health. Second, we have a deeply inequitable health system, divided between the public and private sectors, both of which are in crisis. Unless we address both aspects of the crisis it will be impossible to improve the health of the nation.

Though the causes of good health have social, economic and political dimensions, they are generally known as the social determinants of health (SDH). Key SDH include decent housing, household food security, water and sanitation, personal safety and security, good education, decent jobs and adequate income. People who lack adequate access to these SDH live and work in conditions that make them sick: unsafe physical environments, social disintegration, violent crime and deep distrust of state institutions. As a result, many people get sick from four broad groups of sickness, known as the Burden of Disease (BOD):

• diseases affecting women, and mothers and babies around the time of birth;
• infections like pneumonia, TB, HIV/AIDS and diarrhoea;
• non-infectious diseases like diabetes, heart disease, high blood pressure, strokes, obesity and cancer; and
• violence and trauma.

In addition to this BOD, South Africans also suffer from a less well recognised burden of mental ill health.

Poor people, who lack access to SDH and bear the overwhelming part of the BOD, depend on the public sector for health care. But improving the health services will do little to improve their health without also dealing with the SDH. Experience in other countries shows that improving access to SDH could reduce the burden of disease by up to half. Healthier people need less health care.

But addressing SDH lies outside the ambit of the Department of Health; it requires intersectoral collaborative action across government sectors. Beyond service delivery and an improved health system, we also need mutual solidarity and more social cohesion — one of the aims of the NHI.

How we got here

To make sense of the controversy around the NHI and whether it can lead to better health, we must ask how we got into this mess.

The national health crisis is part of a broader economic, social and political crisis with deep roots in the legacy of colonialism and apartheid. Free market ideology was adopted in 1996 with the neoliberal Gear (Growth, Employment and Redistribution) economic policy. This did nothing to alleviate the enormous structural inequality and the systematic exploitation inherited from apartheid. Instead, household income inequality has grown to dangerous levels. The richest 10% enjoy more than half the total income, while around 60% of households live below the poverty line.

Under Gear, privatisation and public sector austerity weakened the delivery of public sector services, while corruption critically damaged key state institutions and led to a culture of impunity among those who loot state resources. The social fabric is torn apart by deep distrust of practically everything and everyone, and there is an underlying sense of smouldering violence.

These issues substantially underpin both the burden of disease and the current incapacity of the health system to deal with it effectively.

While the NHI has some important flaws, it is the only concrete plan in town that has the potential to improve the health system, through its stated objective of Universal Health Coverage (UHC). This will require drawing on all available health care resources, many of which are hidden away in the private sector, beyond the reach of the majority.

The concept of UHC is, however, open to contestation. The term is used to cover different financing mechanisms and health system designs. These fall into 2 broad categories:

1. Membership-based insurance. People who can afford it join and pay into a private medical insurance scheme. Usually, when they join they are healthy. When they get sick the scheme covers some of the costs of some treatments (benefits) from the pooled contributions of all the members. Often, these schemes are state-subsidised. Insurance-based systems discriminate against the poor and least heathy.
2. Universal systems where membership is compulsory for all. Everyone, rich and poor, gets the health care they need. The money comes from the government through tax; rich people pay a bigger proportion of the tax. This means that wealthy, younger and healthier people cross-subsidise those who are less well off, older and less healthy, in a spirit of social solidarity. This is the model that underpins the NHI.

There is compelling international evidence that only the latter can realise the objectives of universality, equity and (particularly in the South African context) social solidarity. Attempts to introduce UHC must, from the start, address the needs of the entire population and the health system as a whole. Experience, especially in Latin America, shows that piecemeal, scheme-based “transitional” arrangements create groups with vested interests in the status quo. They then resist subsequent attempts to move towards unified systems. Indeed, this is the situation we confront today. The main resistance and most vociferous criticism come from groups with vested interests in the highly profitable private sector. To make progress towards UHC, a single payer system with mandatory prepayment is essential.

Criticisms of NHI

The NHI Bill can rightly be criticised in a number of aspects.

1. Building a good health system requires societal coherence, a functioning state with trusted institutions, and an ethical private sector. We lack all three. While the Bill includes mechanisms to prevent and deal with corruption and fraud, we must question whether these will work with all members of the National Health Insurance Fund (NHIF) Board will be appointed by, and be accountable to, the Minister.
2. The 2019 NHI Bill confuses Primary Health Care (PHC) with Primary Care (PC). Primary Care is about the delivery of health care at community level, with referral to higher levels when necessary. Universal public access to good quality essential health primary care without financial impediment is the essence of UHC. The Bill does not guarantee adequate mechanisms to improve and extend the public health system to the level required for.
   While UHC is essential, it is insufficient for promoting people’s health. Health for All will not come about without 2 fundamental principles of PHC:
   • community participation in issues related to health (including in the planning, provision and evaluation of health services), and
   • collaborative intersectoral action to address the social determinants of health (SDH).
3. It is imperative to fix and upgrade the broken public sector to the level required for NHI accreditation. Only facilities accredited by the Office of Health Standards Compliance (OHSC) will be reimbursed by the NHI Fund. The most recent OHSC report reveals that only 5 of the 696 facilities inspected met the requirements. Private, urban-based facilities are more likely to succeed than public facilities, especially in rural areas. The NHI could, ironically, aggravate urban-rural inequality.
4. The Bill proposes that Districts will contract for services through Contracting Units for Primary Health Care (CUPs). Without substantial improvement in local capacity and mechanisms for monitoring — including by local health committees — the potential for dysfunctionality and fraud is great.

Critical support for the NHI

As a nation we cannot let the health crisis continue. The current state of affairs in our health system is unsustainable and morally unacceptable: the public sector, on which most of the population depend, is under-resourced, badly managed and dysfunctional in many areas. The private sector, where resources are concentrated, is unaccountable, lacks proper regulation and is increasingly unaffordable and unsustainable.

The NHI, with all its faults and lack of clarity, provides a basis for a unified and equitable health system. None of its detractors has produced a viable, realistic alternative.

Moving forward will be fraught with setbacks and arguments, and it won’t be easy. But we must do what is necessary to make it work.

Louis Reynolds and David Sanders have been primary health care activists as well as doctors and academic.