NEWS
NHI
Mistrust in government rife Investors and the public alike question the government’s ability to execute NHI. By Nicky Belseck, medical journalist
A
LTHOUGH A NUMBER of key concerns have been raised about the NHI (National Health Insurance) Bill, including transparency of NHI structures, the extensive powers given to the Minister of Health, and the centralisation of authority in the National Department of Health (NDoH), mistrust of government was the pivotal point raised by panel experts discussing NHI at Daily Maverick’s 2020 The Gathering. UHC NOW There was unanimous agreement on the need for universal healthcare (UHC) in SA. “When delivered properly, UHC is the best gift a country can give its people,” said Dr Mark Britnell, global chairman and senior partner for healthcare, government, and infrastructure at KPMG International. “It’s good for society, it’s good for the economy, it’s good for people.” However, panel facilitator Mark Heywood, Maverick Citizen editor asked if “we’re going about it the right way?” He questioned whether government shouldn’t first fix the public healthcare sector before imposing NHI on the country? “SA has no choice but to embark on the NHI journey,” said head of SA's NHI Office, Dr Nicholas Crisp. “It is not an either/or debate. You can’t address either the public or private sector – or either the money or the system – it all has to be done at the same time. It is the sequencing of how those things happen, that matters.” Discussing the money available to the NDoH Dr Crisp said, “As taxpayers do not want to pay more money, it will have to be done through efficiencies. The problem in the public sector is that in the provincial
administrations we are spending 75-78% of our entire health budget on personnel, on cost of employment. That means we’ve crowded out the ability to buy medicines and devices,”
As taxpayers do not want to pay more money, it will have to be done through efficiencies. The problem in the public sector is that in the provincial administrations we are spending 7578% of our entire health budget on personnel, on cost of employment. That means we’ve crowded out the ability to buy medicines and devices Dr Britnell responded saying, "If you look at Indonesia, Thailand, and Mexico, they spend less than SA and have a system performing better than SA,” said Dr Britnell. “You can spend less than 8.5% of your GDP (SA’s current combined private and public healthcare expenditure) and get better outcomes — that’s a fact. But you have to build from what you have in stages. Be
pragmatic and ideological. “My sadness is that when people take dogmatic and premature positions on NHI, you are in danger of throwing out the baby with the universal healthcare bathwater,” said Heywood. “Government has a record of failure, which means people understandably prejudge the issue, but this has closed down informed discussion. I’m concerned that as a result, the government has closed itself to informed discussion.” THE PROBLEM OF TRUST, OR LACK THEREOF “South Africans are feeling overtaxed and overburdened,” said Steven Nathan, former managing director of Deutsche Bank. “The issue is one of trust and one of delivery. In an ideal world, we would want UHC. But what is the cost and what is the benefit?” Stressing investors’ apprehension Nathan said, “The track record that government has is incredibly poor. Government departments’ ability to deliver is very poor. So, it’s trust. It comes down to how can the government demonstrate to us that it has the capacity and the ability to add value to the system. Dr Crisp acknowledged Nathan’s concern: “The trust deficit is the issue we are working on as hard as we can. It’s a diverse set of stakeholders, but we need to find common ground in a way people don’t feel they are losing something but, in a way, they feel they are gaining something. “We know there’s distrust. And in light of the Zondo Commission I think right now is the best time to start the NHI,” he said. “We are more vigilant than we’ve ever been as civil society about corruption. Now is a good time to build institutions.”
“I’ve worked in a lot of countries where corruption and distrust were rampant,” said Dr Britnell, “like in South America and what they’ve done to demonstrate they want a professional UHC service. I’m not suggesting it happens here, but what you think you’re facing, and think is unique, is not. There are solutions that can take trust head-on and find different ways of finding accountability through actually having professional organisations to help you manage the fund. I’m just saying that where trust is broken there is usually a solution.” THE ROAD AHEAD “In the draft bill, there is a suggestion of a number of phases with time frames,” said Dr Crisp. “They go for more than 10 years. Getting there will be in a series of building blocks. When they started the NHI in the UK, 33% of hospital wings were broken after World War 2 and they are still building that system. "We are planning for the future and building the framework now to bolt the various pieces onto.” By 2026 the NHI Bill requires government to be ‘the single, strategic purchaser of personal health services for the population’. “Before that can happen, we need the IT-systems in place, the systems need to talk to each other,” said Dr Crisp. The Bill says the fund will purchase directly from the hospitals. Can you imagine in SA today how much work has to be done before we have our cost centres realigned in the government hospitals, our clinics aligned, train managers, and have delegated authorities because of the way our Public Finance Management Act works? It’s a huge amount of work.” MEDICAL CHRONICLE | MAY 2020 7
