The NHI will not fix bad healthcare for the poor
Mike Waters, DA Spokesperson on Health
5 December 2011
Over the last few months, the Democratic Alliance (DA) has been studying the government’s National Health Insurance (NHI) proposal. We have also held a series of workshops with key stakeholders from government, civil society and the healthcare industry.
The result of this process is the position paper on the NHI we are releasing today. This will form the basis of our public submission on the government’s Green Paper.
Our research shows that, not only are there serious doubts around the feasibility of the NHI, but that it will actually work against its stated objective to provide improved quality health services for all South Africans.
We believe that the poor will suffer more under the NHI because it will divert billions of rands from other development challenges such as provision of basic services, education and housing.
Furthermore, the NHI will also create a bureaucratic and inefficient healthcare superstructure that will diminish the quality of public healthcare. There are a number of specific reasons why the NHI will not improve the quality of healthcare to the poor.
Firstly, NHI does not fix the real problem of low-quality healthcare provision in the public sector. Instead, the Green Paper focuses on accessibility and finance, when we already have universal accessibility and enough funding to run a quality public health system. What it lacks is quality, which should be the government's main priority.
Secondly, NHI does not adequately attend to accountability and management structures. The Ministerial Task Team report on healthcare funding states that “No part of the health system is held properly accountable for poor health outcomes or poor service delivery.” While the Green Paper calls for an Office of Standards Compliance, its members will be appointed by, and answer to, the Health Minister. It will not be truly independent, making it vulnerable to political influence.
Thirdly, we lack the human resources to implement NHI which demands that we triple the 27,000 doctors that we currently have. But we only train enough doctors each year to keep pace with the numbers who retire or emigrate. The state is unable to train the necessary number of doctors to implement NHI.
Fourthly, the creation of a centralised fund will over-bureaucratise the public healthcare system rendering it more inefficient and costly than it is currently. It will also carry an increased risk of major corruption and financial mismanagement. Under the current system, the Department of Health racked up R43 million worth of irregular expenditure last year alone.
Fifthly, throwing money at a problem does not always solve it. A good health system requires a minimum threshold of funding to be effective. But greater expenditure beyond that threshold does not guarantee better results. Other factors – such as the accountability, governance and functionality – determine the quality of a healthcare system.
South Africa spends R2,766 on public healthcare per person each year – far more than other developing countries. Malaysia, for instance, spends only R2,180 per capita, Thailand just R1,700 per capita, Namibia only R1,594 per capita and China a mere R846 per capita. These countries enjoy higher levels of life expectancy than South Africa, which suggests that money is not the primary problem with our public healthcare system.
What then, is the alternative to the NHI?
The DA believes there is a better way. By strengthening the positive elements of the public sector and removing its deficiencies on a planned and sustained basis, we can improve healthcare for everyone. That is the lesson we have learned in the Western Cape.
The Western Cape has some of the highest health indicators in the country:
• Life expectancy in the Western Cape is currently 61.6 years for men and 67.9 years for women while the national average is 52.7 for men and 56.4 for women.
• Maternal mortality rates in the Western Cape stand at 98 deaths per 100,000 live births, while the national average is 140-160 deaths per 100,000 births.
• Child mortality rates in the Western Cape are 38.8 deaths per 1,000 live births while the national average stands at 69 deaths per 1,000 births.
• The Western Cape has antenatal HIV prevalence rate of 18.5% while the national average is 30.2%.
• The TB cure rate in the Western Cape is 79% while the national average is only 65%.
The DA's health policy in the Western Cape centres on strengthening the governance mechanisms of the public health system and creating the necessary incentives for ensuring that healthcare practitioners deliver optimal performance. We believe this should form the cornerstone of a proper national health policy.
The DA's alternative to the NHI centres on infusing accountability, affordability and efficiency into every level of healthcare.
If the DA was in national government, it would:
1. Create a national health framework with national health targets, minimum norms and standards for healthcare providers and effective oversight of both the private and public healthcare sectors.
2. Strengthen provincial health departments for better delivery by giving them more freedom in policy-making and holding them to account for health outcomes and not just compliance.
3. Capacitate healthcare providers to take responsibility for their performance. Public hospitals and clinics need increased autonomy and accountability and less micro-management.
4. Create an independent health oversight body with the power to investigate complaints of poor healthcare and hold those responsible to account. This would be coupled with a quality rating system applied to all private and public healthcare providers.
5. Revise the means test and require all employed citizens to contribute to a medical aid scheme to cover peoples’ basic health needs.
6. Regulate the private sector to ensure that consumers are not being exploited and that private healthcare is more affordable.
7. Promote public-private partnerships to increase the quality of healthcare in the public sector such as allowing private companies to run public hospitals and making private resources available to the public sector.
8. Aggressively work to reduce the medical skills shortage by promoting the creation of private medical schools, increased mentoring and apprenticeships and retaining doctors and nurses
The NHI, as presented by the national government in its Green Paper, is not a cure-all for our public health system. On the contrary, it promises to make our healthcare problems even worse by centralising and over-bureaucratising public health.
The bottom line is that it is the poor who will suffer most under the NHI. Not only will the quality of healthcare they receive decrease, but the increased spending on healthcare will mean less funding available for other crucial services that give people opportunities to break the cycle of poverty.
The DA believes that there is a much cheaper, more practical and, indeed, proven strategy for improving health outcomes. It revolves around making healthcare accountable, affordable and efficient. Our policies in the Western Cape are working to achieve this at a provincial level. There is no reason why these strategies can’t work for the rest of the country as well.