The new National Health Insurance (NHI) bill should prioritize public interest and make room for community participation, stated the People’s Health Movement (PHM) South Africa in a recent dossier. They see the current version of the bill giving too much room to the private sector, while mechanisms to control conflict of interest remain understated – aspects that could lead to the exact opposite of what the reform is hoped to achieve: better and equal access for everyone and a strengthened public health system.
Discussion about the NHI began more than 10 years ago, when the African National Congress (ANC) brought the first elaboration to the table in 2009. In that first proposal, the insurance model was tied to the introduction of a single-payer system and was supposed to define a comprehensive package of care based on the idea of Primary Health Care. Since then a lot of the proposal’s most progressive content was eroded, and the current version of the bill raises many uncertainties, which may lead to a move away from health equity. These changes include a separation between the purchaser and provider of care, and an inherent belief that it should make no difference to the people if the future state-owned NHI Fund purchases services from public, private, or mixed providers.
Decisive action needed to end health inequities
The current state of the health system in South Africa is one of fragmentation and inequality. It has been made even worse by the implementation of austerity measures, including after the end of the first phase of the COVID-19 pandemic, which have led to bad working conditions and staff shortages, among other things. From the point of view of the patients, the state of the health system is not better at all: sharp differences in access to healthcare persist between rural and urban communities, as they do between poor communities in urban settlements and the rest of the cities’ populations, and between the public and private sector.
The problems that the health system is experiencing need urgent action by the government, warns PHM South Africa, but unfortunately the current NHI bill proposal leaves far too much uncertainty as to whether the NHI will reduce or worsen health inequities. A prominent focus has been given to the future role of the private sector in the implementation of NHI plans and participation in health provision equal to that of the public sector. While foreseeing so much space for private participation, the government and the National Department of Health (NDOH) have failed to introduce elements to the bill which would ensure transparency and accountability of private providers’ work, warned PHM South Africa.
This is not the only aspect of the bill which remains blurred. Key questions – including some related to how the NHI is going to be financed, which benefits are going to be available to all patients, the way that services will be purchased, and coverage defined – remain unanswered by the bill proposal that is being discussed, as pointed out in PHM South Africa’s analysis.
According to Leslie London of PHM South Africa, particularly worrying is the lack of vision when the discussion turns to community participation. “The health system always turns back to service delivery to the patients who present through the front door of the facilities they run, it’s like a reflex. They (health systems) often can’t see their accountability to communities, including people who are not sick and not requiring curative care – but need the social determinants of health addressed. You need good facilities but that’s not all you need,” London said.
State should be fearless in the protection of public interest
In the absence of community monitoring, the risk of private providers usurping the position that has been attributed to them grows. Judging from interventions by Ayanda Ntsaluba, representative of the private sector at a recent report launch organized by SECTION27 and Concentric Alliance, and Nicholas Crisp from the NDOH, it seems that this might have already taken place. From the discussion that took place during the launch, it would seem that delegates from the private sector were being invited to take part in consultations with the NDOH during the COVID-19 pandemic, without them or their results being adequately communicated to the public.
In order to be able to prevent and react to such cases, communities and civil society should be granted concrete tools by the NHI bill. Yet, in the current plans, their participation is limited to the Stakeholder Advisory Committee (SAC), a governance body which according to PHM South Africa is likely to “lack teeth and exists to provide advice with little traction.”
Relying on the private sector in the attempt to strengthen the health system could leave long-lasting marks on the public health system. As was put quite explicitly during the SECTION27 webinar, actions of private providers will continue to be guided by self-interest, albeit by one that is reformed to be “enlightened”. But in the absence of effective regulation by the government and clear parameters for implementing the NHI reform in the public interest, it remains unclear how such enlightenment will be achieved, and whether it will be strictly observed.
In combination with other aspects of the current format of the NHI bill, the friendliness towards the private sector could easily be detrimental to people’s health. For example, given the current state of public health services and the requirements for accreditation of health institutions to be included in the NHI system foreseen by the bill, many public hospitals could actually not be granted NHI accreditation – leaving the scene completely open to private providers and siphoning off more public resources to private pockets.
If it wants to avoid this scenario, the government should take a much more decisive stand and take ownership of the reform, opines London. “The plans we have in front of us can only contribute to people’s and communities’ health if the state gets its act together to be fearless about the public interest,” he says.
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