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South African national health plan mirrors global health headache

South African Health Minister Aaron Motsoeledi. Image courtesy of GCIS

In South Africa, the planned rollout of National Health Insurance (NHI) for all is in the second phase of planning as health authorities conduct an inquiry into alleged malpractice linked to state psychiatric patients.

On the sidelines of the commission of inquiry into Esidimeni, the NHI furore that the Department of Health intends rolling out throughout the country continues.

NHI is South Africa's version of Universal Health Coverage (UHC), which aims at allowing broader and less expensive access to healthcare to poorer patients.

Andy Gray, senior lecturer in the pharmacology division at University of KwaZulu-Natal, thinks the rollout of the policy framework can be affected by some aspects in the current legislative framework pursued by the Department of Health.

“To say they’re obstructive is perhaps wrong, as they were not designed for NHI. However, significant changes would be needed to at least the Medical Schemes Act and perhaps the National Health Act,” said Gray.

According to Gray, there will be a need for an overhaul of the legislative framework because new demands brought into public health by the NHI.

The promulgation of the NHI bill by the South African Cabinet is an example of what governments around the world are trying to do to deal with medical care that is becoming more expensive and more complex.

Among the disagreements in the UHC debacle is the finance model that health systems adopt.

The Free Market Foundation's Dr Johann Serfontein believes that the public health system in South Africa should rather focus on improving management at all the levels as, he says, the touted NHI is impossible to fund. There are relevant examples of such success, across the country according to Dr Serfontein. “Ailing state facilities can be turned around by proper management, as shown by the example of Frere Hospital in the Eastern Cape, where a new hospital manager turned what was a shambolic institution into something that resembles the Department of Health’s proposed ideal clinic model.”

He proposes this as an alternative to taking people off private health insurance schemes, which he says relieves the financial strain on the public health purse.

“We do not have enough taxpayers to fund additional healthcare cost associated with NHI through taxes. Raising the marginal tax rate of the top earners in SA from 41% to 45% in February this year raised R29bn in taxes. The potential NHI tax shortfall could be R150bn per year,” he added.

In South Africa the framework whose implementation is estimated to cover a four-year period was approved by Cabinet at the end of June. Central to the scheme is unifying funding and procurement regulations under one regime. This is also the basis of disagreements between the Department of Health and the private health sector.

At the moment health systems around the world finance up to 32% of their operations using payments from patients. About 31 health systems globally have some kind of universal coverage aspect as part of their system.

The rollout of universal coverage in many regions around the world could make it necessary to pay attention to the legal implications of such frameworks.


"At the moment health systems around the world finance up to 32% of their operations using payments from patients"


Advocate Sello Ramasala of the Health Professions Council of South Africa says that the NHI bill cannot be regarded as an operational legal framework yet. He adds that many of the ethical issues to be dealt with under NHI are not new.

"Ethical issues could arise relating to over-servicing or under-servicing of patients by health practitioners. These issues would still arise even in the absence of NHI as is the case currently."

He suggested comparisons that could be made for one to understand how NHI will function in the South African context.

“Unlike the Road Accident Fund which pays accident victims for damages arising from accidents by operation of the law, NHI will be paying for services rendered per agreement with a practitioner. Practitioners will become parties to the agreement only if the terms of the agreements are agreeable to them and cannot be forced into agreements with the state,” he said.

The NHI has faced stiff opposition for proposing that funds be pooled and that patients have access based on healthcare need. This is different to an affordability based regime where quality healthcare varies by socioeconomic status.

Among the controversies surrounding universal public health coverage are policy reversals and the possible repeal of Obamacare provisions in the US.

On Tuesday, October 17, US President Donald Trump expressed support for a one-year bipartisan deal between Republican senator Lamar Alexander and Democrat Patty Murray.

The deal, which is already seeing some opposition in the Republican party, is basically a trade-off between between permitting health insurance subsidies while also allowing states more freedom to regulate insurance companies.

Under the deal federal payments for low-income healthcare insurance continue rather than be scrapped as unlawful.

According to the World Health Organisation (WHO) member states to the United Nations have discretion on whether or not to have a universal coverage framework.

Commenting on a WHO report on child mortality, Tim Evans, senior director of Health Nutrition and Population at the World Bank Group, alluded to how the public could make use of simple indicators to judge the success of universal health coverage policies.

"The best measure of success for Universal Health Coverage is that every mother should not only be able to access healthcare easily, but that it should be quality, affordable care that will ensure a healthy and productive life for her children and family,” he said.


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