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09 July 2009

National health: just join the dots

A national health insurance scheme is nothing new in larger, wealthier democracies. The question is whether such a system is a good fit for South Africa.

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Recent government documents have detailed the plans for a national health insurance scheme or NHI for South Africa.

Membership will be compulsory and funded from a levy or tax deducted from the salaries of those in the formal sector and by the State for the unemployed. The NHI will, as it is proposed, be implemented over five years, meaning by 2014.

NHI is nothing new in larger, wealthier democracies. The question is whether such a system is a good fit for South Africa. Surprisingly, this question has already been answered in part. On reading the NHI document, one realises that much of the proposed scheme is already in place - it's just a matter of connecting the dots.

The advent of NHI was set out in the National Drug Policy published back in 1996, so proposals on NHI are really not novel. In that Policy, NHI is premised on the ideology that all South Africans are entitled to access healthcare services. This ideology became entrenched in the Bill of Rights and is a Constitutional prerogative for government.

The actual construction of NHI infrastructure began at the turn of the century with a succession of significant amendments to healthcare legislation, affecting all aspects of access to healthcare:

  • the Medical Schemes Act was amended to remove risk-rating and allow more equitable entry criteria;
  • community service was introduced for healthcare professionals and pharmacists;
  • larger corporations were allowed to enter the pharmacy industry and, in theory, use their economic muscle to provide cheaper pharmacy services;
  • the base of primary healthcare providers was broadened to include allied professions and traditional healers;
  • regulated medicine pricing was ushered in and the medicines base was widened to include traditional Western medicines, herbal medicines, Chinese and Indian medicines, etc;
  • certain cost or managed care solutions were introduced for medical schemes, enabling them to negotiate cheaper membership rates;
  • the concept of accrediting healthcare providers was introduced;
  • the national health reference price list was published. In the light of proposed amendments to the National Health Act, it becomes a maximum price for healthcare services;
  • the Medical Schemes Act already makes provision for prescribed minimum benefits and other guaranteed services, which shadow the NHI.

Prescribed benefits, prescribed service providers
The NHI is basically a large medical scheme - to be governed by a board or trustee-like body and providing a prescribed set of benefits from a prescribed set of healthcare providers for a certain cost.

This formula is already used in the Government Employees Medical Scheme, which uses legislative structures to give government employees access to healthcare at the best available price – in much the same way as NHI will provide benefits to the public.

Certainly, I risk the criticism of espousing conspiracy theory. However, armed with the ideology in the National Drug Policy and viewing the nature, type and effects of new and amended healthcare legislation, one is left with the indelible impression that the fundamentals of NHI are in place silently awaiting their final deployment.

However, if we are dissatisfied with the current state of healthcare or access to healthcare services, should we not be supporting NHI?

The point is that if one is to implement a NHI-type solution, then its efficacy, quality and cost must be examined. But such a system excludes a consideration of healthcare outcomes and quality - all it promises is access but access to what?

The state of South African healthcare is far from simple and providing universal access is laudable, as well as a constitutional directive. However, one must be certain that NHI will achieve efficacious and quality healthcare and not just promise it.

I'm not sure I want cheap cardiothoracic surgery without the feeling that I know it will work or fearing that I'll contract some other fatal condition due to badly equipped or under-maintained facilities.

Based on our experience to date and thinking really hard about what healthcare is, does NHI promise anything different from that with which we are already saddled? Is it a gift horse?

It's a case of exercising care over what it is exactly that you wish for as you may just get it.

(Neil Kirby, Director: Health, Pharmaceutical and Life Sciences, July 2009)

 
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