THE National Health Insurance (NHI) conference hosted by the Department of Health last week was a great initiative that showed the government’s commitment to establishing an NHI system as soon as it possibly can.
The speaker line-up was impressive, with many international economists, academics and other experts in the field, as well as familiar South African voices such as Olive Shisana, Diane McIntyre and Mark Blecher.
The keynote address by Health Minister Aaron Motsoaledi highlighted three of the major problems in the South African health system, namely hospital centrism, fragmentation of health services and uncontrolled commercialism. He said these problems cause the current system (in both the public and private sectors) to be unsustainable, curative, destructive and costly.
Motsoaledi once again committed to strengthening the health system and specifically focu sing on two prerequisites for the proposed NHI to be successful: improving the quality of healthcare in the public sector; and addressing the high costs of healthcare in the private sector. Although very negative about prices and cost structures in the private sector, he emphasised he is not the minister of public health, but of health — every aspect of the health sector in SA, both public and private, concerns him.
He concluded by saying there will be no "holy cows" in the health system when planning and implementing the proposed health reforms.
The international speakers shared experiences from a number of developing and developed countries regarding the financing, service provision, institutional arrangements and governance options of their respective national health systems. The lessons for SA included both positive examples of how universal coverage can be achieved quickly, as well as warnings or challenges from which we can learn. While some models may be more appropriate for SA than others, it is important to keep in mind that even if certain initiatives worked well in some countries (for instance, funding and payment arrangements in Thailand), they may not be equally successful here.
Importantly, as Blecher also said, each country’s experience is context-specific and has a particular history and set of problems to solve.
Presentations also focused on issues directly related to SA and the planned NHI, including the legal and institutional context, service delivery and financing arrangements, and so forth. It was clear that the majority of speakers shared similar ideological ideals, in line with those of the Department of Health.
A sobering presentation by the National Treasury’s deputy director-general for public finance, Andrew Donaldson, emphasised some of the practical concerns and constraints related to the financing of the proposed NHI.
He reminded delegates that options to increase any form of taxation (be it sin taxes, VAT, payroll or general taxes) are limited in our specific context. One has to keep in mind that more government funding for health implies less resources for other competing functions, such as education and housing.
He agreed with Gavin Mooney, a renowned health economist, that the public-private split of healthcare expenditure in SA was inequitable, but said the absolute figures should be considered as well — even in the private sector, average annual spending per beneficiary is still much less than what many other countries spend on healthcare services.
The conference was effective in bringing together international thought leaders and health-system experts, as well as various local stakeholders, but there were few opportunities for constructive debate on many of the important (and often contentious) issues that were raised. One is left with a similar feeling to that evoked by reading the NHI Green Paper: impressed with the government’s efforts to move forward with the proposed NHI system, but questioning the contribution to facilitating engagement with many of the real issues. Once again, most aspects were addressed only at an ideological level, without getting into the detail of considering functional, practical options.
It is necessary to have many more events such as this in the future, and it is hoped there will be sufficient opportunity for debate and input on the practicalities of appropriate initiatives to reform the health sector to ensure access to quality healthcare for all South Africans.
• Erasmus is a senior economist at Econex.
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