THE principles of the National Health Insurance (NHI) policy articulated yesterday by Health Minister Aaron Motsoaledi closely echo Karl Marx’s famous slogan "from each according to his ability, to each according to his need".
NHI will demand only as much as individuals can afford, and will provide services in line with their needs, he promised.
This principle of social solidarity underpins national health systems around the world, and dovetails with the minister’s oft- repeated mantra that health is a human right and is not an ordinary commodity to be traded like shoes or bicycles. But as ever, yesterday’s political rhetoric glossed over the fact that SA already has a national health system, funded by the fiscus, to which everyone contributes according to his ability — be it VAT or a tax on earnings. It’s avoided by many because the quality of care provided by state hospitals and clinics leaves so much to be desired. Those fortunate enough to afford it have turned to the private sector, either via a medical scheme or by paying out of pocket. The fact that public servants have medical scheme cover subsidised by the state is a tacit acknowledgement of the failings of the public health sector.
SA is one of only a dozen countries where infant mortality rates are rising, and its maternal mortality rate remains stubbornly high, despite the fact that most women deliver their babies in health facilities with a trained healthcare worker in attendance.
HIV/AIIDS is part of the story, but a shocking report released by Human Rights Watch on Monday into the treatment meted out by nursing staff to women in labour points to a host of other damning issues: patients describe having to bribe nurses to provide medication and care, and describe an alarming level of physical and emotional abuse doled out by staff. Malfeasance of this kind goes unchecked in an environment where no one is held accountable and teachers are appointed as hospital CEOs — as the Development Bank of Southern Africa found in its investigation into hospital manager qualifications.
While SA falls short of the Abuja target of spending 15% of its budget on health, it nevertheless channels a significant portion of expenditure in this direction: 11,5% (R104bn) of the R907bn budget for the current fiscal year. It also spends a greater proportion of gross domestic product on health (8,5% in 2008) than Brazil (8%), Russia (5%), India (4%) and China (4%), yet scores worse on almost every health indicator.
Both Dr Motsoaledi and Finance Minister Pravin Gordhan acknowledge that SA is not getting value for money on the healthcare front. Dr Motsoaledi is already moving to try and improve the public sector’s performance, with an Office of Health Standards Compliance in the offing, and new rules for the hiring of hospital managers.
He’s also driving a shift towards a primary healthcare model, which emphasises preventative rather than curative medicine, and will see specialised medical teams overseeing each of the country’s 53 health districts. Nursing colleges are set to reopen, and a new human resources strategy is to be released next month, spelling out SA’s needs and how the government plans to increase its production of doctors, nurses and other health professionals.
He has also set his sights on dealing with the pricing issues that beset the private sector. A ruling by the Competition Commission in 2004 that scrapped collective bargaining has created a market in which the large medical scheme administrators have some leverage in negotiating prices with private hospital groups, but smaller purchasers and individuals remain price-takers.
Year after year, medical scheme members face contribution increases that outstrip inflation, and co-payments are increasingly common. If the state is to contract services from the private sector, it will have to stabilise the industry, and part of that job will entail figuring out fees that are acceptable to both sides.
While the minister’s efforts to tackle the problems that beset SA’s two health systems are all steps in the right direction, convincing citizens that they should pay more taxes for a public health service that has yet to prove its mettle is likely to be a difficult task. While the finance minister was at pains yesterday to reassure the public that "we (the government) don’t want to burden anybody in this process more than they need to in the normal taxation purpose", the green paper makes it clear that taxes will rise in the long run.
The assumption underpinning the green paper’s funding proposals is that the money people currently pay for medical scheme membership will be diverted to pay for NHI. However, health economists such as Wits professor Alex van den Heever argue this is simplistic: people will only forgo their medical scheme cover when they are convinced they can get the services they need from the state, or because they can no longer afford it.
The sad reality is that until the government can assure people that the public sector will provide high-quality services as and when they are needed, the health system will remain one where you get what you can pay for.