National Health Insurance (NHI) was one of the hot topics at the 2022 Public Health Association of South Africa (PHASA) Conference recently held in Durban. While several speakers and attendees expressed support for the principles underpinning NHI, many also expressed reservations.
Many of the concerns raised at the conference echo those that have been raised during public hearings and in public submissions on the NHI Bill currently undergoing clause-by-clause consideration in parliament's health committee. One difference, however, is that in public health circles there appears to be little of the unreserved support for the current form of the Bill that we've seen from ANC MPs.
The picture that emerged from the various presentations and conversations around NHI at the conference is that hardly anyone is inherently against NHI, but people in public health circles have several concerns about the details of how NHI, as outlined in the bill, might work. The nuances of these concerns and the associated themes are worth unpacking.
'Don't wait for NHI before fixing things'
One widely shared view is that while some form of NHI is needed and could provide much-needed reform in the healthcare system, it should not be seen as a silver bullet that would magically solve all the problems in the healthcare system. Stated simply, we should not wait for NHI before addressing the various problems plaguing our healthcare system.
Quality is not just sub-optimal, but it's actually bad for health, bad for dignity, bad for disease or for control of the spread of disease and I think we have to start talking about those two things together - and start doing those things together - Mark Heywood
Mark Heywood, editor of Maverick Citizen and previously from SECTION27 and the Treatment Action Campaign stressed this during the plenary session on the final day of the conference. He said that the prevailing discussions on creating an enabling system for NHI and the architecture of the NHI Fund, need not be polarised into "the NHI way or the Highway". Heywood argued that the commitment to implementing NHI needs to be complemented by a "commitment that is as strong - in fact, more strong - to what needs to be done to fix the health care service". He insisted that we must address the many factors in the healthcare system that at the moment are causing sub-optimal performance of the healthcare system because what is even more important than just access is equity and quality of care.
"So, what needs to be done to fix the healthcare service and to ensure that we have access to what we need? Quality is not just sub-optimal," he said, "but it's actually bad for health, bad for dignity, bad for disease or for control of the spread of disease and I think we have to start talking about those two things together - and start doing those things together," said Heywood.
Responding to Dr Nicholas Crisp, who leads the NHI project in the National Department of Health and who made introductory remarks in the plenary, Heywood said, "A lot of what Nicholas is [saying] is technical at this stage. So ok, you can be building that ship, that architecture for the ideal, equitable system, but," he said, "while we're building that ship, we can't afford to waste another moment in allowing a steady deterioration in quality of care and the quality of healthcare services and an increasing disease burden in this country."
Also zooming in on the need for quality healthcare, was Dr Thokoe Thabiso Makola, director of Health Systems, Data Analysis, and Research at the Office of Health Standards Compliance (OHSC).
The OHSC is tasked with monitoring quality of care in South Africa's health facilities.
"Quality," Makola said, "should not be an aspiration only to be achieved in the future - it is not for five or ten years from now. What we should be doing now - in everything we do, we must have that in mind. Quality must be at the centre. The right to health is meaningless without quality."
Makola said having a strong regulating system is crucial in health reform. "It is ineffective, wasteful, and probably unethical when we are not providing quality care."
Outlining the role of the OHSC in NHI, he said that anyone contracting with the NHI fund will have to be certified by this body, which means they will have to certify around 40 000 health establishments. "The work is huge, but it needs to be done.
Quality must be at the centre. The right to health is meaningless without quality - Thokoe Makola
In acknowledging the role the OHSC will have to play in NHI, Makola, however, did not touch on the OHSC's existing challenges with resources and capacity - something that opposition MPs have been flagging in Parliament every time the issue of accreditation arises in deliberations on the NHI Bill.
Makola told Spotlight that Universal Health Coverage is something you move towards by improving access to healthcare services, making sure the quality of those services is good, that vulnerable populations are protected and covered, and that there is equity in terms of financing health services.
In a nutshell, it's a process.
"A lot of the health establishments that we have inspected, have not been able to meet the requirements and so to that extent, one can say the health system is possibly not ready for the NHI, but at the same time I think it is important to realise that quality of healthcare is important whether we were moving towards universal coverage or not," Makola said.
'A 'Ferrari without wheels'
There was also plenty of discussion on elements considered to be missing from the current NHI plans. Dr Irwin Friedman, director of the SEED trust, likened it to "a wonderful Ferrari... It's a wonderful machine, it just doesn't have wheels."
Friedman based his plenary presentation on PHASA's submission on the NHI Bill to Parliament.
The NHI is going to spend a lot of money on curative and palliative care. And one wonders whether it would be sufficient on prevention and promotion - Irwin Friedman
Starting off by explaining the "missing wheels", he flagged the language used in the Bill as akin to "commercial business language" which he says is "not friendly language for health systems". "We are using the language of the enemy to try to change and make the system more human. We also don't see much in the Bill on the concept of PHC (primary healthcare)," he said, adding that the PHC approach is the basis of the National Health Act, yet it is not embedded much in the principles of NHI.
Another thing, he said is missing, is the concept of health promotion. "The NHI is going to spend a lot of money on curative and palliative care. And one wonders whether it would be sufficient on prevention and promotion." Friedman also said that there is not enough room in the NHI for monitoring and surveillance responses to population - to pandemics, which will be major causes of ill health.
Crisp later in his response hit back.
"NHI might sound like it's a commercial thing but it's a public economic term used across the world," he said. "We are going for a single-purchaser model. The majority of care will be in the fund. With a purchaser-provider split, which is the problem in our public sector at the moment where there's no purchaser-provider split - so there's no incentive to fix things because you'll get your money whether you do anything or not, whether you report or not."
He also stressed the Primary Healthcare approach has not changed. "We don't have to put it in the NHI Bill, as it is already in the NHA (National Health Act) and several other pieces of legislation."
Responding to Friedman's remark regarding the bill being silent on issues of surveillance, Crisp said, "Of course, we don't talk about surveillance (in the Bill) because this is a funding model. Surveillance is in NAPHISA (National Public Health Institute of South Africa) - That's where surveillance is spelled out," he said, warning against duplication. As far as Spotlight can establish, there has however been very little movement on the establishment of NAPHISA since the NAPHISA Bill became law in August 2020.
Dr Zandile Matyo, a public health registrar at the University of KwaZulu-Natal who has been supporting the implementation of the NHI in KZN for the last two years, argued during the plenary that the new roles and responsibilities have not been clearly defined. "For example, with finances and grants that have been given, yet we do not see who is accountable for the misuse of those grants, how we distribute it in terms of budgeting as well," she says. "And so, we have such things coming up, then it questions what is then the future that we're working towards in the healthcare system. Will we be able to sustain the implementation," Matyo asked.
Another gap, pointed out by Dr Mvuyisi Mzukwa, the chairperson of the South African Medical Association (SAMA), is the role of the private sector. He says the role of the private sector has not been clearly defined and for the private healthcare sector, the NHI poses a potentially significant loss of income. There is also no clarity at this point with regards to what services will fall under the NHI and what services will be in the complementary cover that medical aids will provide. Piloting of the NHI was also not done in the private sector, according to Mzukwa.
Decision-making powers and the law
Another issue raised by PHASA in their submission is that the people given decision-making power over the NHI should be independent and not have their decisions dictated by loyalty to a political party. The extensive powers given to the Minister of Health in the current Bill have been widely criticised during the parliamentary process.
"As PHASA we do believe that Parliament, as a democratic institution, is a better place to be accountable rather than the Minister of Health who's a political functionary," Friedman said. "And similarly, the board that controls the governance of this, it's very important that this is not a party-political place... [that] it's a professional group of people that see their responsibility to the nation rather than to their party, whatever their party is."
Noting the concerns raised by Friedman, Crisp threw the law book at delegates and reminded them that "we can't work outside the other laws of the country when we write an act otherwise you must amend those acts". He referred to existing provisions in the Constitution, the National Health Act, and the Public Finance Management Act (PFMA) among others.
As PHASA we do believe that Parliament, as a democratic institution, is a better place to be accountable rather than the Minister of Health who's a political functionary - Irwin Friedman
"We have a Constitution that is very specific on what different spheres of government may and may not do. For example, ambulance services are said to be a purely provincial function and other health matters are concurrent legislative functions in schedule 4. We also have a PFMA, where in Chapter 6, is clear who accounts for what - for example, the board must account to Parliament. The minister must account to Cabinet based on the Constitution and also to Parliament. You can't just change it now and take away a minister's role cause because we don't like what a previous minister did and what not... We must hold them to account," he said, urging delegates to go and read the PFMA. Crisp said with this NHI Bill the CEO by law reports to the board. "It doesn't matter if we write it in the NHI Bill - it's already in the PFMA. The CEO of a public entity is not the accounting officer - the board is an accounting authority and the CEO is merely an employee of the board. We must make sure we read these things."
The minister must account to Cabinet based on the Constitution and also to Parliament. You can't just change it now and take away a minister's role cause because we don't like what a previous minister did and what not... - Nicholas Crisp
How will the finances be handled?
One issue that was of particular concern to speakers in the plenary was the vagueness around the financial aspects of NHI. This is an issue that has also repeatedly come up during the oral submissions in Parliament.
Questions were raised about how sustainable the funding will be, how it will be managed, and how the NHI fund will be protected against corruption or abuse.
"In terms of financial matters, there's a lot of lack of confidence about whether the funding sources are going to be sustainable. Whether there's going to be the ability to manage the money in an efficient way, whether there's going to be good governance and whether there's going to be adequate risk management... whether corruption is going to be dealt with, whether there is going to be elimination of waste," Friedman said.
Another major concern Friedman mentions is that the NHI fund is going to be seen as a source of income generation for the legal profession and has the potential to be abused as such if the NHI doesn't have a good team of lawyers or a no-fault compensation fund.
"The thing that worried me the most - [is that] suddenly you [will] have a pot of money... for example, everybody that gets mishandled by the system - it will be most of us - will have a legal gripe against the system and a claim. So, if each of us is going to claim R10 million or whatever, the pot of money is going to shrink rapidly," he said.
Crisp, however, in his presentation, noted that one of the directorates in the newly established NHI branch in the health department is for risk identification and corruption and fraud management.
Responding to concerns raised by Friedman on possible abuse of the system by the legal profession, Crisp referred to the Special Investigating Unit (SIU) Proclamation 74 of 2022. The president signed this proclamation to authorise an SIU investigation into "unlawful and improper conduct by claimants or applicants in respect to medical negligence that was fraudulent". He said the government is also working on the State Liability Amendment Bill. "It's contested - the lawyers don't want it, but we want it," he said. "It will fundamentally change the way in which people can or cannot sue, and what the lawyers do with us."
Professor Noddy Jinabhai, a research professor at the Durban University of Technology, told Spotlight, "The actual fiscal aspect, the financial aspects of how we're going to fund the NHI, and how we can build this partnership are still very vague in the bill that's before Parliament and that requires further consultation," he said. "The operational aspects, the management aspect, and particularly the financial aspect of how the NHI Fund is going to be managed - and how the money [will] not [be] abused through corruption - those are the aspects that require a lot more homework."
Are public inputs taken seriously?
Another concerning theme that emerged, either directly or indirectly, is that it's unclear if MPs and people in the health department are listening to the input provided by organisations like PHASA. According to Friedman, none of the issues that were being raised at the conference plenary were new, as PHASA had raised these issues during oral public hearings in Parliament.
In speaking to people at the conference, our general impression is that people in public health circles do not feel that government has been responsive to their concerns about the NHI Bill.
Matyo raised the issue directly, and said during her time at the NHI office, one of several major concerns that were raised is that the university provided assistance and support to the provincial health department but there was no recognition of "the advisory effect of the university". She said the politics within the department also made it difficult for the university to assist in implementation.
Spotlight has been keeping an eye on the clause-by-clause deliberations on the Bill in Parliament's health committee in recent months. Many of the concerns flagged by opposition parties(excluding the IFP) in Parliament during the NHI Bill deliberations mirror the concerns raised by civil society groups and professional bodies like PHASA, especially on issues of quality and accreditation, oversight, accountability, and other governance arrangements, as well as the fate of undocumented persons. The ANC, and in some instances with the IFP as an ally, has so far kept to the general departmental line as featured in the provisions of the Bill and has, bar a few superficial reformulations, not strayed from the original substance of these clauses.
We just have to acknowledge that in the NHI if we're going to sort these problems out it's not going to be next year, it's going to have to be incremental. We're going to have to be agile in the way we learn about this - Irwin Friedman
A long road
Finally, while some politicians may still imagine a quick and smooth transition to NHI - originally it was meant to be fully in place and functioning by 2026 - public health specialists we spoke to generally agreed that it will take longer and the transition will not be straightforward.
Even Crisp said that NHI "is not for now, it's for our grandchildren".
Makola said that it is going to be a long road towards improving quality and being able to implement the NHI. "We just need to be realistic," he said. "The road is going to be long and probably very expensive, but it needs to be done."
Friedman echoed the sentiment.
"We just have to acknowledge that in the NHI if we're going to sort these problems out it's not going to be next year, it's going to have to be incremental. We're going to have to be agile in the way we learn about this. We're going to have to experiment and improve gradually. This is not going to be the silver bullet that we all thought it would be," he said.