Universal Healthcare Coverage and the National Health Insurance (NHI) are major talking points both in South Africa and abroad.
The BMJ in partnership with The Harvard Global Health Institute has launched a collection of articles exploring how to achieve effective universal health coverage (UHC). The collection highlights the importance of quality in UHC, potential finance models, how best to incentivise stakeholders, and some of the barriers to true UHC.
One of those barriers, and it’s a big one, is climate change – patterns of disease will change, both communicable and non-communicable, cataclysmic weather will disrupt systems, and the economic impact is going to challenge our ability to pay for healthcare.
But even against that backdrop, Ashish Jha, and Rene Salas – aren’t totally pessimistic. They join us to talk about the intersection between climate and health, and where effective change can be made.
The release of a final report about the state of competition in South Africa’s private health sector has been delayed again. It was compiled by an inquiry panel made up of medical, legal and economic experts. The panel heard submissions from a range of stakeholders including members of the public, civil society organisations as well as private hospital groups.
The inquiry was set up under the auspices of the country’s competition authority in 2013. It’s remit was to investigate characteristics of the private health sector that may prevent, distort or restrict competition. Its preliminary report, released in July 2018, concluded, among other things that the sector was highly concentrated in the hands of a few major players. The final leg of work was to get inputs from various players on the initial findings before concluding the inquiry. The inquiry has cost tax payers R197 million so far.
Another delay of the report – which should have been released in March 2019 –is therefore bad news. The sooner South African authorities deal with the issues of anti-competitive behaviour in the private sector, the more likely access to quality health care will improve.
South Africa has a two-tiered health care system. The public sector is under-resourced and stretched while the private sector is highly sophisticated and expensive. Even though only 16% of the country’s population uses private health care, it nevertheless gets a large portion of the government’s health expenditure in subsidies.
At the same time, private health costs continue to balloon and fewer people can afford it.
The inquiry’s preliminary recommendations offered a clear agenda for how the private sector can become an integral part of the current national health system. There must be no more delays: if South Africa is to reach its lofty goal of universal health coverage, the report must be released and those recommendations adopted.
Key findings and recommendations
The inquiry examined three aspects of the private sector.
Medical schemes through which people pay for private health services and the administrators who run them.
Private facilities, such as hospitals and clinics.
Medical doctors and specialists in the private sector.
Medical schemes provide multiple plan options for cover without providing adequate information to understand what they cover, how the plans compare and what value the patients receive. As a result, consumers aren’t able to compare what schemes offer or choose plan options on the basis of value for money.
There is a lack of transparency on the pricing of health care goods and services, standardised reporting of health outcomes and implementation of evidence-based guidelines and treatment protocols.
Medical practitioners and specialists are concentrated in the private sector. As a consequence, there is time to over-service and inefficient use of expertise and time.
In light of these and other findings, the inquiry made a number of recommendations to remedy the situation.
These included putting measures in place to enable the Council for Medical Schemes, which regulates medical aids, to exercise more effective oversight.
In addition, to ensure that people who belong to medical aids get more comprehensive cover, the inquiry proposed that all medical schemes also offer a standalone standardised obligatory basic benefit option. The basic option would include a standard basket of goods and services and be comparable among schemes. This option would include cover for the prescribed minimum benefits, make provision for the treatment of these prescribed minimum benefits outside of hospital settings and add primary and preventive care.
And the inquiry recommended tighter regulation of the sector through the establishment of a dedicated health care regulatory authority. This would govern the number and distribution of doctors and hospitals to meet current and future needs. And it would ensure the development of clinical protocols as well as shape the structure of payment systems.
The inquiry also recommended that a centralised national licensing framework be introduced. This would accredit all health facilities including clinics, hospitals and GPs’ rooms. Another recommendation was to establish a price-setting mechanism.
The recommendations are innovative and would go a long way toward making health care in the country more equitable. But South Africans will have to keep waiting to see if they actually bear fruit.
The latest development is that, due to a lack of funds, all the inquiry’s work has been suspended until the end of the financial year in March after which a new date for the release of the final report will be published in the Government Gazette.
It’s important that the inquiry is allowed to complete its task sooner rather than later. This is because its findings could have a bearing on a piece of legislation currently making its way through parliament – the Medical Schemes Amendment Bill. The bill proposes changes to medical scheme governance and benefit options. Reports suggested that the department of health wanted to wait for the outcome of the inquiry before finalising the bill.
The inquiry could also affect the National Health Insurance Bill which is meant to herald in universal health care. But the bill is mired in controversy. The most recent version was recently rejected by the country’s cabinet which instructed the national department of health department to review what’s been proposed.
Until the final report is released, South Africans must contend with a fragmented, poorly regulated and expensive health care delivery system.
We have consistently argued that the implementation of the National Health Insurance (NHI) system in South Africa is a defining piece of legislature which has the opportunity to make an enormous difference in the lives of ordinary South Africans, particularly those who cannot afford private medical care.
Having said that, we believe that the decisions being taken are not informed by real-world data or analytics and could end in a costly situation for South Africans across the spectrum.
To that end, we share the press statement issued earlier today from various civil society bodies:
MEDIA STATEMENT: National Health Insurance Bill – STOP THE RUSH
Date: 27 November 2018
CIVIL SOCIETY ORGANISATIONS CALL FOR PROPER CONSIDERATION OF PUBLIC COMMENTS ON NHI BILL – STOP THE RUSH
What started as a marathon has turned into a sprint. After over a decade of policy documents, each iteration being further denuded of detail and meaning, and with little apparent attention to legitimate comments and concerns, the National Health Insurance Bill looks likely to be rushed through the legislative process following its hasty presentation to Cabinet tomorrow.
The draft NHI Bill was finally published for comment in June 2018 with interested parties (everyone in South Africa) being given only three months to make submissions. Requests for extension by TAC, SECTION27, RHAP, PHM and others to allow for proper consultation were ignored. Further requests by SECTION27 for transparency about the number and type of comments made have also been ignored.
Just two weeks after the final date for submissions (21 September 2018), a version of the Bill amended by presidential advisor Dr Olive Shisana without the knowledge of the Director General of Health and without consultation with the Minister of Finance was leaked, together with a letter from Treasury complaining about this change in direction. This version, prepared so soon after the submission deadline, cannot have taken into account the likely hundreds of submissions made by interested parties across the country. It was also, interestingly, prepared before the Presidential Health Summit of 19 and 20 October 2018, at which delegates made clear the need to focus on system improvement aimed at fixing the crisis in public health rather than on legislation.
Now we understand that the Bill will be presented to Cabinet tomorrow for approval – the final step before it is presented to the legislature. The legislative development process has been removed from the office of the Director General, who bravely spoke out last week about being side-lined by the presidency and her subordinates. We also understand that the Bill has not been discussed in the National Health Council – the body established by section 23 of the National Health Act 61 of 2003 to advise the Minister of Health on policy and on proposed health legislation (before it is introduced to the legislature).
Having ostensibly provided so many opportunities for comment, the comments made over the past decade do not appear to have been taken into account, either between the Green and White Papers and the Bill or after the draft Bill was published for public comment. This makes a mockery of public consultation as required by the Constitution and opens the Bill up to future attack and delay on these grounds.
Pro-poor civil society organisations and healthcare professionals have consistently argued that government needs to focus on fixing the crises in private and public health rather than on hastily passing legislation that, in its current state, takes the country in the wrong direction.
In other countries where national health insurance schemes have been implemented without proper reflection, including in Ghana and Colombia, the schemes and the health facilities providing services have been taken over by private interests and the quality of and access to services has diminished. These examples do not mean that National Health Insurance cannot work. What they mean is that it is vital that protections are put in place to prevent the privatisation of the health system and to improve access and quality, primarily through strengthening the public health system. The NHI Bill as it stands fails to do this and risks damage to the functional elements of the health system – public and private.
We call on Cabinet to send the NHI Bill back to the Department of Health and to require a proper and thorough consultation process and consideration of options available for improvement of access to and quality of health care services in the country. The health of the nation is not a political game.
Treatment Action Campaign (TAC)
Rural Health Advocacy Project (RHAP)
People’s Health Movement – SA (PHM)
Lawyers for Human Rights For further information, please contact Nomatter Ndebele – firstname.lastname@example.org