As doctors struggle to treat a soaring number of patients during the Covid third wave and hospitals go up in flames, medical groups have been presenting their input on the National Health Insurance (NHI) Bill to parliament.
From mid-May until June 23, the parliamentary portfolio committee on health held virtual hearings on the proposed new health law after receiving thousands of written submissions in late 2019.
The contrast could not be more stark — politicians and experts talking while hospitals burn and the health system buckles.
In April, parts of Joburg’s Charlotte Maxeke academic hospital, which had been treating the sickest Covid patients thanks to an upgraded ICU — paid for by private donors — burnt down.
Weeks later, two Covid patients died in another hospital fire, this time in Limpopo.
NHI has been punted for more than 20 years as the panacea for SA’s ailing health system.
The plan for quality and affordable, or free, health care was first mooted in 1994. At the ANC’s 2007 Polokwane elective conference, the party resolved to implement it.
In August 2009, a ministerial advisory committee was established to work with the minister of health to bring the NHI to life.
But after 12 years, two NHI draft policy documents, one draft bill, one staffed NHI office, R4bn spent on pilot projects, and hearings in eight provinces, there is little to suggest the policy is close to being implemented — or the health system improved.
It does raise questions about the utility of the process. And, importantly, is all the talking delaying life-saving health reforms?
Attorney Sasha Stevenson, the head of health at public interest NGO Section27, points out what Covid has highlighted so devastatingly: "SA’s public health system has been struggling for a long time and is, in many places, such as the Eastern Cape, now on the brink of collapse."
NHI, a plan that centralises funding of the health system under the national department of health, hardly seems to offer an answer to overcrowded hospitals, creaking infrastructure, corruption and medicine shortages.
"The NHI Bill focuses only on the funding aspects of the health system, which is important, but it’s far from the only issue facing our health system," says Stevenson.
"There are insufficient broad health system reform efforts taking place in parallel with talk of NHI."
Asked if he believes the protracted NHI process is standing in the way of real reform of the health-care sector, Mike Settas — health consultant and MD of gap cover insurance company Cinagi — says yes.
"One could argue that the amount of time and energy being spent on an unworkable policy framework such as NHI could be better spent on meaningful incremental reform of both the existing public and private sectors," he tells the FM.
Those who made presentations to parliament this month included health professionals from the Pharmaceutical Society of SA; the SA Institute of Environmental Health, which represents health inspectors; doctors’ groups; the National Health-care Professionals Association; and the SA Society of Anaesthesiologists (Sasa).
In their submissions, they pointed out that provincial health departments have imposed moratoriums on filling vacant posts for nurses and doctors. They also questioned how the process of inspecting and accrediting health facilities for NHI — an estimated 45,000 institutions to be checked every five years — would work.
Physiotherapists and pharmacists pointed out that they barely get a mention in the draft law.
The SA Medical Association warned that doctors who are unhappy with the legislation may emigrate, while the Health Professions Council of SA (HPCSA) controversially called for an end to medical aids — the very funds that keep many HPCSA members employed.
One doctors’ group called for NHI to be implemented immediately.
What do these discussions — running for years — actually achieve? And what purpose do they serve at a time when the system itself is crumbling?
Prof Alex van den Heever, a health expert at Wits University who was involved in drafting medical schemes legislation, calls the NHI process a "distraction" from needed health-care reforms.
He doesn’t think anything is actually being done to improve either the state or private health-care systems.
"I can say with complete confidence that the current health leadership is adrift and uninterested in building a sustainable system of universal coverage in SA," he tells the FM.
Health organisations, doctors’ groups, researchers, medical schemes and economists have been making detailed submissions on how to fix the unequal health system for 10 years — in response to the first and second drafts of the proposed NHI law.
Stevenson says these have largely been ignored. "Section27 and other organisations have been making submissions since 2011, yet these recommendations have not made it into the bill," she says.
There are other problems, too. The concept of NHI was promoted as an answer to problems in state health care and pricey private health care. Yet the bill merely proposes a financing system that’s modelled on the Road Accident Fund (RAF).
It’s a system that was chosen despite the fact that the RAF has traditionally run at a loss and was R5bn in arrears by last year.
The bill also proposes that the health minister and boards the minister appoints will have almost absolute power over the health system. It allows the minister to decide on the costs of medical treatment, how medical aids will coexist with the fund and how the fund money — hundreds of billions of rands — will be spent.
The irony of parliament discussing a policy that affords the health minister such influence while current minister Zweli Mkhize has been placed on special leave — he’s at the centre of a probe into an alleged R150m corruption scandal — is not lost on Van den Heever.
In its current formulation, the NHI Bill would have allowed Mkhize, as health minister, "the powers to influence the procurement for the entire health system", Van den Heever says.
He warns, too, that the way NHI is designed could allow insider special interest groups to benefit from political patronage.
The current health leadership is adrift and uninterested in building a sustainable system of universal coverage in SA
— Alex van den Heever
Concerningly, NHI isn’t the first time the government has tried to fix the health-care system, with little to show for the time and effort.
Back in 2002, two different government committees were set up to investigate health insurance for the uninsured. Their proposals were simply ignored.
In 2004, a plan was conceived to make low-cost medical aids available to millions of disadvantaged people who couldn’t afford ordinary medical scheme cover.
The first low-income medical scheme task team was led by Dr Jonathan Broomberg, who would go on to head medical administrator Discovery Health.
The research identified reasons for the high cost of medical aid cover and devised ways to make plans affordable for the uninsured.
The proposals were dismissed in 2006.
In 2015, the idea of low-cost medical aids was reintroduced, but was scrapped by the regulator of medical schemes a month later.
And in 2019, medical aids were again given the go-ahead to design low-cost plans for the uninsured, offering fewer benefits. In December, only weeks before the new plans would be launched, the medical aid regulator, facing complaints from unhappy doctors, prohibited the plans.
The private health sector has also been the subject of extensive hearings — in 2013, the Competition Commission launched its health market inquiry (HMI), which cost taxpayers R196m and took six years.
High health-care costs, dissatisfaction with medical aids, overcharging, unnecessary overtreatment and problems with state regulation all made headlines.
The panel’s detailed recommendations, released in 2019, highlighted just how the average consumer could be helped.
The panel concluded that medical aid plans were too complicated for members to compare and that consumers did not have enough information to help them decide which doctors or hospitals were best.
The panel proposed an organisation that would measure the quality of care in the private sector, allowing consumers and medical aids to choose hospitals or doctors based on their results and not just their price.
Medical aids all needed a basic standardised option, too.
The panel had harsh words for the health department, saying it failed to properly regulate the private sector, and proposed solutions to lawmakers.
As has been the case elsewhere, there’s little sign that anything has been done.
Says Van den Heever: "There is no process in government that appears capable [of] or interested in addressing the findings and recommendations of the HMI."
Sasa was one of the organisations to make submissions to the HMI, and its CEO, Natalie Zimmelman, attended many of the public hearings. "I have certainly seen nothing to suggest that any of the proposed HMI reforms are being considered, let alone implemented," she says.
For the past 20 years, commissions, investigations, plans, recommendations and NHI have been developed, discussed and debated, all with the aim of improving the health-care system. Yet the only meaningful reform was the Medical Schemes Act, brought into law in 1998, says Settas.
To show how little is happening, Stevenson points out that the committees that were supposed to be set up to iron out details of the NHI Bill — first proposed in the 2019 draft — have yet to be appointed.
In a recent Free Market Foundation presentation, Norton Rose Fulbright SA director Patrick Bracher said "the hope of everyone should be that the government recognises the impossibility of implementing the NHI Bill".
Instead, Bracher said, we should hope the government fulfils its obligation to fix existing health-care systems. That would be better than conducting endless talk-shops while hospitals deteriorate and doctors are forced to decide who lives and who dies.
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