With the National Health Insurance (NHI) bill due to become law next month, the question of trust in the government’s ability to run such a scheme was raised at the South African heart congress last month.
Darryl Smith, a cardiologist at Linksfield Clinic who works sessions at Charlotte Maxeke Johannesburg Academic Hospital, called it “an elephant in the room”.
“Why should we trust the government with our money when there are no successful blueprints?” asked Smith. “Money has been poured into Chris Hani Baragwanath Hospital and Charlotte Maxeke — only for these hospitals to return to their former state. We have to ask why we must trust the government, not just with money, but with aptitude and ability.”
But Nicholas Crisp, deputy director-general in the national department of health and the government’s point man on NHI, said: “This pervasive distrust has to stop.” He said he had seen the health-care system from inside when he suffered cerebral malaria.
“It’s a dog-eat-dog, grey environment,” said Crisp. “I didn’t trust anybody when I came out [of treatment]. Then, more recently, I chaired all those Covid committees, where I had CEOs of companies displaying some disgusting behaviour, for which several apologised afterwards. I work with private and public colleagues in all disciplines and there’s excellent management, which doesn’t see us as the enemy. The only enemy is ill health — and we need to deal with it.”
Crisp has described South Africa’s health system as “a complete shambles — a mess”. He told the conference that public and private health care “are disintegrating quite badly and we need one another desperately to solve what we’re doing”. He said he and his small team were trying to create one integrated system.
“The problem is that patients move between practitioners and between sectors. How do we continue to pay for that care without discriminating on all parameters — as we now do? You have to do it very slowly and gently, so you don’t break things,” he said.
Why should we trust the government with our money when there are no successful blueprints?
— Darryl Smith
The NHI will do away with provincial autonomy, said Crisp. “At present the health minister controls only 1% of the health budget. Under the NHI there will be central control, with the budget being allocated to the nine provinces, municipalities, the military, and public and private health-care sectors.
“You can’t have the private sector, which serves about 15% of the people, consuming 51% of health spend. How do we make the 67% of doctors working in the private sector available to the public — and ensure everybody gets health care when and where they need it without [them suffering] financial hardship?” He said that over time the benefits package would grow as more money became available, and instead of 308 medical aid options under 78 medical schemes, there would be one.
Meanwhile, the private sector is to launch a purchasing forum in January to centralise the buying of drugs and medical equipment used to treat diabetes and kidney and associated cardiological problems, to reduce prices and improve patient access.
At the same time, the NHI will centralise buying, also to reduce costs. It will, however, be at least another year before the board that will manage the multibillion-rand fund is put in place, Crisp tells the FM.
The decision about a private sector forum came after a vigorous two-hour panel discussion and debate at the congress.
Experts in the Council for Medical Schemes (CMS) and top drug procurers in the public and private sectors said the most effective new drugs were too expensive for low- and middle-income countries.
CMS public health & occupational medicine specialist Samantha Iyaloo said new health technologies and medicines stood to reshape and improve South African health care.
Several pharmaceutical company executives at the discussion agreed that in terms of drug and equipment procurement the industry is “operating in silos”.
Crisp said a collaborative forum is “well catered for” in the NHI. He said the public sector is already negotiating prices that are sometimes a 10th of the single exit price, while motivations to the health minister about “problematic” single exit price regulations are being addressed. He said that for the first time the South African Health Products Regulatory Authority will start regulating medical devices and auditing companies and products.
Crisp tells the FM that his priority in the NHI is to give the health minister the authority to delegate to the provinces only the provider functions (not financing, which will be national). “That will give us the ability to do strategic purchasing where we really need the services.”
He says resources are “locked up” in private providers that exist because private funders can pay them. With just 8.9-million private sector beneficiaries — a number “rapidly shrinking as people downscale from comprehensive plans to hospital plans” — the system is “simply unsustainable”.
“The key is bringing the public and the private providers into the same payment model. That means not only the clinics and the community health workers, but the 11,000 general practitioners, who have been neglected and undervalued in the health system for far too long.”
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