One of the key topics that the finance minister Enoch Godongwana must address in his budget speech this week is the National Health Insurance (NHI), specifically how much it will cost to implement and what government sees as the next steps in this process. After being completely omitted from the State of the Nation Address, the NHI received a mere mention in the President’s reply following the SONA debate, with the President affirming the government’s commitment to the principle of universal healthcare.
The COVID-19 pandemic showed the need for an equitable and accessible healthcare system for all however, how that is to be achieved and at what cost remains contested. Government now faces the challenge of recalibrating healthcare spending away from the COVID-19 response to responding to challenges that existed before COVID-19, such as the other pandemic, HIV/Aids, TB as well challenges such as teenage pregnancy, trauma from roadaccidents, stabbings and shootings as well as the high incidence of lifestylediseases. At the same time the healthcare system must be made ready for future pandemics, starting with testing capacity as well as that of facilities forisolating patients and vaccine manufacturing capabilities - should vaccines bedeemed a necessary response. Government has some work to do to convincestakeholders that the NHI, as currently contemplated, is the best way toachieve this.
A critical issue that governments need to clarify is the role of the private sector in the NHI value chain . Current indications are that government will compel the private sector to participate through legislation and exclude it from other parts of the system. For example, government contemplates a centralised, single payer model run by the state.South Africa’s experience with loadshedding creates a spectre of a systemcollapsing and patients being unable to access health services for extendedperiods.
As the pandemic showed, private health laboratories carried out a significant portion of the COVID-19 tests and the private sector assisted with vaccine rollout even to individuals who are not members of medical aid schemes. In its Govt Trends 2022 report, Deloitte has found that globally, there is a move towards partnerships to strengthen public health systems. These are partnerships between government, the private sector, the NGO sector and communities. Government has to harness the power of these partnerships for the NHI to work, with each role player’s mandate clearly spelt out.
The first issue that government faces with the NHI is that the platform on which it is supposed to be built, the public health system, is currently fragmented, unstable and beset with operational challenges. There is no clear indication of what percentage of public health facilities currently meet the envisaged standards for the NHI. Another factor to consider is that health is a provincial competency:Provinces are responsible for health infrastructure and while national government carries the cost of hiring personnel. What this means is that theNHI will be built on a very uneven landscape, with some provinces chronicallyunder resourced while others, most notably Gauteng, have relatively moreresources, even if the province buckles under the strain of inward migration. The Budget must show how equitable share adjustment and the Inter Governmental Fiscal Relations can be used to address these imbalances.
And then there is a matter of cost and how the system will be funded. National Treasury has given no recent estimates of how much the system will require and how this will be raised. Measures such as accessing medical aid rebates are only part of funding and will not be adequate on their own. The upcoming period of processing the legislation and public consultation must be used to debate the configuration, design and funding of the NHI more thoroughly.
Government recently won a court battle to proceed to spend R30 million to hire specialists linked to the NHI, even before the legislation has been passed. Government seems determined to wade its way through litigation to implement the NHI. It would be better to meet stakeholders and address theirconcerns and use courts as last resort. Implementation through courts is bound to fail.