NHI white paper: the good and the bad

Socio-economic inequity underpins inequities in health and access to health care. Forty-four percent of all health care spending is concentrated in the private sector, which serves only 16% of the population. The remaining 84% — those with the largest share of the burden of disease who need the most care — rely almost entirely on the under-resourced and dysfunctional public sector (a minority also pays out-or-pocket for limited private care at the primary care level).

Consequently, there is huge public-private inequality; massive unmet health care need in South Africa and a failure to approach anything near universal health coverage (UHC) through accessible, equitable and effective health care services.

UHC is seen as a panacea for low and middle income countries struggling to achieve inclusive and unified health services that do not impoverish people through out-of-pocket expenses. Countries moving towards UHC have healthier communities, better health outcomes and improved economies due to increasingly productive working populations. However, these successes are dependent on the ability of the public health system to meet health needs. The Ebola epidemic in West Africa provided a stark picture of collapsed health systems, which should serve as a lesson to prioritize global health and health system strengthening.

UHC recognises health as a public good - not a privilege to be bought by individuals - and gives the state the responsibility to ensure the provision of unfettered access to health services. To this end, the long awaited National Health Insurance (NHI) White Paper was released on Friday, 11 December 2015, on the eve of International Universal Health Coverage Day. Principles for improving access to and the quality of health services are laid out. The Paper, which is being scrutinized by multiple stakeholders and organisations advocating for the right to health has both strengths and weaknesses.

The strengths of the paper talk to positive health reform based on a human rights approach. The proposed model of risk pooling and the establishment of a single fund from which services are to be purchased favorably speaks to a widely accepted current discourse on UHC. South Africa needs a single national health system that builds social solidarity, where there is greater regulation of private medical schemes, and where the wealthy and the healthy cross subsidize the poor. These actions could indeed strengthen the social fabric of our nation.

Yet how exactly the funding will work, and where it will come from, is not completely clear. While we wait for the release of the business plan from Treasury, several speculative funding models to cover the R225bn needed by 2025 could include direct taxation through personal income or inheritance tax; payroll or premium taxation, or indirect taxes such as VAT. The latter would fall heavily on the poor. Fair taxation as a means of funding and expediting NHI is imperative and all of this needs an overhaul of current legislation.

The NHI provides a basis to address the stark inequities of health outcomes and health care in South Africa, and demonstrates a commitment to primary health care and to human rights, with the notion that health is a public good and not a commodity at the whim of “the markets”. A prerequisite for doing this, however, is the effective delivery of a comprehensive primary health care service (health promotion, disease prevention, treatment and rehabilitation) at community level.

In light of this, the transfer of central hospitals to the National Department of Health, while maintaining the management of district and community-based services under local government control could allow for more effective planning and use of expenditure, perhaps shrinking the role and influence of medical schemes, giving priority to those most in need. The details regarding how the public and private health sectors will work alongside each other, remains to be explained.

A crucial shortcoming of the paper is insufficient attention to primary level care, and particularly the integral role of community health workers (CHWs), who form the backbone of the primary health care system. This cadre of the health workforce is currently undervalued in terms of the potential value it offers to health services at primary care level. The numbers, or ratios of CHWs and their scope of practice are poorly defined.

Governance at community level is also not well considered. If health is to be truly recognized as a human right, the contribution of health committees which include representation from community members to ensure full and meaningful participation is crucial in ensuring health needs are met. Thus the scant mention of health committees as important contributors to primary health care planning and implementation, and a lack of state funding to support them is of concern. A top-down management approach will not be welcomed by the many community organisations and volunteers who have a historically vested interest in the health needs of their communities through well-established community health forums.

Effective health care needs a skilled workforce. Radical reform of health personnel education is required to increase the numbers of health providers at different professional levels. To do this we would need to see the re-opening of nursing colleges, increased state funding of health sciences programmes, and the revitalization of teaching hospitals, as well as an increased collaboration between professionals in the state and private sectors to ensure the exchange of skills.

Both the community and health workforce require access to services. In previous rounds of comments on the NHI Green Paper, the lack of funded transport was raised as a major obstacle to access, particularly in rural populations. Transport has been found to be the biggest cost for users of the public health system in both rural and urban areas. While services may be free at the point of contact, transport barriers prevent people from using them. Since one of the criteria for access to health care in terms of the International Covenant on Socio-Economic and Cultural Rights is to ensure equity in access, NHI would be violating this principle of equity if it did not address the transport barriers especially faced by rural populations. 

The key drivers of the growing demand for health care include the mature HIV and TB epidemics; the increasing incidence of non-communicable disease, including cardiovascular disease, diabetes, cancers, chronic respiratory disease and mental illness, as well as the ongoing burden of violence-related trauma, all of which are intrinsically linked to the social determinants of health.

At the crux of disease prevention lies maternal and child health and its relation to poverty. How will NHI ensure adequate perinatal care and support that extends to the household, especially for low birth weight babies who are often discharged from services when very small? Yet little is described about disease prevention and it is not clear how any of these services will be ring-fenced nor if they will be able to compete with the insatiable appetite for curative health care. A national health service design based on projections of a continuous increase in the demand of these health services to meet an inevitable increase in demand is a denial of the right to health. Therefore, ignoring the increasing sales and consumption of cigarettes while undertaking to provide all the health services required to treat the diseases of smoking is not sustainable.

We cannot expect improved health outcomes if we ignore the prevailing inequities in South Africa. Ultimately, social and economic rights are fundamental in addressing the social determinants of health. NHI cannot be implemented effectively without examining the progressive implementation of socio-economic rights, and this implies a commitment to prioritise the mobilization and allocation of all available resources in an intersectoral effort.

NHI needs to be implemented in conjunction with the delivery of other services across state sectors in a coherent, collaborative approach that embodies “health in all policies”. Addressing this effectively will reduce the load on the national health system and should be regarded as a priority as important as developing the national health service itself.

The right to health demands not only a radical change in the health system but also a turnaround in general priority setting by the state towards basic service delivery. To ensure effective resource allocation and prioritisation, prestige government projects that benefit elites should be put on the back burner. This means putting environmental health, water and sanitation before another state bailout. Corruption must be rooted out as it is the single worst enemy of central funding systems. While the People’s Health Movement welcomes the NHI White Paper, in collaboration with other civil society movements we wait for further developments and will ensure that the people’s voices are heard in light of their right to health.

Kathryn Stinson is an epidemiologist with an interest in public health. She writes as Chair of the People’s Health Movement, South Africa. Follow on Twitter: @kathryn_stinson; @PHMSA1, and Facebook.

Views expressed are not necessarily GroundUp’s.