Since 1994 South Africa has invested substantial resources in health care services. As a result, it’s has made significant health gains. For example, nearly 4 million people get HIV treatment and mother-to-child transmission has nearly been eliminated.
Service delivery has also been significantly expanded to more than 4000 health facilities. And there’s been a large increase in the number of health care professionals.
But health care needs aren’t static. For example, non-communicable diseases like diabetes and hypertension are now responsible for more deaths than HIV and TB combined. And in some instances successes have created challenges. For example, the expansion of HIV treatment has meant that there’s now a large cohort of chronic patients requiring ongoing care. In addition, the reality of a largely youthful population requires interventions so that health gains aren’t lost.
Health services in South Africa are delivered by a large public health system as well as very sophisticated (and profitable) private health providers. Funding in the public sector has declined progressively for the past six years. The result is that public health services are under increasing strain and unable to deliver adequate care to poor people, particularly those living in rural areas.
The private sector has also been under pressure. This has led to price hikes, making many medical aid schemes unaffordable. Membership numbers aren’t growing, partly due to the country’s very high unemployment levels – medical aid membership is linked to formal employment. The result has been even more pressure on the public sector.
Reform is clearly needed. All that’s in dispute is what it should look like.
The release of the National Health Insurance bill is the government’s answer to the problem. The central plank of the plan is a National Health Insurance Fund that will buy health care services from health professionals and deliver through both public and private facilities.
The bill has been met with a raft of criticism, included funding concerns and the fact that it won’t fix the collapsing public system. But I believe that more fundamental questions need to be asked: does it address the goal of delivering universal access to health care for all South Africans? And can it do it in a way that doesn’t incur catastrophic expenditure?
The answer to these two questions I believe is yes.
Breaking with the past
Despite the bill’s flaws, it has two great merits.
The first is that it addresses the country’s current approach to health care where the quality and type of services people receive is informed more by their socio-economic status rather than their need for care. Instead, it adopts a population-based approach. This means that budgets would be allocated based on how many people live in an area and what their disease profiles and health care needs were.
If properly implemented, this approach would result in lower health costs over time because diseases like diabetes and hypertension could be detected earlier and health conditions would be managed more efficiently.
It’s second major merit is that it looks at health services through three vantage points:
what services are needed,
who needs them, and
who will deliver them.
This means that it separates who procures the health services from those who will deliver them.
A change of focus
The bill also promises to transform the way money is spent on health care because it’s premised on separating the procurement and the provision of health care services. This has two benefits.
Firstly, it will mean that health budgets are allocated more efficiently based on health needs rather than purely on use. Secondly it can potentially unlock significant savings through strategic procurement.
The country spends just under a half a trillion rand on public and private health care combined. But the funds aren’t allocated and spent efficiently.
For example, nearly half of the money that goes to primary care services is being spent on managing chronic HIV patients. While spending to maintain access to HIV care is important, funds need to allocated to dealing non-communicable diseases which are becoming an increasingly significant public health threat.
The private sector services has its own set of problems. Chief among them is that it’s approach is curative – that is treating people in hospitals – rather than preventative.
The bill envisages that primary health care facilities will become the main point of entry for all patients.
There’s another benefit to the proposed scheme: a more equitable spread of services.
There are currently over 4000 public health facilities that service over 80% of the population’s primary health care needs. In the private sector there are close to 5000 general practitioners who service the health care needs of only 16% of the population. And most are concentrated in urban areas.
People in rural areas are therefore largely dependent on an ailing under resourced public sector.
At the centre of the proposed universal health care system is the promise that everyone will have access to health care where they need it without incurring vast expenses.
By consolidating the health market, the bill opens the door to more equitably allocate resources.
If it’s successfully implemented, this approach offers a real opportunity to address the country’s grossly unequal access to health services.
A marathon, not a sprint
The national health insurance should be seen as an opportunity to bring about much needed health care reform in South Africa. But South Africans need to wake up to the fact that implementing this highly complex new system will be more like running a marathon rather than a sprint.
The final implementation of the national health insurance is still a long way off – another two phases are planned. And the release of the bill is also only the first legislative step. Over the next four years 12 additional pieces of legislation are expected to be introduced.
South Africans should be prepared to be patient.