The South African government’s ambitious plan for universal health care is faltering. Short of a strong push to get the four-year-old plan implemented, South Africa risks losing its best chance of solving deep inequity in access to health services.
Announced in 2011, the plan was to pilot the National Health Insurance (NHI) scheme in 11 districts as test cases for system-wide reform. But they have not delivered what was expected. Provincial and district authorities lacked the technical capacity to co-ordinate and implement innovations and underspent their budgets. The pilots have gone so badly that plans to extend them to 20 districts have not been fulfilled.
If fully implemented, the NHI would provide universal access to health care based on a contributory system with wealthier people contributing more. It also involves South Africa’s health department entering into contracts with public and private hospitals, specialists, public clinics and private GP practices to deliver free health services to everyone.
South Africa needs the NHI. It is a practical mechanism to contribute towards redistribution and redress in post-apartheid South Africa, which makes sense for reasons of social justice and improving access to care for all.
In addition, the current set-up is highly ineffective, inefficient and costly. The public sector does not have the resources to meet the need for care, while the private sector is concentrated on expensive and inefficient specialised care only available to a select few.
Big hurdles still to clear
The NHI seems to be slipping further and further down the government’s priority list as government departments appear unable to agree on how the system will be funded. This is delaying legislation to establish a fund to finance the system.
The National Treasury is reluctant to implement reforms that will place an additional financial burden on what is believed to be an overstretched tax base. It is still not known what the NHI will cost. The green paper released by Health Minister Aaron Motsoaledi in 2011 estimated that it would cost R255 billion by the time the full roll-out was completed in 2025.
There is also no clarity on what the relationship between the key players in the industry would be, particularly what role the private sector will play – if any at all.
A big challenge the government has is that the private sector, particularly private hospital groups, wields enormous power by dint of its size and entrenched market dominance. Other than a market inquiry into escalating costs in the private health care sector, critical engagement with the role it will play in providing care under a unified system remains conspicuously absent in policy debates.
Inequality remains the name of the game
The reality in South Africa is that 21 years into democracy, access to quality health care is still largely determined by race, income and geographic location. Access to health care remains one of the most prominent, although not the only example, of persistent structural inequities.
Recent research has shown richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. South Africa’s wealthiest 20% access 40% of health care services. The poorest 20% only has access to 10%.
These inequities are largely sustained through a health system divided unevenly between public and private systems. In 2015, South Africa will spend R158 billion – or 8.8% of its gross domestic product – on health care. This is well above the 5% recommended for a middle income country by the World Health Organisation. But more than half of this is spent in the private sector, which is only accessible to the 16% of the population who can afford private medical scheme coverage.
Earlier attempts were made, and failed
This isn’t the first time radical restructuring of the health care system has been mooted in South Africa. It was one of the first countries to recognise the need for progressive reform towards what is understood as universal access.
In 1944, the Gluckman Commission recommended a unified health system built on a Primary Health Care (PHC) approach. This would be equally accessible to everyone living in South Africa. The implementation of apartheid in the 1940s put an end to the chance of universal access to health care for the next 50 years.
After the 1994 democratic elections, the government set up three separate committees to explore the introduction of social or national health insurance. In each instance, recommendations never moved beyond parliamentary committee reports and certainly had no meaningful influence on policy.
At least some progress has been made in the last two decades. Initiatives have been introduced to shift the system from delivering health care through hospitals to one that focuses on primary health care, health promotion and disease prevention.
The NHI is at risk of going the way of other far-reaching health system reforms of the past unless there is a shift in political will and significant social pressure to take it forward.