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SA’s universal healthcare plan falls short of fixing an ailing system

The NHI Bill proposal still contains many inconsistencies and unanswered questions for it to be the final roadmap to universal healthcare in SA.

South Africa’s Health Minister Aaron Motsoaledi has finally gazetted the bill detailing an ambitious plan to roll out universal healthcare in the country through a National Health Insurance.

The bill responds to a global campaign spearheaded by the World Health Organisation and linked to the UN’s sustainable development goals to make sure that no-one is left behind in accessing quality healthcare.

There’s no dispute that South Africa’s healthcare system needs major reforms. There are considerable inequities in healthcare between urban and rural areas; between public and private health sectors and between primary healthcare and hospital care. And the country has a complex disease burden with heavy caseloads of HIV, TB and non-communicable diseases.

South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on healthcare. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector.

The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private healthcare costs and poor quality of care.

But in its current form the proposed legislation won’t be a silver bullet. There are still too many inconsistencies and unanswered questions for it to be the final roadmap to universal healthcare in the country.

For example, the bill focuses on curative services, missing an opportunity to take a public health approach that focuses on disease prevention, health promotion and health protection. In addition, it doesn’t address the relationship between the public and private health sectors which is seen as a major impediment to fundamental change.

How it will work

The bill is informed by a vision of ensuring equitable access to quality health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The proposed insurance fund envisages the consolidation of public and private revenue into one funding pool.

The idea is to enable a more equitable system through, for example, cross-subsidisation and ensuring that essential services are made available.

All people will have to register as users of the fund at an accredited healthcare establishment or facility (whether public or private). And the fund will decide on the health benefits that the facilities will have to provide. This will depend on what resources the facility has. People will be able to pay for complementary health service benefits not covered by the fund.

To be paid, healthcare providers, such as general practitioners and hospitals, will have to register with the fund. They will have to claim for each patient that they treat and will have to keep a record of diagnosis, treatment and length of stay.

The structure that’s been proposed for the fund is raising concerns on two fronts: it appears unnecessarily cumbersome and there’s a lack of clarity on lines of command.


The bill makes provision for the fund to establish an independent board that will report to South Africa’s Parliament. But it makes no mention of how the board will engage with the health minister (political custodian) and public servants in the health department. Nor does it explain how the performance of the fund will be evaluated.

The bill also introduces two additional management layers: district health management offices and contracting units for primary healthcare. These units will provide primary healthcare services in specific areas. It includes a district hospital, clinics and community health centres as well as ward-based outreach teams and private primary care service providers. They will be contracted by the fund.

National, provincial, and municipal health departments will still exist.

But the bill fails to explain the relationship between the district health management offices and the contracting units and how they will engage with the national, provincial and municipal health departments.

Given that there are ten health departments operating in South Africa – a national department and one in each of the country’s nine provinces – these additional offices and units could result in a more cumbersome bureaucracy. This could lead to more inefficiency and greater opportunity for corruption.

The new structure will also change the responsibilities of provincial health departments. Some of the proposals don’t make sense such as the idea that municipalities should take control of managing communicable diseases. Ideally this should be a national function, given the serious threat that is posed by some infectious diseases.

Many questions

Other parts of the bill are also unclear. These range from financing to how complaints will be managed.

Health financing and management: The bill doesn’t explain what the tax implications of the national health insurance will be for citizens. It also doesn’t set out the mechanisms that will be put in place to strengthen financial planning and monitoring systems, particularly in the public health sector. These are very important given current chronic overspending, inadequate financial management and corruption and lack of accountability in many provincial health departments.

Service provision: The bill says everyone is entitled to a comprehensive package of services at all levels of healthcare. But it doesn’t spell out what these packages will include. Given budgetary constraints, it’s obvious that there will inevitably have to be trade-offs and difficult choices.

The health workforce: South Africa doesn’t have a comprehensive health workforce strategy with detailed norms and standards. This remains the Achilles heel of health sector reform in the country. The lack of detail remains a serious omission in the bill.

Complaints mechanisms: The bill introduces a new separate complaints directorate – the investigating unit. But it’s unclear whether this will be the first level of complaints or whether it’s a duplication of the complaints directorate in the existing Office of Health Standards Compliance. There also isn’t clarity about where the Health Ombud fits in.

Ensuring that South Africa has a quality affordable healthcare system is critical. And the bill presents an important opportunity to think systematically about what needs to be done to fix the current health system. But there is still a long way to go.

This article was published with the permission of The Conversation, the original publication can be viewed here

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Eskom. PRASA. Denel. SAA. Road Accident Fund. Etc.
Now NHI!

Being cynical I wonder if the NHI is about health or just a scheme to extract more money from taxpayer under the guise of offering as compulsory service. Obviously the more money in the kitty the one one can misappropriate. So ultimately I think it is a scheme to facilitate corruption.

You’re not being cynical, that is exactly what the outcome of this will be, regardless of the intention.

All they know how to do is to create more problems,instead of fixing the exisying infrastructure
The various heath services that is in place is already national health care, upgrade it and increase mechanism to collect payment from those who can afford,and maintain accountability

The fact that a useless politician earns more than a highly qualified doctor, is the root of the problem with healthcare. This fundamental law of the free-market explains why we have an abundance of useless politicians and not enough skilled doctors.

Now this useless, over-payed politician who is a drag on society, thinks it will be useful to prescribe to the under-payed doctor where he should work and what his maximum salary should be. Then this useless politician goes even further and he abuses his power to make laws, to force hardworking citizens who save to provide their own healthcare, to also provide healthcare to those who do not work hard and who do not save.

The competitive force of the free market drives efficiency and creates value for money. The state healthcare system imploded because there is no competition to deliver an efficient, cost-effective service. Privatize state hospitals and clinics and let entrepreneurs provide the services the state fails to provide. Then pass a law that no politician should earn more than a teacher. This should solve the problems with healthcare in South Africa.

Maggie was on record saying that the problem with socialism is that you eventually run out of other peoples’ money. This may be true but has also now become a cliche. Even most socialists have realised that true socialism cannot work as it creates an undemocratic society of entitled but unincentivised incompetents who eventually put their masters before the firing squad- a la Romania. Socialists have thus found refuge in “social democracy”. Like a tick needs a dog, any parasite needs a host thus the socialist mantra has become “inequality”. Not poverty but inequality. Equality of outcomes not equality of opportunity. This is achieved through the ballot box. The message is simple: “vote for me and I shall take wealth from those who don’t vote for me and give it to you”. On this promise the socialist master lives it up in the capitalist society. Should inequality be eliminated, then so would the rationale for the socialist’s existence. There is a Goldilocks zone of socialism and it is a fine balancing act targeting the median voter. A least half the voting public must be better of with the socialist in power. What is good for the politician is, however, disastrous for the country long term. The productive minority stop pulling the wagon and jump on for the free ride or simply leave for other jurisdictions which allow for a better life (and who are evidently governed by those with more savvy). The purchase of votes thus leads to a downward economic spiral to the point where other peoples’ money is no longer sufficient to maintain the status of the burgeoning elite and their armies of mandarins on the state payroll. This is exactly what has happened in SA. One million of the elite professionals, managers, artisans and health care workers have jumped ship under the ANC regime and now contribute immensely to the economies of Australia, New Zealand, Canada, USA, UK, principally. The ANC parasites are now left to scrap over an ever shrinking pie. And scrap like rabid curs is what they are doing.

One could argue this is a failure of democracy or possibly the abject failure of a diabolical regime who are too busy extorting money and looting the coffers to create an environment where the private sector and productive individuals can prosper.

I see no way to make the numbers work.

Every time there is a headline dealing with NHI / BEE / EWC an unknowable number of tax payers (key word ‘payer’) lose faith and decide the risk associated with staying in SA is not worth taking….and away they go…Oz, NZ, UK, other. There are those that welcome the departure of the ‘traitors’ but they fail to recognise they take their taxes, consumption and skill with them. Driving around DBN and JHB is a reminder that there is still a lot for people to fight for but I have less faith every day that SA is going to come out of this downward spiral.

Based upon my travels around Africa it will eventually emerge from the downward spiral but there is still a long way to go down. Also we are looking 10 to 20 years down the road before things start to improve.

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