NHI is a funding model masquerading as a delivery system

National health insurance (NHI) is one of the most misunderstood terms in healthcare in SA. Its real meaning is sometimes augmented and most frequently diminished to represent something that it should not be or will not be. It is a funding system, not a delivery system. But the latter concept seems to be a good political tool and is sold to the voter as the solution to our healthcare problems.

NHI is not a strategy or a health structure. Far from that. It is actually only a funding system in which money for healthcare is centrally managed — not the process or quality of care.

Universal healthcare means people have universal access to healthcare. Ideally, the quality of such healthcare should be good enough to improve the health status of the community, and of the individual when needed. A good universal healthcare model will therefore define the areas of health concern for communities and individuals. It will plan for and service those needs through good planning of high-quality services that include health system reviews, adequate staffing and leadership, and effective management, understandable care processes, accessible efficient facilities, health data acquisition and proper budgeting and budget control.

But people, not governments, pay for healthcare. SA healthcare is funded by individuals (for themselves) and by the taxpayer (mainly the same individuals who fund their private health insurance) for the public sector. The funding per individual in the two sectors (private and public) is therefore highly unequal, mainly due to SA’s small taxpaying base. If quantified, private sector health care medical scheme members will pay for their and their family’s private health insurance according to what they can afford in benefits. These taxpayers will collectively also pay about 60% of the care in the public sector through taxes.

The NHI is one way to fund universal health coverage. It uses (mainly) tax money to fund healthcare for all and the taxpayer is therefore mainly responsible for footing the bill. It also, in the SA guise, may reduce the ability of the individual to continue to pay for non-NHI benefits in a medical scheme. This is likely to be unappetising for many taxpayers and voters.

The quality of care in the two sectors (public and private) is, with some infrequent exceptions, very different. Where it costs more, the service is normally better, but not yet optimal for the money spent. Although more expensive than the private sector, care in the private sector is mostly, but not always, comparable to services in first-world countries. In these countries the per capita expenditure in real money on health (not percentages of GDP as is frequently used) is six (UK) to nine or 10 times (US) what it is in the SA private sector.

Market inefficiencies, market inquiries and other reports have shown this. These cracks are not very large or insurmountable to rectify in the private sector. But even if the faultlines are fully fixed and amount to R10bn–R15bn savings, this will not be enough, even if efficiently funnelled in some way or another, to prop up a failing public sector. There is much less money per capita in the public sector.

Management of money can improve patient benefit. Compared with the private sector, the quality of care in the public sector is frequently low and is fraught with solvable problems: bad access or, when accessed, frequently suboptimal care, overcrowding and more than occasionally a noncaring attitude from the health professionals who are closest to the patient. There are frequent reports of drug outages, nonavailability of existing theatre and other treating facilities due to a lack of qualified staff to man open workspaces, and other problems that may elevate this to a potential perfect storm that will threaten healthcare on the ground.

When we fund we must know what we are paying for and how much we need to deliver those services. The NHI as funding system can only work if there are predefined healthcare benefits covered under this system. These must be carefully defined and quantified. This calls for gap analysis on facility and personnel needs and concerted efforts to improve these.

It calls for a list of carefully planned NHI-funded healthcare benefits that will be universally available. This will lead to a clear idea of the quantum of funds needed and how funds will be spent if procured. It will also afford SA well-grounded motivation to secure funds and speed up funding for a good health system from overseas. Investors in countries’ wellbeing want to know what they are funding.

Pragmatic modelling

So where to with the possibilities of NHI? How can it work? A pragmatic approach to implementation of a funding system such as NHI is needed. It is not adequate to say it is a political decision and that we will start to plan the nuts and bolts of who and what will be funded after implementation.

The NHI will not solve the other problems that make healthcare in SA such a challenging space. It will not solve infrastructure, scarce leadership and management, the attitudes of health professionals, or how it will service ill people and look after the health of those who are healthy.

Deeper, pragmatic modelling of care systems on the ground, concerted implementation of such good planning, infrastructure, care system logistics, supply of consumables to meet demand and prevent outages, staffing and good leadership and management skills (including financial planning and management skills) are needed.

Can universal health coverage funded by an NHI mechanism improve health for South Africans? Yes, but only if we do the right things right.

If the above is quantified and properly implemented, well-rounded planned universal health coverage, funded by adequate amounts of money with services delivered by good facilities with motivated staff, may be possible.

• Prof De Klerk heads the University of Stellenbosch Business School MBA in healthcare leadership.