Picture: 123RF/SAMSONOVS
Picture: 123RF/SAMSONOVS

The problem with long processes is that you risk the world changing in the interim. The reforms to our health system put forward in the draft National Health Insurance (NHI) Bill were designed in what feels like a different era.

There are several reasons why we need to revisit our chosen reform pathway. We find ourselves in altered circumstances, entering a period of austerity accentuated by Covid-19. The reform pathway as now conceptualised requires substantial reorganisation of a fragile system in a relatively short time-frame. This big bang approach poses several risks, the biggest being that our system may never be reformed because of resistance from across the political spectrum.

At the same time, the collective wringer we have been put through has affirmed the need to overhaul our system. The imperatives for social solidarity principles (where resources are contributed on ability to pay and received based on need) and for high-quality care make intuitive sense when we are faced with questions of who gets an ICU bed, what constitutes elective care and how we prioritise who gets vaccinated and who doesn’t.

We would be terribly remiss if we didn’t pause to take stock and deeply consider how our reform pathway needs to be adjusted in light of our current context. Percept has been working with the Inclusive Society Institute on engaging health sector stakeholders in deep discourse on SA’s path to universal health coverage. In a report published late last year we laid out alternative pathways for SA to achieve that goal. The four scenarios are: “Status Quo Gold Standard”, “NHI Rejigged”, “Power to the People” and “Reorienting Towards Value”.

Status Quo Gold Standard addresses the chicken and egg question of whether financing reforms or service delivery improvement should come first. A clear emphasis on strengthening the public health sector has greater resonance in the present moment given that our already fragile health system is more deeply fissured than ever. There are missed health services that need to be caught up, and traumatised and exhausted health workers.

NHI Rejigged sees reform of the public and private sectors running in parallel. This reform pathway draws on the wisdom from the German health system to not break anything before building a viable alternative.

Bottom-up accountability sits at the crux of Power to the People, and the need for this approach is even more resonant in a low-trust environment, in light of the failure of large government institutions and corruption in a time of crisis.

Reorienting Towards Value provides a reform pathway styled on the international Leapfrog to Value movement. This approach gives preference to data-driven improvements to the quality of care and a leveraging of community-based resources, rather than being ever more dependent on top-down health system reforms. It also allows for greater system accountability and governance through the power and transparency afforded by publicly available measurement of both the cost and quality of care.

All of these approaches recognise that financing reforms are insufficient to truly shift health outcomes. The fiscal space we find ourselves in requires a much clearer sense of priorities and detailed strategies for system strengthening.

It isn’t only the fiscal environment and current mechanisms for delivering care that have shifted. We’ve been awakened to the silent threat of our noncommunicable disease burden, our awareness of the human impact of serious illness and death has deepened, and we have a telemedicine revolution brewing.

The growing burden of noncommunicable diseases globally, and specifically in SA, poses a large and potentially destabilising burden on the health system and economy. This is driven by the high prevalence of risk factors for noncommunicable diseases in the SA population and so-called syndemics, where conditions cluster together because of underlying commonalities in their risk factors. There are unacceptably high levels of still undiagnosed and untreated noncommunicable diseases in SA, a service delivery failure that can be addressed without financing reforms.

Palliative care gets only the lightest of mentions in the NHI Bill. Our collective experience of illness and death has shifted in a moment where families are separated, where patients die alone in hospitals and where humanity matters more than ever. The role of palliative care in deepening system-wide empathy and providing support to patients and families dealing with serious illness is irrefutable. A recent Medical Research Council webinar made the moral case, the economic case and the legal case for palliative care. The proposed reforms need to reflect a palliative orientation more deliberately.

The combined fiscal context and service delivery reality means we must figure out, with some urgency, how to do better with less.

Leveraging digital innovation provides a plethora of options for enhancing the value delivered by our health system. Shifts in telemedicine regulation to accommodate Covid-19 have been fertile ground for a nascent local industry. We have seen a wide range of innovation emerge in a relatively short time, speaking to the magic of the SA ability to seize opportunity and make the best of a bad situation.

Yet how we collect evidence to inform future policy and regulation is unclear, with the Health Professions Council of SA startlingly silent on the issue. This means we risk missing an opportunity to solve exactly the problems NHI is intended to solve.

Reform pathways that are overly centralised and slow-moving risk being blind to the fundamental barrier of a lack of trust between stakeholders, changes in our context, in our values and the opportunities created by fast-moving technological change. In thinking ahead, key criteria for assessing policy choices need to be responsiveness, resilience and bottom-up accountability, all of which run counter to the current approach.

• Ranchod is CEO of research and analytics consultancy Percept.


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