CRAIG COMRIE: SA can ill afford to put all health funding eggs in one basket

In a resounding declaration at the ANC’s 112th-anniversary rally earlier this month, President Cyril Ramaphosa proclaimed that the National Health Insurance (NHI) Bill is destined for enactment, a fait accompli that leaves no room for dissent.

Should the current iteration of the bill be signed into law, citizens face a stark reality: a healthcare system tied to the bureaucracy of unfriendly processes to access care listed as NHI services. This process, devoid of choices of where and how to access healthcare, is going to be the biggest compromise for a healthcare consumer who has no alternative care and is in effect tethering their fate to the state’s monolithic single-funder structure.

As the bill stands, it would signal a profound, seismic change to the very fabric of SA’s healthcare system. Exactly how this will work in practice appears deliberately unclear, with crucial details around funding and the list of services that will be available from the NHI not yet defined or budgeted for.

Quality healthcare should be available to everyone, irrespective of the capacity to pay for it. But there is more than one path to universal health coverage, and there are quicker and more effective ways than the NHI Bill to bring our current two-tiered health system into closer alignment with its stated objectives. It is possible to work towards the aims of universal health coverage while protecting and building SA’s health assets and protecting constitutional rights.

As the bill stands, any procedure or service listed as being covered by the NHI cannot be paid for privately or with medical scheme cover. Everyone will be at the mercy of a single state funding system for these services, which greatly diminishes the right to freedom of choice in how and where a person can access healthcare in SA.

Consider that under the proposed NHI model patients requiring standard procedures such as tonsillectomies and hip and knee replacements, among others, would have no option but to live in discomfort until their turn comes up on the NHI’s waiting lists. 

If we look at the UK’s comparatively well-funded National Health Service (NHS), which has been held up as a model for SA’s NHI, procedures such as these typically have waiting lists, often longer than a year, while patients receive pain management treatment.

That said, UK patients still retain the right to go the private route to access life enhancing procedures sooner outside the public health system. Many other European countries struggle with the same issue of growing costs, and where national budgets aren’t able to keep up queuing becomes a national pastime.

At this juncture it is worth pointing out that the UK’s GDP per capita to support the NHS is $46,510, compared with SA’s mere $7,055. The public health system of Denmark, which has a GDP per capita of about $68,007, is another that has been held as an example of what SA’s NHI aspires to achieve.    

It is clear that we are going to have to be more realistic about how we can get closer to universal health coverage as a society; we cannot afford to put all our eggs in one untested basket and hope for the best. Bringing the public health system closer to the private system to improve access to quality healthcare for everyone while maintaining the option for additional funding mechanisms would advance the aims of universal health coverage more speedily than the NHI Bill proposes.

Medical schemes are nonprofit funds established to fund private healthcare and remove the pressure on public health services, thereby reducing queues and government funding. People who belong to medical schemes are removing the obligation from the state for funding their healthcare needs, while still contributing tax to sustain public health services.

Nationalising healthcare funding, as proposed under the NHI Bill, is an extremely risky step, since removing private funding diminishes opportunities for the retention of specialist skills, general infrastructure investment and the development and long-term management of health resources.

Alternative models have been discussed that would allow for the improvement of public health facilities with combined public and private funding, and proposals of partnerships to improve the quality of the public health system while reducing costs to those with medical scheme membership.

A single, centralised funder model is by no means necessary to speed up progress towards the goal of universal health coverage — it is possible to get there without taking on the risks and constitutional pitfalls of the NHI Bill as it now stands.

• Comrie chairs the Health Funders Association.