Bitter pills: The hard questions the Health minister must answer
From costs to lawfulness, Motsoaledi will face a barrage of questions when he sets out National Health Insurance Bill
When Health Minister Aaron Motsoaledi reveals the long-awaited Nation Health Insurance Bill on Thursday, it will be the culmination of a decision taken in 2007 at the ANC conference in Polokwane, where the party called for universal health care.
During a speech to the National Council of Provinces this week, he said he expected a “hurricane" when he released the bill along with the the Medical Schemes Amendment Bill.
The Medical Schemes Amendment Bill is expected to shake up the medical scheme industry and set standard tariffs and standard offerings of health care, making all plans similar.
The first National Health Insurance (NHI) green paper was released in 2011, followed by a white paper at the end of 2015.
In submissions from doctors, NGOs, dentists, policy institutes and hospital groups, many raised concerns while lauding the concept of free, affordable, quality health care for all.
Some of the questions the minister will have to answer:
How will it be paid for?
The SA Private Practitioners Forum, which expressed support for high-quality health care for all, said even rich countries with a high tax base, such as South Korea, have struggled to pay for it.
It also notes that there are only 5.7 million taxpayers supporting 55 million people, which is not a large enough tax base to pay for free high-quality healthcare.
The SA Private Practitioners’ Forum (SAPPF) said: “Looking at figures of what NHI is projected to cost according to Treasury, taking into account inflation estimated at 7% a year and 1.5 % growth a year, the cost would amount to R587-billion. This equates to 12.50% of the GDP.
“Taking into account that South African government budgeting is currently not allowed to exceed 25% of GDP, it can be seen that this health care spend would lead to half of the government budget being spent on health care.”
Economic consultancy Econex worked out that NHI as proposed faces a R200-billion shortfall by 2025-26, which is almost double the amount initially anticipated by the Department of Health.
The Helen Suzman Foundation notes: “The hard fact is that the financial basis for moving the platform up significantly will not exist until South Africa again grows at a rate faster than that projected by the International Monetary Fund for any year up to 2021.”
Why is NHI suggesting a single fund to buy all private and government services?
The NHI white paper proposes putting all medical aid money and government spending on health care into a single fund to buy health services.
SAPPF research showed the Road Accident Fund only pays 41% of claims a year, and the Workers’ Compensation Fund 61% of claims a year. Both funds are bankrupt.
Based on these examples, the SAPPF also asks how a single fund will improve healthcare and whether it will pay doctors, hospitals and suppliers efficiently.
What has happened in the pilot projects?
The Helen Suzman Foundation pointed out that very little information has been released on pilot projects that were supposed to test NHI concepts before implementation.
Will the government employ more staff in the state facilities as promised?
The NHI documents and the Health minister speak about better resources in health care for poor and rural areas. But the elephant in room is that state posts are frozen and the government is not employing many doctors and nurses who want to work in the state sector.
In 2017, director-general of health Precious Matsoso told the parliamentary standing committee on appropriations that the health care system had 45,733 vacant posts and 351,925 filled posts — a shortfall of 11.5% .
Why is health care taken away from those who have it?
The NHI white paper says most procedures will be covered in the state system and medical aids can only cover “complementary” conditions.
Many critics, including the Free Market Foundation, suggest that the minister fix the state sector first before criticising and dismantling the private sector that works.
Motsoaledi has said the rich will subside the poor with NHI.
Profmed Medical Aid principal officer Graham Anderson said: “The middle class already subsidise the poor by paying taxes for state healthcare.”
How will the NHI be lawful?
The Hospital Association of South Africa, representing private hospital groups, has raised the lawfulness of the idea.
“The effective removal of the ability of medical schemes to provide and charge for benefits, prima facie, constitutes an unlawful infringement of a medical scheme's right to property in section 25 of the constitution.”
The association also notes that the proposed idea of giving the powers to buy supplies, run central hospitals and employ staff to the minister of Health, and taking them away from provinces, is against the Constitution that divides up the powers to run the health system.
Section 27 explained in their white paper on the system that state needs to be improved for NHI.
“A dysfunctional health system costs lives. Unfortunately, our health system has been in a state of dysfunction for some time. While universal health coverage is undoubtedly needed, for NHI to function it needs a strong base in accordance with the WHO Health System Framework building blocks.”
The question persists ...
If the state system worked, we would have NHI already, said Graham Anderson, principal officer at medical aid Profmed.
State care is free for many patients and medical aids pay for hospital care for members. “The minister needs to sort out the state system as the situation is dire.”