ANALYSIS: How Cyril's got it wrong on NHI
Experts say his remarks in his Sona contradict the NHI Bill, and punch holes in the policy itself
President Cyril Ramaphosa created confusion with a remark about the proposed National Health Insurance (NHI) during his State of the Nation address, health experts told Times Select.
Those surveyed said his comments about the NHI appeared to contradict what the NHI bill states – but it could also just be proof of the incoherence of the NHI policy.
Elsabe Klinck, a lawyer who specialises in healthcare, said the president’s remarks that NHI will be rolled out while clinics and hospitals are improved, was different from what the bill states. Up to now it was understood the NHI would only be rolled out once clinics and hospitals had been upgraded, not during the upgrade process.
“The draft bill said a facility must be quality accredited before NHI will contract or appoint. This is different,” said Klinck.
Ramaphosa said in his address: “By introducing the NHI together with a multipronged quality improvement programme for public health facilities, we are working towards a massive change in the healthcare experience of South Africans.”
The NHI is proposed in law to be a single fund – like one national medical aid – that will buy health services from private and provincial hospitals that meet the standards of inspectors.
The NHI Bill, published in 2018, says it will use only “health facilities that are compliant with certification requirements of the Office of Health Standards Compliance (OHSC) and meet set criteria”.
But the president, whose office did not respond to Times Select’s requests for clarification, seemed to suggest that the improvement of health facilities and the NHI rollout would occur together, and not after facilities had been upgraded.
In the most recent OHSC inspection report, released in 2018, only five of the 696 hospitals inspected passed with a score of 80%. Hospitals and clinics are assessed on criteria including staff attitudes, patient safety, waiting times, infection control measures and medicine stock.
OHSC chief executive Siphiwe Mndaweni told parliament in the same year that the conditions at some hospitals had worsened since the first inspections in 2014 and 2105. “Most provinces have not been doing well and showed a decline.”
Health consultant Johann Serfontein said quality improvement needed to take place before the NHI was rolled out.
“The NHI pilot sites all had additional NHI infrastructure and funding. None of them had hospitals and clinics that passed the OHSC inspections. So, if focused effort and funding does not even fix the system, how do they plan to do it?”
Asked if fixing the system while rolling out the NHI contradicted the NHI Bill, Professor Alex van den Heever of the Wits School of Governance said the NHI policy was not coherent.
“To ask for consistency is a tough call.”
A day before the State of the Nation address, the head of health at Section 27, Sasha Stevenson, wrote in a Treatment Action Campaign and Section 27 publication, Spotlight, that the NHI policy was unclear.
“National Health Insurance has been the buzz phrase for years, but somehow it is still one of the most elusive policies of our time and it is made less tangible with each iteration of the policy.”
Stevenson points out that the NHI is a fund that will buy health services, but this would not fix problems in the health system such as crumbling infrastructure and staff and drug shortages.
“People are losing their lives every single day while we fixate on the passage of an NHI Bill that says little about quality and instead is focused on the creation of a fund. Health financing is a vital component of health system improvement, but the creation of a fund does not itself improve the health system.”
‘It’s like Brexit’
Ramaphosa also mentioned a war room set up to design NHI policies.
“Realising the magnitude of the challenges in healthcare, we have established an NHI and quality improvement war room in the presidency consisting of various key departments to address the crisis in the public health system while preparing for the implementation of the NHI,” he said.
The war room is led by Dr Olive Shisana and is in the presidency buildings.
However, Van den Heever was critical of the war room process. “They haven’t come up with a coherent NHI plan in 10 years. Changing offices won’t fix that.”
Russel Rensburg, spokesperson from the Rural Health Advocacy Project, questioned why the national department of health was not driving the warn room.
Van den Heever said the NHI, as it stood, was like Brexit: a policy that did not have an implementation plan and “undermined the very health system” it planned to fix.
Neither the Presidency nor the health department responded to requests for comment.