Why the NHI is clearly a dream that never was nor is likely ever to be

The world of practical policymaking has five basic prerequisites for success – that is, of course, if you care about the public interest.

First, work from the world as it is and not as you would like it to be. Second, understand your context by doing your homework through research and productive engagements with society. Third, diagnose what is not working with the systematic use of evidence and reasoning.

Fourth, prioritise what to address from the myriad possible issues. And fifth, identify appropriate interventions – again using evidence and reason – that match your capabilities, are aligned with your objectives and are not harmful to the public interest.

The larger and riskier the area of policy intervention, the greater the need for these five prerequisites to be adhered to fully.

It is, therefore, a matter of considerable concern that not one of these five prerequisites has been complied with in the National Health Insurance (NHI) policy process. Instead, it has been characterised by a disregard for submissions and evidence, and an overemphasis on rubber-stamping.

Since 2007, when the NHI proposal first emerged at the ANC’s national conference in Polokwane, to the present, no systematic research has addressed any of the five prerequisites. This is despite convening ministerial advisory committees and spending several billion rands on 11 failed “NHI pilot projects”. The diagnostic is simply a retort: South Africa has a two-tier health system and it should be a single-tier health system.

False assertions

As an alternative to evidence, various ministers, deputy ministers and the Department of Health have sought to motivate this simplistic remark by resorting to false assertions about the performance, sustainability and outcomes of the medical schemes system, in an attempt to bolster the case for an otherwise nonexistent motivation for the drastic NHI proposals.

Such assertions included that medical schemes are on the verge of collapse; that their members run out of benefits halfway through the year and are dumped on public hospitals; that 77% of medical scheme beneficiaries are white; that private health systems are always harmful to the achievement of universal health coverage; that medical schemes are causing the movement of health professionals from the public to the private sector; and that many members face unacceptable out-of-pocket expenses. 

Each of these assertions is false and cannot reasonably be regarded as evidence worthy of consideration. First, medical schemes are solvent, providing coverage to nine million beneficiaries (nearly two million more than in 2005) and showing no signs of collapse. Note, the status of medical schemes is published each year based on audited financial statements, and these reports are provided to the minister of health.

Second, there is no evidence of medical scheme beneficiaries running out of benefits and needing to be “dumped” on public hospitals. It is somewhat surprising that no systematic report exists showing that this is a problem. Contrary to this assertion, major medical expenses are mostly covered as prescribed minimum benefits, which schemes must cover in full. It is therefore impossible for members to run out of benefits. 

Third, the assertion that 77% of medical scheme membership is made up of “whites” is false. Evidence from Statistics South Africa shows that most beneficiaries are in fact “black” and that “whites” make up only about 30%.

Fourth, private arrangements, whether funders or providers, form part of every universal coverage framework around the world. In countries such as the Netherlands, Germany and Belgium, regulated private mutual funds, akin to South Africa’s not-for-profit medical schemes, are responsible for all coverage. Most countries have hybrid arrangements mixing public sector provision with social insurance funds and private funders.

Fifth, there is no official research-based report that demonstrates that the private health system removes any health professionals from public employment. In fact, the only official reports produced indicate that they don’t have adequate data on health professionals in South Africa, whether in the public or private health sectors.

Sixth, according to the World Health Organization, South Africa has the 11th-lowest levels of out-of-pocket expenditure in the world. This outcome is entirely a result of the two large systems of coverage: one offering healthcare free at point-of-service for the majority of the population, and the other the system of medical schemes, where care is mostly prepaid or funded from a pool.

When signing the NHI Bill, the President continued this polarising tradition by arguing irrationally that medical scheme members are somehow privileged and spoilt.

Medical scheme members, however, pay for their own healthcare from their disposable incomes, while at the same time funding about 75% of the public health system. This double payment is logical and it is why South Africa can provide a big public health system together with a sustainable medical scheme system.

Unlike the political elite in South Africa, most medical scheme members are teachers, police officers, civil servants and secretaries. In contrast to the insulting picture painted by the President, this group of law-abiding, tax-paying citizens have to pay more and more for education, healthcare, electricity, property rates and taxes, security and water because of the public sector failures directly attributable to the predatory political elite.

Scant chance of implementation

The NHI proposals and the legislative framework are largely unimplementable, which is why the public is advised that very little will change over the medium term.

In fact, of all the NHI puffery, this inability to implement is the only aspect that is plainly true. Not because the groundwork needs to be carefully laid with millions of well-thought-through milestones and “sub-milestones”, but because the policy framework is unimplementable.

The NHI proposals are premised on the government being able to raise an additional R300-billion in tax revenue, which, even if phased, is impossible. The money is needed as the proposals seek expressly to deny income earners the right to cover their own healthcare, regardless of the ability of the state to ensure adequate access to it.

By kicking the can down the road, therefore, the President plainly seeks to avoid accountability for a stillborn reform that has no prospects of success.

More importantly, if everyone is sufficiently distracted by his newfound pen, he clearly hopes no one will notice the absence of genuine health reforms in both the public and private health systems.

What South Africans really need to know is who the obstacle is to genuine health reform. Powerless medical scheme members? I think not.

This article was first published in the Daily Maverick.