[Debate] 1. Zille on NHI (Gus Gosling)

[Patrick Bond]

Sean Jacobs wrote:
> Is Gus Gosling a pseudonym for a DA media spokesperson and the RSS  
> feed for South Africa's version of Politico?
>   

No worries Sean and no need for insults... because it's good to have a 
reminder of DA silliness:

> ...
>> There is no perfect health system on Earth but some are very good,  
>> including those of Canada, Singapore and Taiwan. 

The SA single-payer proposal the ANC will be announcing soon is rather 
like Canada's and Taiwan's.

Here's a good antidote:


Cape Times

Public sector badly underfunded, private sector hugely expensive
A chance to provide proper health care for all

June 18, 2009 Edition 1

Di McIntyre

The South African health system is in deep crisis. We need a major 
transformation of our health system and we need it now. Problems in the 
public health sector are splashed across the front pages of our 
newspapers on a weekly basis: patients being turned away from public 
clinics and hospitals and some dying as a result, some provinces running 
out of antiretroviral drugs, the doctors' strike, and so on.

These problems are a direct result of underfunding of the public health 
service for more than a decade.

 From 1996, government spending on health care did not keep pace with 
inflation and population growth, let alone the Aids epidemic. It was 
only in 2005 that spending levels on public health services returned to 
1996 levels. Health budgets have increased in recent years, but the 
years of severe underfunding had taken their toll on staff morale and on 
buildings and medical equipment that could not be maintained.

Although given far less media coverage, the problems facing the private 
health sector are no less severe. Medical scheme contributions have 
increased yearly at rates far exceeding general inflation, since the 
1980s. The range of services covered by schemes has declined and scheme 
members have to pay more and more out of their own pockets to cover the 
portion of the bill charged by a health care provider that the scheme 
will not cover.

A far greater share of our salaries is being consumed by medical scheme 
contributions than 20 or even 10 years ago. It is becoming increasingly 
unaffordable for South Africans to belong to medical schemes. And 
medical scheme members seem to be dissatisfied with this situation. A 
recent national household survey found that 71 percent of medical scheme 
members were willing to join a publicly supported health insurance 
scheme if their monthly contribution was less than for current medical 
schemes.

The private health sector in South Africa is rapidly becoming a mirror 
image of the US health system - a system that Americans themselves want 
completely transformed. To quote a highly respected American Professor 
of Medicine (Arnold Relman, Emeritus Professor at Harvard) "… most of 
the current problems of the US (health) system - and they are numerous - 
result from the growing encroachment of private for-profit ownership on 
a sector of our economy that properly belongs in the public domain. No 
health care system in the world is as heavily commercialised as ours, 
and none is as expensive, inefficient, and inequitable - or as unpopular 
… there is now much evidence that private businesses delivering health 
care for profit have greatly increased the total cost of health care and 
damaged - not helped - their public and private nonprofit competitors."

While the public health sector in South Africa has been drained of 
financial and human resources, the private health sector has seen 
massive increases in funding. In 1996, spending on medical scheme 
members was about 3.5 times greater than that spent by government per 
person dependent on public sector services. This gap had increased to 
nearly six times greater spending by medical schemes by 2006.

What is important to note is that although medical schemes account for 
well over 40 percent of health care funds, they only benefit 16 percent 
of the population. What this means in reality is that those who have the 
greatest need for health care do not get their "fair share" of benefits 
from using health services - what happens in one sector impacts on what 
happens in the other. A recent study undertaken by the Health Economics 
Unit at UCT found that the richest 20 percent of the population receive 
36 percent of the benefits from using health services (public and 
private) in SA, although they only account for 10 percent of health care 
needs (or the burden of poor health). The poorest 20 percent of the 
population receive less than 13 percent of the benefits but have more 
than 25 percent of the need for health care.

Some argue that these inequities are unavoidable because we have such an 
unequal distribution of income. The recent Income and Expenditure Survey 
from Statistics South Africa indicated that the richest 10 percent of 
South Africans have 47 percent of total income while the poorest 10 
percent have a mere 0.2 percent of all income - one of the greatest 
levels of income inequality in the world.

I would argue that because we have such large income inequalities, we 
must have a health system that better meets the needs of the entire 
population, and that this can only happen through a strong, publicly 
funded health system. Substantial public funding of health services, and 
other key social services, has been internationally shown to be the key 
vehicle for ensuring that all citizens have the opportunity to live 
healthy, secure and productive lives.

Substantial public funding is also in line with the 2005 call by the 
World Health Assembly for member states to provide universal health 
financing coverage " … in order to guarantee access to necessary 
services while providing protection against financial risk".

What would be the core features of a National Health Insurance (NHI)? It 
is not yet clear what the ANC proposals on an NHI will include, but the 
following are likely to be some key elements: an NHI would be universal; 
every South African would be entitled to benefit from the services it 
covers. It would be funded partly by compulsory contributions by 
employers and employees and partly by tax funds, all placed in a single 
"pool". In this way, every South African would be contributing to 
funding health care - even the poorest bear a heavy tax burden through 
VAT and other indirect taxes such as fuel levies (which are built into 
taxi and bus fares). In effect, tax funds would be used to pay the NHI 
contributions of those who are not formally employed. The rich will pay 
more than the poor, but given the massive income inequalities, so we 
should.

Some argue that an NHI will be unaffordable for South Africa, and point 
to what it would cost to extend medical scheme cover to all South 
Africans. The question is, why would we want to follow this path anyway? 
This would lead us even further down the route of the American 
nightmare, where over 15 percent of GDP is devoted to health care but 
where millions remain uninsured and unable to get the health care that 
they need (as graphically illustrated in Michael Moore's movie Sicko). 
The NHI that is envisaged for South Africa would be more akin to the 
excellent publicly funded health systems found in countries such as 
Costa Rica, where the NHI as a large, single purchaser of health 
services is able to improve resource use in the overall health system 
and to get "value for money" for its citizens.

But, for the vision of the NHI to be fulfilled, it is critical that the 
services that South Africans will be entitled to under the NHI are seen 
to be of acceptable quality. Even if the NHI purchases services from 
public and private providers, public hospitals will be the backbone of 
the system. This is not only because most of the beds are in public 
hospitals but also because purchasing a large share of services from 
private for-profit hospitals at their current, excessive fee levels is 
simply unaffordable in a universal health care system.

It was not too long ago that South Africans from all walks of life were 
entirely confident in the services provided by public hospitals. I 
believe it is possible for public hospitals to once again be regarded as 
the provider of choice of the vast majority of South Africans. Actions 
that would be required to achieve this include:

# Addressing health worker conditions of service through implementing 
the long-awaited "occupation specific dispensation".

# Increasing the staffing in the public health sector - a recent report 
by the Development Bank of South Africa indicates that compared with 
1997, we need an additional 80 000 staff in the public health sector 
simply to address the increase in the population size and the greater 
burden of ill-health from Aids.

# Address the backlog created by inadequate funds to maintain buildings, 
equipment and other infrastructure.

# Grant greater management autonomy to public sector hospitals so that 
problems arising in the hospital (eg broken toilets) can be immediately 
resolved rather than having to send requests through to the provincial 
head office.

We currently have a window of opportunity to transform our health system 
from a highly inequitable and unsustainable system to one that meets the 
health care needs of all South Africans in an efficient and sustainable 
way.

That window of opportunity is presented by the ANC's commitment at its 
policy conference in Polokwane in December 2007 and in its recent 
election campaign to implement an NHI. Strong political commitment is 
essential to successfully introduce health system change of the 
magnitude required. We must seize this opportunity and implement the 
changes required in a carefully planned and phased manner, and with 
widespread engagement and communication with the general public, whose 
support for these changes is also critical.

# Professsor McIntyre is the South African Research Chair of "Health and 
Wealth", Health Economics Unit, University of Cape Town.