A woman in labour is rushed to the hospital. Her panic-stricken husband calls ahead to alert the nurses of their imminent arrival as he weaves his way through traffic. On arrival, the patient is whisked up to the maternity ward while the husband is detained for paper work. He produces a card with his medical insurance details and completes the required paperwork. Within half an hour, he is led up to the room just in time to witness the birth of his fourth child.
That scene is played out regularly in the United Kingdom, while South Africans are inundated with stories such as the recent one of a Free State mother who is suing the Department of Health (DoH) after she gave birth to her baby in a hospital corridor and the baby died.
In Grahamstown, a young mother gives birth to a beautiful baby girl in the pristine maternity wing at Settler’s Hospital. Fortunately for her, the public wing of the hospital is staffed by community service doctors and clinical associates – doctors in their final stages of training – who work at the hospital full-time and provide neo-natal services free of charge.
Infant mortality rates and maternal mortality rates are two of the most important indicators of a functional healthcare system. South Africa ranked 125th out of 164 countries in a study published in the British medical journal Lancet in 2010, and it is consistently among the worst performing countries in the world.
According to a 2011 DoH report, 310 out of 100 000 women died during childbirth and 40 out of 1 000 children born that year died.
However, in August 2011, Health Minister Aaron Motsoaledi announced plans to introduce a National Health Insurance (NHI) fund to address the nation’s healthcare system and provide universal coverage for all South Africans. The announcement sparked widespread debate, with many experts doubting the government’s ability to deliver.
Dr Diane McIntyre, who served on the Ministerial Advisory Committee on National Health Insurance, was at Rhodes University recently for the annual AB Xuma Memorial lecture. She told italGrocott’s Mail/ital that she believes South Africa has no option but to adopt a universal healthcare system if the country hopes to overcome persistent inequality and ensure equal access to quality healthcare at an affordable price.
McIntyre said the two reasons for introducing the NHI fund were to give poor South Africans access to adequate health care, and to tackle the increasing cost of private medical care.
“It is fundamentally important that all South Africans are able to access the same healthcare benefits regardless of their socio-economic standing,” McIntyre said. “It comes from an understanding of healthcare as a basic human right embedded in Section 27 of the Constitution.”
According to McIntyre, the majority of stakeholders recognise the need for a national health system that provides universal coverage, however there is debate about how it will be funded. According to the DoH policy paper, revenue would be collected through a mandatory health insurance contribution. The department is evaluating proposals on whether to introduce additional VAT or whether contributions should be based on percentage of salaries. The latter is the model used in the United Kingdom, which is considered to have one of the best public health systems in the world.
In the UK, the National Health System (NHS) is primarily funded through the general taxation system. Up to 20% is deducted from the salary of every working citizen and legal immigrant as a national insurance contribution. A portion is allocated to NHS, which provides every fully registered member with an NHS number, to access the full breadth of emergency and primary health services, as well as specialist services such as cancer and HIV treatment without any out-of-pocket payment of any kind.
In South Africa, the situation is entirely different.
“The real problem in South Africa is that we have an incredibly small pool of taxpayers,” said Reg Rumney, director of the Centre for Economics Journalism in Africa at Rhodes. “This is a reflection of the huge inequalities in the system. That small pool of taxpayers has to bear the burden of personal income tax, and many of them are already resentful because they don’t see the benefit of the tax they do pay already.”
According to Rumney, the middle class doesn’t have confidence in public health services, and so feel that they are forced to pay for private healthcare in the form of medical aid. Yet the rate of inflation in medical aid contributions means that this won’t be sustainable in the long term.
“We just won’t be able to afford medical aid if medical aid contributions continue to increase at this rate,” Rumney said.
In terms of the costs, McIntyre said that research showed only 16% of South Africans are members of medical aid schemes, but that they paid up to R11 300 per year for health care services. An additional 16% were not covered by medical aids but paid nearly R2 500 to private providers for primary health care services, while 68% of South Africans were totally dependent on the inadequate public health system.
The system is plagued with countless problems ranging from poor infrastructure to ill-equipped personnel, mismanagement and corruption.
McIntyre acknowledged that in order to achieve universal coverage the current healthcare system would have to be completely overhauled. She said that government was taking a phased approach to the implementation of the NHI. In phase one, resources to hospitals would be improved. This would involve an audit of facilities, equipment and human resources, as well as re-engineering the public health system by bringing healthcare closer to the people by introducing mobile clinics within the next three years.
Already underway are 11 pilot programmes in all nine provinces, including the OR Tambo district in the Eastern Cape. The health department has allocated R2 billion for the refurbishment of the Nelson Mandela Academic Hospital in Mthatha as part of a drive to overhaul South Africa’s health facilities in preparation for the NHI.
Grahamstown is one step ahead, however, providing a model for both inpatient and outpatient care. Settlers’ Hospital is a private-public partnership between the DoH and a private consortium, Nalithemba Hospitals, that offers healthcare services for both private and public clients side by side. Its facilities were upgraded in 2010 and include a new theatre complex, including a third theatre and a recovery area. The accident and emergency sections were improved and an outpatient wing added. As part of the modernisation process, all out-of-date equipment at the hospital was replaced by state-of-the-art medical equipment.
But the Settlers’ Hospital project did not just involve the upgrading of the hospital. The private consortium took responsibility for managing both public and private facilities for the next 15 years, including providing services such as catering, cleaning, linen and laundry, maintenance and replacement of facilities and equipment.
Elsewhere in the Eastern Cape, hospitals are still in complete disarray. An article appearing in the italMail Guardian/ital Online in June by health journalist Mia Malan quoted a doctor saying that “all the money in the world will not be enough to fix” the hospital system in which many patients, physicians and even government officials believe is rife with bad service and corruption.
Even Motsoaledi is on the record saying that one of the biggest problems with the public health system was that it had become a “tender-care” system.
Speaking to Grocott’s Mail, Malan said the NHI simply isn’t feasible given the current state of the healthcare system. “If we can’t turn around public healthcare, there will be no way that the NHI will work. The fact that there will be more money in terms of tax revenue collected doesn’t mean that the system will be better. Ineffective administration, particularly in the Eastern Cape, is the biggest problem.”
Acting CEO of Fort England Psychiatric Hospital, Dr Roger Walsh, on the other hand, is optimistic. He believes that the NHI could work but only if drastic changes are made. Walsh, who practised medicine in rural areas in the former Transkei and KwaZulu-Natal for 15 years agrees, however, that there is a lack of qualified personnel in the right positions to administer the healthcare system.
“In the past hospitals were run by middle managers who had no medical training,” Walsh said. “There is now a move to have healthcare professionals in charge of administration. This is a step in the right direction. “But it will be important to attract doctors to rural areas where primary health care is needed most,” he continued. “The government must make it attractive for doctors to move outside of cities. This means they will have to pay healthcare professionals properly, and on time.”
McIntyre said that payments to suppliers and healthcare personnel were part of the immediate plan to fix the healthcare system, and that the second phase, introducing the NHI fund, would happen in five years. She said the system would be in place in 14 years but warned that if government didn’t achieve its goals, taxpayers could face a huge financial burden as a result of the spiralling costs of healthcare.