NHI could be the next SARS – not the next Eskom: Crisp

 ·27 Jun 2023

Despite loud and vociferous lobbying both for and against National Health Insurance (NHI) in South Africa, the Department of Health says that citizens will ultimately have to trust that the government will get it right.

In a virtual debate on the NHI this week, Deputy Director General of National Health Insurance, Dr Nicholas Crisp, said that while the risks of universal healthcare becoming another Eskom or SAA are present, it is just as likely for the system to become like SARS or ACSA.

He said that South Africa’s public and private healthcare systems are fundamentally broken, and something needs to be done to course-correct.

He acknowledged the growing vocal opposition to the NHI as a solution, but insisted that the government’s new framework was absolutely necessary to prevent the collapse of healthcare in South Africa.

“If we continue to run what we are doing now, and we don’t make the changes we envisage in this framework, we will definitely see a complete collapse of the health service,” he said.

According to Crisp, many of the complaints and pushback against the NHI are rooted in applying concerns about healthcare today to solutions that will only be realised in 15 to 30 years.

The NHI, he said, is a framework that will rebuild healthcare in South Africa over time and not something that will happen suddenly.

However, this does not remove the deep concerns over the government’s competence to implement the NHI – nor does it address the questions around funding and the future of private healthcare.

“(State competence is) a fair concern and a fair comment. I’m a citizen like everyone else who has the same concerns; who shares the same issues with South African Airways and Eskom and so forth,” Crisp said.

“But we have to plan for the future – we have to take responsibility for fixing the things that don’t work. We don’t fix them by 1 April next year; we fix them on a continuous and ongoing basis,” he said.

“Can we fix what is wrong? Yes, we can; we’ve done it before. We have good organisations in this country. Every now and then, someone has an attack on them, but look at SARS today – also an entity of the state – and today it’s fine. The airports company (ACSA) runs efficiently and hasn’t been in trouble.

“There are many of them (state-owned companies that are not in trouble). Unfortunately, there are these few that are bad apples and have given us all grey hairs and made us all unhappy.”

The big change

According to Crisp, the fundamental problem with public and private healthcare stems from inequality.

The public sector is unable to retain skilled doctors and nurses to serve the greater public interest because they are drawn to the more lucrative private sector, which has been largely unregulated, particularly in pricing, and serves a small portion of the population.

Complexities and inefficiencies bog down public healthcare on a structural level, where provincial health departments have no control over disparate parts – like human resources, infrastructure, etc. In addition, corruption has also become rife.

Thus, the public sector has become inefficient, delivers no value for money and provides poor quality of care.

The private sector, meanwhile, has become a “free-for-all”, with hundreds of packages and schemes that only a few benefit from. Crisp noted that most people on private medical schemes are on hospital packages and have to pay out of pocket for their day-to-day needs anyway – something the NHI will resolve.

Crisp said that the NHI’s ultimate goal is to do away with these complexities and simplify healthcare by making the state the sole procurer of healthcare services from accredited healthcare providers – public and private – covering a single package of services.

Private healthcare

In the government’s lofty NHI dream, private healthcare is part of the system rather than isolated from it. However, the role of other private service providers – like medical aid and medical insurance – are significantly diminished.

The medical aid industry has raised this on several occasions and the problem has even been flagged as a constitutional issue by Parliament’s legal advisors: implementing the NHI would remove freedom of choice from those who would prefer to seek private healthcare.

However, Crisp hit back at the notion that the NHI was seeking to kill private healthcare in South Africa, insisting that there will still be choice – just not as much of it.

He said that when it comes to freedom of choice, decisions aren’t made based on public health needs but rather on who has the money to pay.

This isn’t necessarily a bad thing where society is more equal, but in a country like South Africa, “where inequality is the worst in the world”, the private healthcare sector will invariably drain all the resources (skills, development, personnel) from the public sector.

But even so, he said the NHI doesn’t remove the private sector, rather it creates a single package of services, and anything outside of those services – things deemed unaffordable or unnecessary – can be covered privately.

Despite Crisp’s views and assurances, however, there is a long way to go to convince healthcare professionals, businesses and taxpayers that the government can deliver – especially given its poor track record.

Dr Eric Buch – Health Policy in Management at The University of Pretoria – said that the NHI’s greatest risk is falling to corruption. Somewhat ironically, however, he said that the scheme also holds the greatest hope of getting rid of corruption.

He said the system might be able to deliver the necessary structural changes needed for healthcare in South Africa to finally start working for the people – but it is up to the government to actually follow through and deliver.

Read: Parliament raises more red flags about the NHI – government unbothered

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