NHI, the huge dilemma

"The system will then be driven down to the lowest common denominator - less medicine and equipment, fewer doctors and nurses, and broken buildings," writes Naushad Omar. Picture: Tracey Adams/African News Agency(ANA)

Back in the eighties, when I was a member of anti-apartheid health organisation, the National Medical and Dental Association of South Africa, we were all staunch advocates and supporters of a universal health care system like an NHI that existed in first world countries like England, Australia, New Zealand and Canada because no third world countries have such a system.

We were young, full of energy and extremely idealistic to right the wrongs of apartheid, especially, its disparate spend on health care, along racial lines. Today, forty years, much has been revealed about the the country’s health needs’ topography, the disease profile, the country’s economy, the astronomic levels of corruption in our SOEs and the high rate of unemployment, all of which was not known in the eighties.

We have ten million people out of a population of fifty eight million, whereas the US has six million people out two hundred million people unemployed, and they, the US still does not have an NHI.

The countries that have NHIs have unemployment rates of less than five percent, which means that they rely on a tax from the  ninety five percent of its workforce. Many of the citizens in these countries turn to private healthcare providers because they are unhappy with the services of the NHI, so what chance do we have of doing any better.

In England, a patient has to wait eight months for a scan or up to three years for a hip replacement. Many patients, who can afford it, come to South Africa for treatment, which is highly affordable for them. Tourist medical care is fast becoming a booming business for the specialist private sector in this country.

Our country’s healthcare system, unlike the countries with an NHI, apart from having a very low tax base of about ten percent, has diseases like HIV and TB, and in addition to that, has to deal with a growing range of expensive injuries due to violent crimes and motor vehicle accidents.

The reality is: we just don’t have the money to run a proper NHI. The cost of running an NHI is based on a thumb suck because there isn’t any data on the cost of treating violent injuries, which accounts for more than fifty percent of all trauma in our state institutions. If the corruption in our SOEs like Eskom, Prasa, SAA and government departments like SARs is anything to go by, then corruption in the NHI will pale into insignificance the corruption of these SOEs.

An NHI is so big and widespread, like the police force, that it is virtually impossible to police. The private sector, on the other hand, has become way too expensive for ordinary citizens. Fortunately, medical cover has been tweaked to allow poor individuals to buy inexpensive, good standards of primary healthcare. GPs are paid far less to see patients than it costs the state to see these patients, so it is a myth that the private sector at a GP level is very costly.

The main drivers of private healthcare are the hospitals, medicines, expensive and, often unwarranted, costly investigations plus the new expense of medical litigation. The policy makers of the NHI are being somewhat presumptuous, if not simplistic to say that the private sector sees only twenty percent of the population.

This is not the case at a primary care level. About fifty percent to seventy percent of a GPs patients in the townships and  in the rural areas are not on medical aid and these patients include pensioners and even the unemployed. Families club together to help their sick moms, dad’s and grand parents. Let’s not forget that millions of indigent patients self medicate and go to pharmacists.

This fact is conveniently overlooked by proponents of the NHI to justify their call for an NHI, without fully grasping the fact that we just don’t have the resources to run and fund an NHI. In an ideal world, an NHI would be a wonderful system but South Africa with its high unemployment rate, and imminent relegation to junk status, has a long way to go to afford and run an NHI efficiently.

Some of my suggestions are: contract services with GPs, Radiologists, pathologists, specialists and suppliers of medicines and supplies. Designate patients to service providers for a fixed fee. Encourage the setting up of hospitals that are not listed on the JSE; limit or tax the excessive profit incentive and high admin costs of the medical aid industry and reduce the number of medical aids.

Finally, the NHI would drive many service providers out of the country and see a huge shortage of doctors, unless the government plans to recruit doctors from Cuba and the rest of Africa.

Dr Ellapen Rapiti is a family physician, specialising in child and mental health and addiction counselling.