Why all the negativity around National Health Insurance in South Africa?

Why all the negativity around national health insurance (NHI) in South Africa? There is so much bad news such as comments by the Solidarity Research Institute that NHI will collapse the healthcare system, the Free Market Foundation believes the NHI will be a gateway for corruption, and Alex van den Heever at Wits University thinks NHI will deteriorate both the public and private healthcare systems. In other words, South Africa should not implement NHI according to these negative views, and the dual healthcare financing and delivery system should continue, broadly divided between the public and the private healthcare systems.

National-Health-InsuranceAll this bad news seems to overlook that there is a positive side to implementing NHI. So we've compiled a list of the eight positive and eight negative aspects related to NHI. The list is not exhaustive, there's a lot more that we could add, but the purpose is to encourage a balanced and critical perspective on NHI in South Africa. For example, few would disagree financial risk protection is a crucial element of NHI, but wholesale inefficiencies in a large state-run agency may erode the benefits of averting catastrophic healthcare expenditure.

What do you think? Do the negatives outweigh the positives?

The Positives of NHI

  • Financial risk protection: no person should be rendered poor because of unexpected healthcare expenditure.
  • Reduction in out-of-pocket payments: to access healthcare services many South Africans are required to pay at the point of service.
  • Improved affordability and access to health care services: with national health insurance healthcare services that were ordinarily outside of the reach of the poor and vulnerable members of the community, will now be within reach.
  • Earlier healthcare interventions: patients that delayed seeking healthcare services may now be motivated to act earlier.
  • Sustainable care: patients with chronic conditions are less likely to interrupt medicine consumption or healthcare services due to financial constraints.
  • Improved social cohesion: all members of society are covered by national health insurance, including the rich and the poor, the young and the old, women and men, and employed and unemployed.
  • Risk pooling: by including everyone under the national health insurance system, the risk of adverse health events is spread across a large group of people.
  • Improved benefit transparency: a carefully designed and well-communicated benefits package may improve the transparency of entitlements for everyone covered under the national health insurance system.
  • Improve the quality of life: through access to essential health care services and financial risk protection, the overall quality of life of those covered by the national health insurance system will improve.

The Negatives of NHI

  • NHI depends on a strong economy: South Africa's slow economic growth and increasing emerging-market financial risk reduce the amount of resources available for the national health insurance system.
  • Inefficiencies in state-run agencies: the poor track record of state-run agencies in managing public resources, such as Eskom and SAA,  may provide a glimpse into future obstacles faced by a national health insurance system.
  • NHI requires investments in equipment and infrastructure: the quality of South Africa's public healthcare infrastructure is weak as evidenced by the report of the Office of Health Standards Compliance.
  • Available human resources for NHI: evidence suggests there are insufficient healthcare workers in the public sector to manage the future demand,  and providers in the private healthcare system are hesitant to join the national health insurance system.
  • NHI depends on strong service delivery: poor service delivery by government-run hospitals results in significant harm to patients, as evidenced by data on severe harm in Gauteng's hospitals and growing medico-legal expenses at all levels of the healthcare delivery system.
  • Strong governance facilitates NHI: the poor management of access and funding for trastuzumab (indicated for HER2-positive breast cancer patients) in the public sector, may be the canary in the coal mine of how access to new healthcare services and technologies are managed under the national health insurance system.
  • Improvements in quality-of-care boost the success of NHI: South Africa's public health care system has not implemented meaningful processes that lead to improvements in quality of care, eroding the confidence in a national health insurance system.
  • Transparent and strategic purchasing strengthen the NHI system: South Africa's serious corruption problems as evidenced by the Transparency International Corruption Perceptions Index suggests that the national health insurance system will encounter bribery, nepotism, tender entrepreneurship, and inappropriate use of public resources for private purposes.

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