Desperately seeking health reform - Is 'NHI' the answer?

Kate Francis, a Researcher at the Helen Suzman Foundation wrote a piece for on the National Health Insurance Green Paper. You can read the article here and watch the corresponding interview.

If 2011 was the year of headlines of despair on South Africa’s poorly functioning public health system, from mismanagement and corruption, to preventable deaths, 2012 needs to be the year of carefully considered health care reform. The key question is this: can the National Health Insurance (NHI) Green Paper, released by the Department of Health in August last year, steer South Africa toward improved quality and access to health care? Careful analysis of the Green Paper conducted by the Helen Suzman Foundation suggests that it will not. The Department of Health thus needs to take this opportunity to begin a dialogue to collaboratively, creatively and openly establish more suitable and strategic health reform policy.

South Africa’s health outcomes have historically been plagued by policy stagnation, a lack of positive and practical action and failure to hold those responsible for preventable deaths and poor management to account. Attempting to implement an inappropriate policy at this stage may well result in further deterioration of a health system which is in dire need of constructive and practical reform.

The Helen Suzman Foundation’s analysis reveals a number of flawed and inappropriate strategy proposals and a lack of clarity as to what is actually being put forward. The following are some of the most concerning issues and proposals contained in the Green Paper.

Firstly, the exact meaning of ‘NHI’ is not clear from the Green Paper. It is not clear if it is a funding mechanism or, rather, a substitute for the entire health system. Such use of the term ‘NHI’ without adequate definition creates meaningless rhetoric and is not useful in policy development. This article thus refers to the ‘Green Paper proposals’ rather than ‘NHI’ as such.

The second red flag, and a major concern, is that although acknowledging many of the problems in the health system, the Green Paper fails to provide evidence-based links between South Africa’s poor health outcomes and their causes. The Green Paper cites the two-tiered health system and inequalities between the public and the private sector as the root causes of the majority of South Africa’s poor health outcomes. While these factors may undermine an attempt at creating an equal society, it does not follow that inequality itself is the cause of poor health outcomes. The Green Paper thus fails to take into account the systemic, institutional problems evident in both the public and the private health systems.

The Foundation’s analysis shows that lack of governance and accountability, ineffective monitoring and evaluation, poor management, lack of implementation of existing policies, over-centralisation and corruption are primarily responsible for the poorly functioning public health system. In the private health sector, market imperfections as a result of hospital market concentration (through corporate ownership of multiple hospitals), lack of price competition and lack of effective regulation are to blame for rising costs and inefficiencies. If the Green Paper does not correctly and accurately diagnose the causes of South Africa’s poor health outcomes, how can it hope to propose the reforms required to improve the lives of millions of South Africans?

A third concern relates to the lack of detail in the Green Paper. Too many statements and claims are not supported by evidence or appropriate references. Such oversights lead one to question the validity of the policy proposals. Citizens and stakeholders need to urge the Department of Health to provide clear and reliable evidence to demonstrate that its proposals will improve the ability of South Africans to access health care. Without such evidence it is difficult for the general public engage meaningfully with the Green Paper.

The Helen Suzman Foundation also identified lack of management capacity as a key cause of South Africa’s poor health outcomes. Although ‘management’ is mentioned several times throughout the Green Paper, very few practical reforms are suggested and the focus is rather on increasing health spending as a solution. This is concerning as the Foundation’s analysis shows that South Africa’s spending on health is comparable to its peer countries, yet those countries have far better health outcomes. South Africa’s health system is thus clearly underperforming given the level of health expenditure. This suggests that management, not money, is the problem. Discussions around the Green Paper should thus be seen as an important opportunity to learn from best practice and to correct substandard management in the health system.

In a constitutional democracy, evaluating any health reform policy entails determining whether it will improve the constitutionally enshrined right to access health care. It is thus difficult to support an initiative which is only thinly based on evidence and does not provide adequate justification for how its policies will achieve improved access to, and quality of, health care. Creating and implementing health care reform is a complicated process and international experience highlights the benefit of wide stakeholder consultation, a feature troublingly missing from the government’s development of the Green Paper.

South Africa has reached the stage where it cannot afford not to develop and implement the correct reforms to the health care system. It is vital, however, that reforms are discussed and debated in a transparent manner, with broad-based consultation and sober acknowledgement of the real challenges facing the health care system. Open, creative and considered discussion is the only path to ensure improvement in our right of access to quality health care for all South Africans.

Written by Kate Francis, a Researcher at the Helen Suzman Foundation.

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