Roseanne Harris, who is leading the Business for South Africa (B4SA) National Health Insurance project, says the rush to push the NHI Bill through without considering B4SA’s input could delay the implementation of a workable universal health-care system for “decades”.
The bill was passed by the National Council of Provinces (NCOP) on Wednesday after being approved by its select committee on health & social services in less than an hour.
“It does seem as though the impending election is what is driving this because the NCOP process has been very rushed. There is no evidence that the select committee has even considered our very detailed and constructive written submissions. There was no deliberation on, or even mention of, those submissions.”
The bill has “massive ramifications” for the country, which makes the refusal to engage with its pros and cons “really concerning”.
“In a project of this size and complexity, one needs to work really carefully through what the implications and ramifications are, and particularly the unintended consequences.”
The determination of the department of health (DOH) to run NHI alone could spell disaster for the country, says Harris, an adjunct professor of actuarial science at Wits University and head of policy and regulatory affairs at Discovery Health.
“The challenge is the resources that are available to them to be able to work through it, and that's why we are pleading for a collaborative approach. In the private sector we have expertise in structuring benefits, assessing data, developing treatment protocols, and managing a benefit structure.
“We're not saying, 'We've got the answer and you just need to listen to us.' It's more a case that this is a massive project, it's massively important for the population, and it's something we need to embark upon together.”
If the B4SA proposals were adopted, the country could move forward with something “far more workable” that would start immediately making a difference to health-care access, “rather than something that's going to take decades, if it happens at all, because its feasibility is in question”.
The biggest threat to success is the department's fixation on seeing business as the enemy of NHI.
The restriction on the role of medical schemes is not necessary and it impedes us working together
“We're not anti-NHI, we're supporting the establishment of the NHI fund. What we're saying is that a single-fund model is not appropriate for the best interests of everyone in South Africa.”
Nobody knows yet how much NHI is going to cost. Deputy director-general of the NHI, Dr Nicholas Crisp, says it will be not much more than R400bn, but Harris responds: “I would love to see that analysis. Surely a public participation process involves engaging on what those numbers are.”
The last numbers published, in the white paper of 2017, are from 2010.
The cost of NHI will depend on what benefits are available, Harris says.
The DOH speaks about taking an incremental approach to benefits, which will increase over time as affordability permits.
“But what drives affordability is the need to grow the economy, because that's what will enable us to afford more. The difficulty is, if you're taking away benefits from people who currently have them through their medical schemes, you have to have some certainty of what that trajectory looks like, and that we don't have.
“The alternative is you take an incremental approach on a more integrated, multifund model and that way you can manage how the benefits are moved across into the NHI fund without it having to be damaging to the rights of medical scheme members.”
This is not about looking after medical aid members at the expense of everybody else, she says.
“If a portion of the population are funding themselves for these benefits, there is more available to fund everybody else. So everybody is better off than in a situation where you're trying to spread the public resources over the whole population.”
One of B4SA's biggest fights with the DOH has been over section 33 of the bill, which spells the end of private health care for 9-million medical scheme members.
“The restriction on the role of medical schemes is not necessary and it impedes us working together. We could rather be developing plans to get decent health care to people than deliberating on something that might only happen decades hence.”
There is no contradiction between fighting to preserve the rights of medical scheme members and “completely agreeing” with the need to address inequality in access to health care, she says.
“The challenge is that you don't achieve equity by putting everyone in the same pot. You achieve equity by creating appropriate cross-subsidies, by leveraging those who can afford to provide for themselves to do so and potentially cross-subsidise those who can't afford to do so.
“What you want is to make sure that you're managing cross-subsidies in an appropriate way, and that's what we're appealing to DOH to consider in a more integrated, collaborative approach.”
Harris says there's a need for a “reality check” on the arithmetic.
“I've heard lots of politicians talking about NHI as if it's a big medical aid with unlimited benefits. Of course it would be wonderful as a country if we could afford to do that, but we simply can't.
“Even with heroic assumptions of what we can collect in taxes, the scope of benefits is going to be extremely constrained. That's the reality of the arithmetic.”
Another necessary reality check is around the skills and expertise required.
“The complexity of managing a universal health-care system is immense. If you have a risk pool and you're not managing it in a sound way, then that's when things start going into a spiral.
“A risk pool is when you're putting a lot of people with different health statuses into a single pool with a common set of benefits. You need to manage it so that the people get what they need when they need it.”
Crisp has conceded that it will be hugely difficult to get the right people in place to run NHI.
“The fact is you have people with those skills and expertise, and it makes absolutely no sense not to take advantage of that.”
She says the constitution provides for President Cyril Ramaphosa to send the bill back for reconsideration if there are constitutional concerns, “which we have highlighted there are. So this is not a done deal.”
