South African think tank the Center for Risk Analysis (CRA) this week held a debate on the viability of the government’s National Health Insurance scheme, which it says is moving ahead despite concerns from private and public health stakeholders. .

Last week, the Department of Health’s deputy director-general, Dr Nicholas Crisp, told the Sunday Times that both the public and private health sectors in South Africa were in bad shape, adding that “one looks better than the other”.

Crisp said the country had two parallel health systems and the NHI was a project to link the two systems together in a “major multi-year program of health system reforms going forward”.

He said the country spends 8.5% of its budget on health and has the 35th largest economy in the world, but it has poor health outcomes. He said it is even worse because the country has two health care systems, both of which are not functioning well.

Speaking to the CRA, Michael Settas, managing director of health insurer Cinagi and head of health policy at the Free Market Foundation, said the attempt to paint the private and public sectors as “equally bad” was a failed attempt to make a clear case for why the NHI should to exist

“The private sector has problems, there’s no doubt about that. But we did a six-year investigation into the healthcare market… and it came up with a plan to fix it. It is unfortunate that the plan has been shelved to be replaced by the NHI – which is largely driven by ideology,” he said.

Settas noted that very little feasibility study has been done for the NHI, and to date no costs have been incurred. At its core, the NHI simply wants to nationalize the private sector and merge it with the public sector, Settas said.

The CRA posed the question: If the NHI had access to all the public sector cash resources – especially healthcare – would it be able to solve the problems in the public sector?

Throwing money at the problem isn’t the solution, Settas said, because the foundations of public health are broken. “The political answer to everything is ‘more money,'” he said.

“This fundamentally ignores that the public health sector budget doubled from 2000 to 2020 – in real terms and per capita. This is a huge increase in resources. So if the argument is that it’s a resource problem, why aren’t public sector outcomes better than they are?”

“All we see every day is a recession. There is always a publication with some public sector failure story. It becomes so obvious that it is impossible to ignore. To say it’s a resource issue is complete nonsense,” Settas said.

The same can be said about personnel, he said. A review published in 2020 showed that the number of health workers employed by the state is 50% higher than in 2006.

“It is also a significant increase in human resources. We need to get better health outcomes. The trend should be upward, improving, due to the massive increase in resources. But we don’t see it.”

Settas said the problems in South Africa’s health sector – particularly in the public sector – stemmed from failing foundations.

“There is just a complete lack of management. The frameworks have either been dismantled or removed and there’s just no governance or accountability in the (health) department, which has led to things like widespread underpayment of medical staff,” he said.

Settas cited a 2014 Wits University study that found two-thirds of nurses in South Africa reported working overtime and part-time work that posed a risk to patient care.

“NHI is not going to fix these things. You can throw more money at a dysfunctional system, it won’t fix it. You have to fix the basics – management and similar issues. If you can fix that, then you don’t need the NHI, you fix what’s there.’

“What people don’t realize is that South Africa’s public sector is a very significant asset – by far the largest health system on the African continent. By miles. We must do much better. I agree with (Crisp) here. But I don’t agree that the NHI is the way to go.’

Settas said that health systems take decades to build and that the NHI is more of a political tool used by the government between election periods. He also said the conversation should move away from “building” a new health system in the country because South Africa doesn’t need to do that – it already has one.

“(NHI) is all about selling the political aspect, but we don’t need to sell it. What (the government) has to sell is that we have a very strong health care system that has a lot of problems, but the assets are still there and we haven’t lost that.

“Let’s fix this, we’re going to have a lot more success than trying to build this ‘new system’ which, even if they can build it – and I don’t think they can – will be decades away.”

Read: Here’s how private health benefits can work with South Africa’s new NHI

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