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NHI: infected with doubt

Health systems news and health systems financing news, in particular, seldom get the nation talking. But the announcement of the imminent arrival of National Health Insurance (NHI) on our shores, and the subsequent release of the policy paper on the NHI, certainly did. And rightly so! For a country that spends a respectable percentage of GDP on health care but yet does poorer on health indicators than most of its economic counterparts, it was a long overdue topic of discussion.

So as I tried to keep up with the back and forth of “it won’t work” vs. “it will work”, and googled my way through the abnormal economics of health economics and battled to make sense of the graphs and diagrams that had our country’s economists furiously drawing, I wondered what all the fuss was about. Isn’t it obvious? A no-brainer? Of course NHI! Yes NHI! Now NHI! Viva NHI! South Africa’s health care system as it now stands is highly inequitable. Haven’t the researchers shown time and time again that the privileged few access health care to values almost five times higher than the poor and vulnerable majority? Hasn’t it been demonstrated again and again that our health care resources are distributed along deeply inequitable lines? Don’t we know that most of our country’s doctors are in the private sector serving a small fraction of the population while the public sector crumbles under the weight of the masses?
Why are we wasting time? Why are we not rolling up our sleeves and getting to work at making it work?

It made me angry when people said it was infeasible. How easy it must be to call it infeasible when one speaks from the comfort of hospital cover and accident cover and dental cover and travel cover and hail stone cover. The way the word infeasible was being tossed around from article to article made me wonder about what our values are as a country. This commodity that we call health isn’t just a bag of potatoes or a ton of coal, it’s who we are, it’s the thing we live in, it’s our essence. And even if there is no altruism in us, the wise economists from all over the world have shown that healthier nations are wealthier nations. So why is doing the right thing for the health of our country’s people like taking blood from a stone?

I was convinced that there was no nobler goal. I was sure, 100%. Not just sure: certain. Excited. Amped. This must work. This will work. And was quick to remind people that there were reams of examples of things in history that were said to be infeasible, and later surprised the world.

But as I sat getting ready for school yesterday morning, and listened on the radio to the scary financial mess our provincial governments have gotten themselves into, incapable of paying the laboratories that our hospitals simply cannot function without, I could no longer deny that, although still hopeful, I too was now infected with doubt.

Author

  • Kopano Matlwa Mabaso is a South African medical doctor, author and Rhodes Scholar. She is currently pursuing a DPhil in Population Health at the University of Oxford.

16 Comments

  1. Graham Johnson Graham Johnson 8 February 2012

    South Africa badly lacks management skills because it badly lacks numeracy in sufficient depth because it badly lacks quality education because our government badly lacks management.

    It’s a loop. Adding NHI will just make it worse.

    Get someone who can fix it. Soon.

  2. Geoff Smart Geoff Smart 8 February 2012

    NHI now is like putting the cart before the horse.
    First fix public health management – as in paying the laboratories.
    Then fix the public hospitals.
    And only then bring in NHI.

  3. Ivan Moor Ivan Moor 8 February 2012

    A functional NHI would be so nice, make us all feel pretty good about ourselves, kinda noble what, with all those sick little babies being saved instead of being thrown into pit latrines.

    I mean Thabo and Bob’s Britain has a good system which works damn well if you have an accident, stroke or life threatening condition.Their system seems to be our holy grail.

    If you have a condition which requires “elective” surgery such as a hip replacement things are not so good. Expect to wait a year or so for your place in the queue. Sure, it will be an unbearably painful year of immobility, but sorry, you must understand the money only goes so far and resources are limited.

    How much money are we talking about in order to fund a British NHS? Well, the Brits spend 2,000 GBP per head per year (out of taxes) to pay for socialised free health care, That is some R24,000 per citizen, but even then one still has to wait a year for elective surgery.

    We want to emulate that. Spend R24,000 per head for similar benefits. Great

    O.K., we have 50 million + citizens, times R24,000 so all we need is R1-2 trillion per year

    Hold on a sec. Is that not 20% more than our total current tax take? Is that not 20% more than Tevor Manuel says our total mining industry is worth? We cannot find a trillion bucks over a period of time to nationalise the mines but we can find one point two trillion bucks every year to run the NHI? Every year, six times more than we spend on social grants…

  4. Ivan Moor Ivan Moor 8 February 2012

    Clearly we do not have a trillion plus per year to spend on universal, free, world-class health benefits, so it is a relief to hear that the ANC says it will only cost R200 billion p.a. or so.

    R200 billion gives us one sixth of what the Brits pay per head for their NHI. Am I dof to think that, all being equal, we will get one sixth of their benefits?

    Actually the only dof thing is saying, “all things being equal” The U.K. has 3 times more doctors per head than we do (even counting our Cuban and bush university doctors), they have functioning hospitals, they have a system that works. We, on the other hand, have anarchy with dysfunctional, septic hellholes more like hospices than hospitals, staffed often by mercenary ANC cadre sociopaths.

    Alright you Thought Leader readers, tell me, “Would you entrust your wife or child to the homicidal savageries of a NHI hospital?”

    Thought not, I would rather die in peace in my own bed.I would at least die without lice, pox and sif caught from the blood-soaked bed linen.

  5. Ismail Moola Ismail Moola 8 February 2012

    The governement want NHI. They cant pay suppliers with order numbers. They cant collect fees from Folateng patients in their own beds, They cant even give the patients clean linen and food for Gods Sake. The new hospital in soweto is a dream, and yet the masses keep voting for the people who steal from them. Your naivete to even think NHI might work is bizarre, your hopes that it may work are but delusional daydreams…. The ANC is a ship without a sail or a captain – lost in a ocean of ineptitude, graft, corruption, self enrichment and BEE ( or should i say tenderpreneurship). AMADLA AWETHU

  6. Tiger Tiger 9 February 2012

    NHI is a pipe dream. I have worked in the public sector all my career. It has never been worse in Gauteng than it is now. I don’t touch patients anymore. They lie in their faeces for days. No linen. No staff. No medication. No gloves. No face masks. It is now exceptionally dangerous to work in these hospitals. Patients with resistant TB lie next to patients with Diabetes!
    25 per cent of patients are foreigners. Malaria. Cholera. AIDS. It is an indication of just how porous our borders are, and just how unaccountable government is. In short it is a nightmare, and if you cannot afford a basic hospital medical aid plan, you are screwed.
    Will NHI solve these problems? A resounding NO. There are no doctors or nurses. The doctors that are qualifying are dumbed down so much so that they cannot work unsupervised for a good period of time. They hardly learn because they see only how to treat patients when you have nothing. They all expect huge salaries simply for being a doctor. The car park at the bombed out hospital I work at is like Investment Cars. If you study for 6-12 years, work 36 hour shifts, get shat on literally, get coughed on by deadly TB patients daily, I suppose you at least want to drive home in luxury. Who wants to be doctor in SA? It can no longer be a calling in this country….
    The nurses have to cope with ridiculously overcrowded wards, and families with unrealistic expectations.
    NHI is just another money spinner and tender bender.

  7. Ernst Marais Ernst Marais 9 February 2012

    Hospital cover, accident cover and dental cover comes at a hefty price.
    The Public Health System cannot handle the billions at its disposal.
    Expensive medicines, if not stolen, is stockpiled past its “use by” date.

    The reason for our very expensive private health care is in part due to the failure of the Public Health care system. Private Health care knows it and exploits it – 1994 and efficient Public Health care is long gone.

  8. Balt Verhagen Balt Verhagen 9 February 2012

    Had work started on the beginnings of a NHI scheme at the very outset of our new democratic dispensation, in the same way as work should have started on ensuring new generating capacity for the ambitious roll-out of electricity, strengthening the then-existing vocational training institutions (e.g. nursing), by supporting and valuing their staff rather than paying them off, emphasizing technical colleges rather than closing them and creating the illusion that everyone should go to a university, strengthening education-industry relations rather than doing away with the apprentice system , and so much more, what a different country would we have been living in. The new dispensation came in on a wave of hope and idealism, and considerable sacrifices could have been elicited from the economically established population and institutions had frugality, probity, competence and hard work become the message and the official example.

    We have squandered so much of what was presented in that brief window of opportunity, those precious first 5 years. Now we have to claw back the lost ground in trained manpower, infrastructure and services at huge and often prohibitive cost to achieve the very necessary elements of a developmental state. We have, in Kipling’s immortal words, to ‘stoop and build them up with worn-out tools’.

  9. Balt Verhagen Balt Verhagen 9 February 2012

    contd…

    If we wish to achieve anything at all, the nation will have to start thinking out of the box. It will have to start questioning structures and slogans that keep it in thrall. We need a new national compact with an open agenda, a new Kliptown; to take stock of how best to unleash this country’s immense potential residing in its soil and in its people that seems to recede further and further from being realised. We still have the potential of a peaceful Arab Spring because we have the underpinnings of centuries of acculturation and of a common faith. The talents of so many who now withdraw in cynicism, anger and hopelessness could be harnessed.

    We can become ‘men’ again. Yes, we can.

  10. peter peter 9 February 2012

    Realistically, it would be better to put one’s faith in self medication rather than run the risk of entering a hospital for treatment that is managed by people who could’nt even run a trailer park decently. Paying the government more money in order to take care of one’s health never was and never will be a good idea. They do not care, they just want the money. Unable to build decent houses, unable to establish decent education facilities or sustain health laboratories, unable to maintain roads or any other infrastructure, unable to stop corruption, unable to uphold the law, unable to do much else other than to persecute instead of prosecute. Sounds ominous to me. Ag ja well no fine – can’t wait for the Presidents reading tonight. More hopey changey?

  11. Toni Benoni Toni Benoni 9 February 2012

    Our healthcare system doe snot have am obey problem. it has a skill problem. Our minister of health knows this. How to fix it is the problem. Paying more to the same nurses who steal sheets and cannot be held accountable is not going to improve anyones lot. The NHI is just another way for the ruling elite to steal more, hire more comrades and blame something “structural” as opposed to their own ineptitude for the mess we find ourselves in. then again, all those people who get shocking health services vote every 4 years for the same clowns. You get the government you deserve. And if their idiocy kills you, you deserve that too.

  12. The Creator The Creator 9 February 2012

    Surely, the problem is that a very large number of people in this country receive poor quality healthcare from the state, while a small number of people in this country receive (relatively) high quality healthcare from the private sector.

    The simplest thing to do, surely, would be to identify why state healthcare is poor, and fix the problem. It would probably cost hundreds of billions to do so, but that’s affordable over, say, a decade.

    But NHI is not about solving state healthcare. It’s National Health Insurance, which is about obtaining money. Essentially, it’s a form of taxation. As I understand it, the plan is to spend this money, not on improving state healthcare, but on giving people a kind of medical aid with which they will be able to go to private healthcare. In other words it’s a way of transferring more resources to the private sector while continuing to starve the public sector. (“Starve” in the sense that clearly more resources will be needed in order to cure the problems there, and this money will instead be going to private healthcare.)

    If this is a correct reflection of NHI, then it’s a healthcare disaster waiting to happen, and a disgusting neoliberal scam. Can anybody clear this up?

  13. Yaj Yaj 9 February 2012

    Let’s not conflate health with medical/hospital services albeit they are inter-related. Good health outcomes and healthier nations are products of a healthier economies- higher wages, higher standards of living, higher levels of meaningful employment, better infrastructure(housing,sanitation, transportand fuel/energy) and lower levels of inequality.
    If we fail to achieve a healthier economy, our medical services become overwhelmed by an escalating and excessive disease burden and the costs become evermore onerous and unmanageable- a massive drain on the fiscus. Prevention is always better than cure.
    While we definitely need a decent and accessible health medical services to cope with the current disease burden, we need to address the underlying causes of it and stem the haemmorrhaging.
    We, therefore need to do everything we can to achieve a healthier economy with better education, higher wages and standards of living etc.
    The big question is HOW are we going to achieve this given that we have an insolvent global financial system and where economic growth is constrained by limits of finite natural resources such as crude oil(the peak oil issue etc.) ?
    The answer is that the present economic system is unsustainable and increases our disease burden by concentrating wealth and increasing inequality while rapidly depleting resources and destroying the environment.
    A healthier economy can only be achieved through democratic monetary reform of the current system.

  14. Ivan Moor Ivan Moor 9 February 2012

    One can find many reasons why a NHI will not work, but the real clincher is the argument that nothing the ANC plans or proposes works, and there is no reason to think this pipe dream will either.

    Not an intellectual argument, but nevertheless unassailable.

  15. MLH MLH 9 February 2012

    Can’t imagine anyone wanting to toss the word ‘infeasible’ about when there’s a perfectly good word ‘unfeasible’ to use.

    It’s a bit like tossing the acronym ‘NHI’ around…a pipe dream.

    Twenty years ago I had a hysterectomy in Edenvale Hospital. It was okay. Most of the patients walked the corridors naked and partied half the night. Our meals consisted of a slice of bread (sorry, the grated cheese/powdered soup is finished). That was okay too; if you are sick enough a menu is not necessary, but a few vegetables are probably a good idea. The hospital at least still managed a pair of sheets and a pillowcase. But even then most of the linen had been stolen by the staff.

    It’ll be at least another twenty years before you could bribe me to use another public hospital, because I now know how bad it can get. I empathise with those who have no other option and I may soon be in the same boat; decent medical cover costs around R2 500/month these days when there is no employer to chip in. It’s scarcely affordably for retirees.

    Fact facts, this government, the one that’s been in power since 1994, couldn’t manage its way out of a paper bag, let alone into NHI.

  16. Karney Karney 10 February 2012

    In the past week I have dealt with a patient not given his post op intravenous antibiotics after a major op ( nurses too lazy to hook it up , so taken away from next to patients bedside ,unused ); a patient told by nurses that if she complained about their treatment or lack of it with 2 newborns that the died she would be transferred to a psychiatric ward and not be allowed to see her baby. ; patients who have to bribe nursing staff for their hospital food. This all happens at King Edward hospital in Durban.So no the NHI ain’t going to happen. The gvt cannot confront and deal with the powerful unions who protect ” rotten ” members.

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