National Health Insurance in South Africa
Political Party and Alliance Views of National Health Insurance
The major news is the release of a document by the African National Congress (ANC) in September 2010, timed for the ANC National General Council meeting. This is the first publicly available document on the NHI proposals since the Polokwane congress in December 2007. The ANC National Executive Committee (NEC) Sub-committee on Health and Education, chaired by Dr Zweli Mkhize, set up an ANC Task Team led by Dr Olive Shisana in July 2008 to prepare a policy proposal for consideration by the subcommittee and later by the NEC. While there were two earlier leaked documents, in February and June 2009, this is the first publicly released document.
The document forms part of a larger discussion document:
African National Congress (2010). ANC National General Council 2010 Additional Discussion Documents. Section 1: National Health Insurance. September 2010.
URL: http://www.anc.org.za/show.php?include=docs/pr/2010/pr0921.html&ID=6013
“There is a strong social and economic case to implement a national health insurance (NHI) in South Africa without delay. Our 52nd National Conference in Polokwane instructed the National Executive Committee (NEC) to take forward the task of implementing the NHI. As the reports to this NGC indicate, a lot of important work has been done so far to take forward the Polokwane resolution: from the ANC NEC sub-committee report, prepared to its task-team to the development of a more detailed proposal by the Ministerial Advisory Committee on NHI. We are now a stage where we can release our discussion paper for the NGC.”
“Key proposals of the report are that NHI will be founded on the principles of the right to health care, universal coverage, social solidarity and a single public administration in which access to health will be based on need (and therefore ensuring universal free access to health care, at the point of service, to all South Africans) rather than ability to pay.”
“A publicy [sic] administered NHI Fund – operating like SARS and situated within the Ministry of Health - will be created to receive [duplication removed] funds through a single-payer system. This refers to one entity acting as administrator, or "payer", set up by the government to receive all health care funds, and pay out all health care costs for all South African citizens and legal residents through a single "insurance pool".”
“The NHI Fund will provide a comprehensive cover of health services primary, secondary, tertiary and quaternary (high-care services) which will be provided by accredited public and private providers to ensure quality health care standards. At the core of NHI would be primary health care, which is the first point of entry into the health system. The report foresees a "reengineered primary health-care system", served by teams, each consisting of a doctor or clinical associate, a nurse and three to four community health workers.”
“Membership to the NHI would be compulsory for the whole population, but the public can choose whether to continue with voluntary medical scheme cover.”
“The NHI will be in parallel with a health system strengthening plan. The improvement, expansion and revitalisation of public health-care infrastructure and services are critical to realising the principle of universal coverage and reducing inequalities of access. Much improvement in quality will be seen within the first five years.” ...
“The NGC discussions will be able to benefit from the work of the ministerial advisory committee is working [sic] with national treasury to explore NHI funding and various sources of revenue. Proposed funding methods include a surcharge on taxable income, payroll taxes (for employees and/or employers) and an increase in value added tax which is earmarked for the NHI. However, the main sources of revenue for the NHI Fund will be allocations from general taxation. All of these funds will be combined in the NHI Fund, from which all services covered by the NHI system will be funded.” ...
“Going forward, the process will kick off with wide consultations with all interested parties. This will be followed by a review of the current legislation and the drafting of new legislation to facilitate the NHI system.”
“Implementation will be phased in over 14 years, and roll out will start in 2012 in the seriously underserved areas where people have difficulty accessing health care. In a simultaneous process, various mechanisms will be put in place to, create a national heath fund, revitalise the public health infrastructure, the introduction of quality improvement and assurance programmes, and the development of human resource programmes.”
Response to announcement of NHI at ANC NGC by Patrick Craven:
http://www.polity.org.za/article/cosatu-statement-by-patrick-craven-congress-of-south-africa-trade-unions-spokesperson-welcoming-the-announcement-of-the-national-health-insurance-220920
Keynote address to the Civil Society Conference by Zwelinzima Vavi, General Secretary of COSATU, 27 October 2010, Boksburg
http://www.cosatu.org.za/show.php?include=docs/sp/2010/sp1027.html&ID=4170&cat=Conferences
On Health:
“It is the same story in our healthcare service. The apartheid fault lines persist. While the mainly white wealthy can buy world-class healthcare in the private sector, 86% of mainly black poor have to struggle to get any service at all in an under-funded, understaffed public sector where in some parts patients are told to bring their own bedding and with only Panado available, in filthy hospitals where rights of patients are hung on the wall but not their living reality.”
“Our belief is that if we were to confiscate all the medical aids, that most of us here have; if our cabinet Ministers and MPs were forced to take their children to the public hospitals and be subjected to the same conditions as the poor; if we were to burn their private clinics and hospitals and private schools; if the children of the bosses were to be loaded into unsafe open bakkies to the dysfunctional township schools; if the high walls and electronic wired fences were to be removed; if all were forced to live on R322 a month, as 48% of the population has to do, and if their kids were to die without access to antiretrovirals, we would have long ago seen more decisive action on many of these fronts.”
“So I appeal to every organisation represented here today to sign the post-World Cup Declaration, which will commit us all to: .... 4. Unite behind a goal of transforming our health system and implementing the National Health Insurance Scheme. We have to fix our public hospitals and defeat the scourge of HIV/AIDS to build a healthy nation and improve our country's life.”
Declaration of the Civil Society Conference held on 27-28 October 2010, Boksburg
http://www.cosatu.org.za/show.php?include=docs/pr/2010/pr1029.html&ID=4164&cat=COSATU%20Today
“The Civil Society Conference held on 27-28 October 2010 was a historic turning point in the history of South Africa. Over 300 delegates from 56 mass-based civil society organisations, with a combined membership of millions of South Africans, came together to rebuild a strong, mass democratic movement which will work with the people and the government to tackle the massive social problems with which we are confronted.”
“Advancing Rights to Health and Education:
Conference supported the National Health Insurance in principle, but expressed concerns regarding the model to be used, the implementation strategy and the many unknowns around the content of the NHI envisaged. We caution against an NHI bureaucracy that will become another feeding trough for the predatory elite. We call for government to publicly release an NHI policy to be discussed in an open and transparent manner.”
“While the NHI policy is developed, the Department of Health must continue to move forward on the Minister`s 10 point plan in order to strengthen the public health care system in the interim and for when NHI begins to be rolled out. Implementation of NHI must start in under-served areas where it is most needed and rolled out from there.”
“Community Health Workers are a critical component of public health care, but are exploited by the failure to respect their rights as workers. Community Health Workers must be formally brought into the health care system as employees of the Department of Health and unionised. The Department of Health must fill all vacancies and stop the practice of freezing posts across the country as a cost curtailment measure.”
“Self-regulated, industrial- and sector-based healthcare facilities should be supported and strengthened by the NHI, not undermined.”
“While National Health Insurance is a necessary intervention, we must also combat the social determinants of health, including unemployment, poor housing, stress, alcohol abuse and poor education. A campaigns committee should be formed that will co-ordinate the campaigns of labour and civil society around many of the questions that cannot be answered in the absence of a specific government plan on NHI.”
NUMSA, a COSATU affiliate, commenting on the State of the Nation address by President Zuma:
http://www.politicsweb.co.za/politicsweb/view/politicsweb/en/page71654?oid=160392&sn=Detail
“We welcome and support the following commitments made by President Zuma which are in sync with the ANC-led Alliance Elections Manifesto and electoral mandate bestowed to the current administration by the overwhelming majority of our people;.... 6. The reaffirmation to establish a national health insurance system. ....”
“We are vehemently opposed to the suggestions by President Jacob Zuma that the private hands have a strategic role to play in rebuild our public health system, through the private - public partnership. We strongly believe that through this disastrous intervention, it will reproduce the racialised and unequal health system and undermine our efforts of building peoples health-care system that puts people first as opposed to profits.”
The ANC National General Council and the SACP's Red October Campaign: Critical platforms to further consolidate the national democratic revolution
http://www.sacp.org.za/main.php?include=pubs/umsebenzi/2010/vol9-19.html
“The ANC NGC also took further steps towards the implementation of the National Health Insurance (NHI), with a determination to move even faster. We are indeed encouraged by this.”
Dr Blade Nzimande, General Secretary of the South African Communist Party, speaking at the NEHAWU 9TH National Congress, 27-30 of September 2010
http://www.nehawu.org.za/uploads/Blade%20Nzimande%20Speech_9thcongress.pdf
“The SACP was adamant that National Health Insurance (NHI) plan should not be funded through VAT because that would affect the poor but rather that it should be funded through general taxes. The rich must pay more.
Nzimande praised NEHAWU for leading the argument for NHI rather than SHI at previous congress. Polokwane and COSATU followed and thereafter government.”
DA MP calls on Minister of Health to provide the full details of the NHI programme
Statement issued by Mike Waters, DA shadow minister of health, September 22 2010
http://www.politicsweb.co.za/politicsweb/view/politicsweb/en/page71654?oid=200561&sn=Detail&pid=71616
“The Democratic Alliance (DA) calls on Minister of Health Dr. Aaron Motsoaledi to provide the full details of the National Health Insurance (NHI) programme to the public right away, or, if he is unable to, to withdraw this proposal until the details can be properly laid out. The ANC's Health Committee spokesperson Dr. Zweli Mkhize released some details of the programme yesterday. The details, however, remain very vague, and although we have now been presented with some funding details, the actual specifics of the programme remain obscure.
In addition, the Portfolio Committees on Health and Finance need to be brought into the process of formulating and costing these proposals. Parliamentarians, independent researchers, non-government organisations and ordinary citizens have a right to gain sight of the specifics of the proposals, and debate them. In the absence of this, we are faced with a situation where a potential major overhaul of the public health system is being done behind closed doors, in a fundamentally undemocratic and non transparent manner.
We are particularly concerned at the financing calculations which the task team has produced. A variety of other organisations have produced calculations indicating much higher costs, and countries which have three times South Africa's GDP have struggled with the finances of implementing the kind of system that appears to be on the table. The fact that the proposal, up until this point, has been fundamentally hidden from public view, makes the funding issue particularly concerning. The ANC says it is considering raising VAT to fund the NHI - this is a move that would disproportionately impact upon the poorest South Africans, because of the regressive nature of that tax. The ANC also says it is considering raising the funds through payroll taxes, which could push up unemployment. Any programme of this kind is bound to come at a cost, but the fact that the ANC has refrained from presenting their plans to the public means that it is impossible to engage in any of kind of proper debate about the nature of the opportunity costs involved - particularly in respect of job creation and general societal welfare.
It is also important to bear in mind that the government does not even have accurate figures on how many specialists there are working in the public sector, or what the cost is of the individual services it provides. Until a system exists for determining these kinds of figures, it is hard to obtain any idea about the accuracy of the ANC's calculations.
We agree with the ANC that reform of the public health system is urgently needed. The present system is collapsing. But any attempt at reform must be done without resorting to the creation of the sort of cumbersome centrally-controlled bureaucratic structures. All the evidence points to three central problems in our health care system:
Firstly, we need to remove the inexplicable constraints on the training of medical professionals, of which we are desperately short. These include the removal of a prohibition on training doctors in the private sector and quotas on the training of nurses by the private sector and the re-opening of nursing colleges closed in the 1990s.
Secondly, at ground level major problems continue to exist with the capacity and efficiency of hospitals, and their managers in particular. The problem is not necessarily related to funding; if every hospital were staffed with a well-trained, experienced and committed CEO, then we could make enormous inroads into resolving our major public health care problems. All too often, as was the case in the Frere Hospital scandal, it is the appointment of hospital managers based on patronage rather than fitness for purpose that is holding back the provision of quality health care services in public institutions.
Thirdly, our bureaucratic and outdated hospital management system needs to be changed to give hospital management the authority to do their jobs. Basic functions like making staff appointments need to involve far less red tape.
The DA supports some aspects of the proposals. We support mandatory contributions towards medical cover for people who are employed, because everybody has a responsibility to take charge of their own health, and because this would help to alleviate the pressure on the public sector. This does not change the fact that until the full details of the proposal are released to public scrutiny, and the financing models are properly assessed - in Parliament, by the people's representatives - we are no nearer to resolving our public healthcare crisis.”
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