By Leslie London
The Minister of Health, Dr Aaron Motsoaledi, gave a presentation on the National Health Insurance (NHI) at the Public Health Association of South Africa (PHASA) Conference on 12 September 2018. Although the Minister reaffirmed a commitment to a Single-payer system in his presentation, he once again referred to the need to consolidate five funding streams in moving towards NHI (see slide 16 of the presentation below). This remains a worry because it is hard to think about five funding streams supporting a single benefit package. The danger is that the separate funding stream also translates into a separate package of benefits. Once established, transition arrangements will be difficult to unravel.
There was a welcome commitment in the Minister’s presentation to starting with those who are uninsured – elderly, children, rural people, the disabled. But the benefits for these groups are unlikely to match those in formal employment or on government medical schemes. Meaning, we will have differentiation both in the financing and in the benefits package. It is hard to see how there will not be differential benefit packages if Government Employees Medical Scheme (GEMS) employees are used to a certain package of care and the uninsured will be getting a public sector package plus gradual increments.
If financing stream is the focus, then there should really be only two funding streams – those who are insured and those who are not – and within the uninsured, to start with those who are most vulnerable. The fact that the insured are separated into government employees, large employers and SMMEs (small, medium and micro-sized enterprises) is cause for concern, since even within these groups there are non-insured persons.
Although there was no mention of making medical scheme membership mandatory (cited in the July 2017 Gazette), which would amount to a rescue package (potentially with public funding) for the ailing medical schemes desperate for members, it is still lurking in the background. Nobody has said it will not happen. It would be a complete contradiction of the intention of the NHI were this to happen, since it would be using public money to prop up a fatally flawed private system that is not sustainable.
It is therefore still unclear what is intended. The Minister is able to be very inspiring on WHY we need an NHI, but we also need details on HOW it is going to work.
This presentation does not allay fears that this NHI plan will result in a ‘tiered’ system, with different packages of benefits for different socio-economic groups. Moreover, there is NOTHING about how the public sector will be capacitated to implement the NHI, i.e. nothing about Human Resources for Health (HRH) development (numbers, redistribution and skills), or about how sub-district units will be prepared for the complex process of contracting for services, and so on.
We need these plans urgently.