By Nicolien Welthagen and Morné Malan
The NHI, as envisaged at present, will be the largest state institution in the history of South Africa. Given the omnipresent mismanagement in state institutions, this is an immense source of concern.
It is not clear how the purchasing and management of assets, medication and equipment are going to work, or how and by whom it is going to be distributed. The fact that the state will be the sole purchaser means that any errors in this regard could have drastic consequences. A central fund has to be managed perfectly to be effective. When the risk is spread among a multitude of funds and institutions, some of them could intervene and make up where others fail.
The question as to how maintenance of infrastructure and equipment will be managed remains unanswered. Also, it is not clear what incentive state hospitals or practitioners will have to maintain equipment that is not funded by themselves, or how health practitioners will be motivated to improve their service if it is not linked to any tangible reward.
Effectiveness of the sector will be hampered by the immense bureaucracy the fund will require. Orders, repairs, shortages, etc will be delayed because everything will have to be channelled through one central body.
The approximately 33 000 private health bodies will have to be accredited before 2025. It is unsure by whom and how this is going to happen.
Healthcare workers in the private sector will be forced to work in the public sector at rates determined by the NHI. This socialist type of system will bring about equal pay, removing incentives to perform. The need to be effective and excellent will disappear because doctors will not be able to work for themselves and build their own practices. Competition among private hospitals will disappear. Furthermore, it is in conflict with the Bill of Rights (as contained in the Constitution) to force people to join the NHI and pay for it. Section 18 of the Constitution guarantees everybody’s right to freedom of association. You cannot be forced to join any fund, club, scheme or association you do not want to join.
No-one knows how and where training will take place. “One of the things we are going to demand is that teaching hospitals be removed from the provinces. They must be governed nationally,” Motsoaledi said. In addition, the face of emergency services would change under NHI, he said. “All ambulances must have the same colour so the country doesn’t have so many diverse services.”
The SA Institute for Race Relations (SAIRR) says the white paper ignores the main causes of the inferior state institutions and makes a wrong diagnosis of problems, resulting in a misrepresentation of how to address and solve these problems.
Numerous studies indicate problems with qualifications, skills and attitude of staff, staff shortages, long waiting periods at state hospitals and clinics, hygiene, shortages of equipment and medication, infection control, and safety of staff and patients. Other problems relate to poor control and management, as well as poor accountability, lack of discipline and non-compliance with policies.
A worrying report by the Office of Health Standard Compliance was released on 5 June 2018. It inspected 696 health facilities. Of these, 172 were “critically” non-compliant with standards, and 240 had serious concerns: that is, nearly 60% of the facilities inspected were in poor shape.
The Treatment Action Campaign (TAC) released a study in November 2017 that monitored 254 health facilities across the country. The TAC claimed that “less than half of facilities were considered to have sufficient staff” and in 34% of the facilities, patients waited for over two hours to be served.
How are private hospitals going to accommodate a large number of new patients? Any increase in patients will have to be accompanied by an increase in medical staff. There are already huge shortages of medical staff in South Africa.
South Africa has an extraordinary disease load the state has to carry at present as a result of HIV and TB, and an increase in patients will cause the quality of care to deteriorate even further.
The first phase of implementation, possibly targeting women, children, the elderly and persons with disabilities, over a period of four years, could cost R69 billion.
It is estimated that extra tax amounting to R368,8 billion will have to be collected by 2025 to provide for the NHI. After this date, taxpayers will have to pay an additional R156 billion every year. This is estimated to double South Africans’ present medical budget.
Additional tax amounting to 5% of gross domestic revenue will be required.
Various options are being considered, including automatic tax addition (1% – 2%), automatic deductions by employers (1,5% – 4%), or charging premiums.
Who is going to have the powers to appoint medical staff, how will it be done, where are they going to be appointed and how many will be appointed at what rates?
According to Minister Motsoaledi, at least three times as many doctors as there are now will be required to implement the NHI. At present, South Africa trains 1 200 doctors every year at eight medical faculties (Cuba trains 4 000 doctors at 21 institutions every year). Such a radical increase in doctors within the next decade is highly unlikely.
In addition, 25% of all doctors who have completed their training in South Africa, leave the country. There is currently a total shortage of 83 000 healthcare workers in South Africa. Filling the posts that are vacant now will cost about R40 billion. The Department of Higher Education and Training does not have the capacity to deal with this problem.
There is a real risk of health workers, especially doctors and specialists, emigrating as a result of the NHI. A real loss of medical technology and capital in the private sector may take place, which could result in lower standards.
Deur Cilleste van Dyk Ek skryf vandag die derde opeenvolgende brief vir julle vanuit my woonkamer-kantoor, maar tog voel dit vir my soos ’n keerpunt. Ons is uiteindelik op vlak 2 van die inperking en dis byna asof daar weer ’n mate van normaliteit terugkeer. Die klein bietjie meer vryheid het my laat besef dat […]
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