While it supports the concept of universal health coverage and access to quality healthcare for all South Africans, the South African Private Practitioners Forum (SAPPF) does not support the National Health Insurance (NHI) model chosen by the South African government.
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"We believe that the proposed NHI model will cause irreparable harm to the entire South African healthcare industry if the content of the current NHI Bill and NHI White Paper Policy is implemented. SAPPF is also concerned by attempts to implement NHI without the government providing any clarity on what the initiative might cost and how it will be funded in the current economic climate," says Dr Chris Archer, CEO: SAPPF.
"Once again, we refer you to the attempts of Ireland to implement NHI which were scrapped four years after a White Paper was published. The costing of the model proved unaffordable for Ireland “now or ever” and the Irish NHI was scrapped, with alternatives now being considered. The fact that the South African NHI Bill is published in order to “achieve sustainable and affordable universal access to quality healthcare services”, without any costing of the model having been published in the 10 years since the inception of the scheme, is disingenuous at best and a gross failure of due diligence at worst."
Services basket would be compromised
The SAPPF concern stems from the belief that implementing this NHI model in an environment, which is not able to afford a very comprehensive NHI service basket, will lead to the majority of South Africans having access to less comprehensive health services than is currently the case in both the public and private sectors. This would not be the progressive realisation of healthcare that is demanded by Section 27(2) of the South African Constitution. All indications have suggested that the service basket would be adapted to the available budget, which could lead to an ever-shrinking set of services being made available to users.
Section 33 of the Bill indicates that medical schemes will only be allowed to provide complementary cover, for services not reimbursable by the NHI Fund. Services rendered by an uncontracted private provider will not be reimbursable by the NHI fund and would therefore form part of such “Complementary Cover” which medical schemes may provide. Section 3(3) of the Bill indicates that the NHI Bill supersedes almost all other legislation.
This would imply that the Medical Schemes Act and the registrar of medical schemes will not be able to limit the ability of scheme options to pay for such uncontracted services, which are not reimbursable by the NHI Fund. This is seen as positive step for private practitioners to be able to make the choice of whether they want to contract with the NHI fund or not and still being able to render services to South African patients, even if not contracting with NHI.
Presidential Health Compact
SAPPF remains concerned with the ability of government to successfully implement the Presidential Health Compact to radically improve the quality of the public sector. Failure of the Health Compact to turn around every facility in the public healthcare sector, will mean that the public sector facilities will not be of sufficient quality to contract with the NHI Fund. The continued implementation of the NHI, without confirming that the Presidential Health Compact was successful, could do immense damage to the Healthcare system and could result in a shortage of public sector service providers for the NHI Fund to contract with.
"We find it unlikely that incumbent managers, who have overseen large scale state failure for many years, will implement the Health Compact successfully and turn around the public sector," he says.
The Bill remains vague on the compensation of private practitioners under NHI, only indicating the minister may make regulations pertaining to such reimbursement models. The indication of specialists forming part of DRG reimbursement in private hospitals, raises the concerns associated with doctor employment in private hospitals. In a 2017 survey amongst SAPPF members, 54.7% of respondents indicated that they would not want to be employed by hospitals. These figures should serve as a warning on sentiment of employment amongst doctors and reimbursement models and regulations that do not require such employment should be forthcoming with utmost speed, prior to any reimbursement models being implemented which propose and force the employment of specialists by hospitals.
Socioeconomic impact assessment
The NHI Bill in its current format is still too vague and ambiguous on many aspect pertaining to the NHI, and unless certainty and clarity is forthcoming very soon, the Bill, combined with the current economic climate, could lead to South Africa losing many healthcare practitioners and tax payers to the overseas employment market. SAPPF urges government to reconsider the proposed NHI model until such time as a costing of the system under NHI has been forthcoming and considered in light of the current economic duress in South Africa.
It is also of utmost importance that alternative models of universal health coverage, which consider the practicalities and South African environment, be considered. A socioeconomic impact assessment of the current Bill should not focus on comparison between NHI, the status quo and full privatisation, as no one is proposing the healthcare status quo or full privatisation as alternatives to NHI. Instead, the SEIAS should do an honest assessment of the socioeconomic impact of NHI in our fiscally strained environment and compare it to other proposed UHC systems which has been put forth by various stakeholders, including SAPPF.
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