So many questions: Professor Alex van den Heever
The National Health Insurance green paper was released this week. Chris Barron asked health economist Professor Alex van den Heever of the University of the Witwatersrand school of public and development management ...
Is NHI premised on the notion that more money will fix our public health system?
It's premised on two questionable notions. One is that more money will solve the problem. Second is that, because people in the private sector spend around 3% of GDP on medical schemes, that legitimises the introduction of taxation equivalent to that 3%. When they say more money is the problem, the question is, where would it come from? They're saying because people are prepared to spend 3% of GDP on medical scheme contributions, they'd be happy to pay 3% of GDP in taxes to a public system.
Is there any justification for that argument?
Very little. The types of revenue that are raised in the two different systems have a completely different logic associated with them. The people who are contributing to private medical schemes are the same people paying taxes for the public health system as well, but don't use it.
Government argues it isn't fair that so much public money should be spent on the private health sector...
Public money is not spent on the private health sector.
What about tax rebates for medical aid contributions?
This is a subsidy equivalent to the amount of public services medical aid members are not using, but still pay for. The point of the rebate is also to incentivise people to become part of a prepaid system so they're not left out of pocket in the event of a catastrophic health expense. So it's nonsense to use that as an argument.
Will throwing more money at our health system cure it?
Governance and accountability structures are not addressed in the green paper - how the hospitals will be run. We have a system that is designed to fail regardless of how much money you put into it. You can double the amount of money going into our public hospitals and you will get nothing more out of them. There is nothing in the proposals that shows how they're going to be turned around. There is no reference to international best practice, to making them independent, autonomous, depoliticised structures. If you don't do this they won't change.
What about assurances that the calibre of hospital managers will be improved?
Even if they are appointed on merit, if you don't have a proper governance and accountability mechanism within which they report and operate then even a good person will perform badly.
What about the proposed office of standards compliance?
Is the framework proposed independent, impartial and free of ministerial control? No, it is not. A structure that is not independent of political influence will be unable to achieve or perform its function. The proposed structure fosters patronage rather than accountability, which is the current problem.
Will our NHI be like the National Health Service in the UK?
No. In the UK you have a decentralised administrative system, the hospitals are autonomous, they have very strong governance structures, strong resource allocation mechanisms. They don't have a central payer.
Whats wrong with the proposed central procurement system?
It will be equivalent to putting a brand-new BMW with the keys inside the car in Hillbrow. What they're proposing is a centralised fund with a politicised governance model able to interfere in the procurement of stuff to the tune of 6% of GDP throughout the entire country. Every health provider would be beholden to this central structure, every single medical devices or product company could be forced to pay kickbacks.
Will it open the door to even more corruption than we have already?
Look at the alleged Malema structure in Limpopo. That's the classic model of capturing the procurement system. Through political links people are able to capture the central purchasing function within a province, anybody allocating tenders. And when you are in that position you can charge kickbacks for accessing tenders. This structure will be that, it will be exposed to that conduct. It will be a procurer of note and in a strong position to demand patronage, and it will. So that's a serious risk. Health systems which have a political governance model are all very susceptible to corruption internationally. They're vulnerable to it because of the extent of buying, procuring, and because people can gain power by allocating coveted positions and posts. That's a standard risk you have to eliminate through design. But instead of mitigating that particular risk, the proposed system will soup it up.