A commentary on the National Health Summit 2018 Report
1 April 2019
On 19-20 October 2018, President Cyril Ramaphosa convened the inaugural Presidential Health Summit. The purpose of the summit was to invite key stakeholders from the health sectors to discuss the state of our health system and to enable collective planning of good health for all. In February 2019, the Department of Health released a report on the outcomes of these deliberations.
The drafters of the report reached a number of conclusions which require some analysis and comment.
A UNANIMOUS SHOW OF HANDS
“There was unanimous support for the principles of National Health Insurance (NHI), which include: universal quality health care, social solidarity and equity in health access, and a call for NHI and its implementation [our emphasis]”
While section 27 of the Constitution guarantees each person the right to access to healthcare services, it is widely accepted that the current South African health system is unsustainable and in need of strategic reform. The NHI purports to do so and in turn, bring about Universal Health Coverage (UHC). The two terms, NHI and UHC, are, however, not mutually interchangeable. It is, though, of paramount importance to distinguish between the two.
The objectives of UHC are as follows:
1. Equity in access to health services - everyone who needs services should get them, not only those who can pay for them;
2. The quality of health services should be good enough to improve the health of those receiving services; and
3. People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.
Conversely, the objectives of the NHI are:
1. The consolidation of revenue;
2. Serving as the single purchaser of health services;
3. Ensuring the sustainability of funding for health services; and
4. Actively purchasing health care services, medicines, health goods and health-related products.
UHC is a goal to give effect to health as a fundamental human right. The NHI is the South African government's proposed policy to achieve this goal. It would be correct to say that there is unanimous support for achieving UHC and the need for reasonable steps to realise this goal. However, since its inception, the NHI has remained highly contested. Civil society and stakeholders alike have expressed opposition to the process. The Helen Suzman Foundation (HSF) raised a number of concerns about the NHI in our submission on the Draft NHI Bill - which can be read here. Although the NHI purports to achieve UHC, it is both inaccurate and misleading to state that there exists unanimous support for the NHI when the contrary is true.
“Private sector has a critical role to play in the realisation of NHI, thus [a] harmonious working relationship between private and public sectors, in a way that puts the needs of the people of South Africa first, is needed.”
An approach to UHC which advocates public-private partnerships is commendable, and one which the HSF supports. The issue, however, is that under the current NHI framework, this relationship is better described as one of coercion.
Under the NHI Bill, only those healthcare practitioners who have been registered and accredited by the fund will be entitled to claim for services rendered from the fund. As written, the NHI Bill does not make it compulsory for private practitioners to do so and, on the surface at least, it appears as if private participation in the NHI is voluntary. Issues arise, however, when the NHI Bill is read with the proposed section 34(3) of the Medical Schemes Amendment Bill.
Section 34(3) provides for prohibiting medical schemes from offering the same benefits as those provided by the NHI. This amendment has two consequences. First, it is highly exclusory as far as medical schemes are concerned, reducing their function to providing funding for complementary services. Second, it creates a situation where private practitioners are either forced to participate in the NHI process to ensure their patients can receive funded services or to charge their patients out of pocket.
It is difficult to see how, moving forward, the exclusion and coercion of two key groups of stakeholders in the private sector can be regarded as harmonious.
CROSSING THE TS
“Accountability and transparency in implementing NHI interventions [were] overemphasised. This must include a plan to have consistent and comprehensive communication in ongoing engagements and to report regularly to the nation on the progress made to improve the quality of the health system.”
While we are still trying to make sense of State Capture, the need for improved accountability and transparency cannot be overemphasised. The NHI policy is a radical intervention whose potential for success is an unknown as no process of its kind has been attempted before internationally. Testing of the NHI is paramount.
It is intended that the NHI be implemented in three phases. Phase 1 took place between 2012-2017 and included testing of effective health strengthening initiatives. Part of these strengthening initiatives was to establish several pilot sites that would operate under the NHI framework. The objectives of the pilot sites included: testing the ability of the districts to assume greater responsibilities under the NHI; to assess utilisation patterns; and to assess costs and affordability of implementing a PHC service package.
Phase 1 of the NHI has been completed, yet, to date, no evaluation report of the pilot projects has been released into the public domain. To improve accountability and transparency – as the drafters of the report emphasised a need for - this report should have been voluntarily released. Instead, the HSF has had to resort to bringing a PAIA application to acquire such evaluations after formal requests were denied. It is also important to note that these requests were made post the 2018 Health Summit and refused in spite of the stressed need for accountability and transparency, indicating a lack of commitment to for real action.
A RETOLD STORY
Part of the methodology used at the Health Summit was to identify and differentiate between actions which needed to be taken either immediately, short term or medium term to combat the declining state of our health system. Below are a few select examples:
Figure 1: Immediate and short-term actions needed, identified at the 2018 Health Summit.
There is an urgent need to review the organisational design in the public sector to redress the top-heavy organisational design. There must be a separation between the political and administrative leadership in public health. [our emphasis]
Review of the policy on registration and employment of foreign-trained medical practitioners to address shortages of skills.
Review the concept of community participation in health to clarify roles and responsibilities.
Standardise (IT) systems using the health standards normative framework (for interoperability and develop a policy to deal with the 42 systems currently in use in the health system across the country.
There are two commonalities between these examples, although, these commonalities and not necessarily restricted just those the examples listed here. These examples all require some form of policy implementation from the Department, and were stressed as requiring urgent or short term action.
What is disheartening about these action plans is that they are not novel. The National Development Plan 2030 (NDP), which was released in 2012, acknowledged the failings of our health sytems. It stated that top-heavy centralised management, feeble accountability, inconsistent budgetary spending and poor implementation of policy had lead to an inability to get primary health care and the district system to function properly.
In order to address these failings, the NDP identified a number of priority areas that highlighted the key interventions needed to achieve a more effective health system. A few examples are listed below:
Figure 2: Priority interventions required, as identified in the National Development Plan 2012
Centralised guidance, technical support and monitoring should be aligned with decentralised, devolved responsibility and decision-making.
Bringing in additional capacity and expertise to strengthen a results-based health system, particularly at the district level. This should include revised legislation to make it easier to recruit foreign skills.
To achieve this model of community-based health care, the powers of conservative professional councils will have to be curtailed and the scope of practice for non-doctors, especially community health workers and nurses, enlarged.
Integrate the national health information system with the provincial, district, facility and community-based information systems.
What these examples help illustrate is that despite the consensus that these and other areas require immediate action, they have done so for several years and have yet to be rectified. The NDP recommendations themselves largely originate from the 2008 consultative process to create a roadmap for health. For over a decade now there has been a lack of political will to really commit to addressing these issues.
It is commendable that the government is seeking to involve stakeholder participation in addressing issues plaguing the health sector. Inclusive public-private partnerships are key to reform and more processes like the Summit will be required to do so.
It is unfortunate then that the outcome of the Health Summit seems to have led to a reiteration of a number of hollow promises with a lack of commitment to follow through. Overdue policy intervention, a material commitment to accountability and transparency, and inclusive participation practices are needed to convince stakeholders and the public alike that there is a real will from government to improve the health system.
This article first appeared as an Helen Suzman Foundation Brief.
 Presidential Health Summit 2018 Report pg 9, and as reiterated on pg 61
 The National Health Insurance Bill, s 4
 Note 1 supra, pg 40
 Note 1 supra, pg 61
 Note 1 supra, pg 30, 30, 55 and 59 respectively.
 The National Development Plan 2030, pg 337, 336, 347 and 338 respectively.
 A Roadmap For The Reform Of The South African Health System, 2008