The HSF's comment on the NHI

Foundation says Green Paper makes statements and claims not supported by evidence

HSF Submission to the Department of Health on the National Health Insurance Green Paper

Executive Summary

The Helen Suzman Foundation (hereafter: Foundation) welcomes the opportunity to engage in an open debate on strategic health reform. The Foundation sees this opportunity as a way to foster greater collaboration and critical, yet constructive, dialogue between civil society and government in terms of the policy-making process.

Challenges facing South Africa's health system

The Department of Health has clearly made significant gains in certain areas of the health system. However, the situation analysis in this submission presents a picture of a South African health system which is underperforming in almost every area. South Africa spends similar, and in some cases more, on health care than its peer countries, and yet is experiencing poor health outcomes and a rise in the burden of major diseases. Although acknowledging many of the problems in the health system, the National Health Insurance (NHI) Green Paper fails to provide evidence-based links between the poor health outcomes and their causes. 

The Green Paper cites the two-tiered health system and inequalities between the public and the private sector as the root causes of the majority of South Africa's poor health outcomes. While these factors may undermine an attempt at creating equality in society, this proposition fails to take into account the systemic, institutional problems evident in both the public and the private health systems.

The problems in the public health system include: lack of governance and accountability, ineffective monitoring and evaluation, poor management, over-centralisation, lack of implementation of existing policies, and corruption. The issues resulting in rising costs and inefficiencies faced by the private sector include: market imperfections, a lack of price competition and lack of effective regulation. Whether or not these issues can be resolved by the introduction of a NHI scheme remains unclear.

Review of the Green Paper

The Foundation finds that the Green Paper is characterised by statements and claims which are not supported by evidence or appropriate references. The Green Paper also lacks much of the detail required to provide a more engaged response to the policy proposals. A primary concern is that the apparent lack of a comprehensive, evidence-based plan could result in further deterioration of the health system. It is imperative that clear and reliable evidence is provided to demonstrate that the policy proposals of the Green Paper will improve the ability of South Africans to access health care.

Constitutional and human rights implications

"Section 2 of the Constitution reaffirms that the Constitution is the supreme law of the Republic and that law or conduct inconsistent with it is invalid and that the obligations imposed by it must be fulfilled. Thus, every citizen and every arm of government ought rightly to be concerned about constitutionalism and its preservation."

In this regard the Department of Health needs to show that the policy proposals outlined in the Green Paper will positively assist the state in the progressive realisation of the right to access health care enshrined in Section 27 of the Constitution. Similarly, the Department of Health needs to ensure that the Green Paper proposals are in accordance with the Constitution. A particular area of concern in this regard is the potential for the undermining of the constitutional rights and decision-making powers of the provinces.

The importance of public consultation

Public participation and consultation with regards to the proposed NHI still has a long way to go. Historical and international evidence of creating and implementing health care reform suggests that it is a complex process requiring an equal measure of open debate in the policy-making process and resource capacity in the implementation stage.

The Department of Health appears to have presented an already defined proposal drafted with minimal public and stakeholder consultation. As a result, the Foundation sees the Green Paper rather as the first step towards health reform, with space reserved for further consultative development of the detail and scope for creative thought.

The goal of universal coverage

Universal coverage in health care can be described as a system whereby all citizens have access to quality health care when needed and are not exposed to ruinous financial risk when accessing it. It could be argued that South Africa already provides universal coverage by virtue of the current two-tiered health system: On the one hand, the tax funded public system provides coverage to those who are unable to afford private health care.

On the other hand, formally employed individuals and those able to afford it, are covered by the private health sector via contributions to medical schemes. The problem is thus rather one of access and quality than lack of coverage. The key question then is: what are the most important and critical steps to take in working towards improving access to quality health care and what are the most relevant policy mechanisms for achieving them?

The importance of management

Appropriate management across all levels of the health system is crucial for the successful reform of the health system. The introduction of the Green Paper provides an opportunity to finally and emphatically correct malfunctioning management structures and practices in the health sector.

Health management needs to be clearly distinguished from administration, should be decentralised, and must take a long term view. Managers must be trained and granted the opportunity to make decisions in respect of the areas of the health care system that have been entrusted to them. Similarly, regarding decentralisation, the Foundation believes that the most effective decisions are those made closest to where problems and issues arise.


The Helen Suzman Foundation is positive that the correct reforms to the health care system can be decided on and implemented. It is vital however, that reforms are discussed and debated in a transparent manner, with broad-based consultation and sober acknowledgement of the real challenges facing the health care system. We trust that this is the start of an open discussion on the best way to move forward to ensure improvement in access to quality health care for all South Africans.

Key points made in this submission: 

  • The Green Paper for a NHI in South Africa must be seen as the first step in opening up genuine debate as how best to reform the health system and not as a final model requiring only minor adjustments.
  • Systemic issues in the health system relating to lack of accountability and governance, poor management and inefficiencies - not the two tiered health system and inequalities between the private and public health system - need to be recognised as the primary reason for South Africa's ineffective and inefficient health system.
  • Appropriate management across all levels of the health system and decentralised governance structures are crucial for effectively reforming South Africa's health care system.
  • The issue of access to quality health care needs to be the driving force behind all reform efforts in the health sector and not simply the provision of universal coverage.
  • The NHI must be seen as a long-term goal in improving the institutional efficiency of the health system and a complementary tool in the larger process of strategic health reform.
  • Short-term goals attending to issues of quality and efficiency, particularly in the public health sector, should be prioritised above the broader reform strategy proposed in the Green Paper.
  • Greater public consultation, engagement with key stakeholders and constant communication and dialogue is vital in order that civil society is provided with a true reflection of developments in the health care debate so as to avoid misinformation and disaffected public opinion.
  • Given the importance of up-to-date data and information, the National Health Information System needs to be vastly improved and upgraded so as to ensure all policy proposals are based on reliable evidence and realistic assumptions.
  • Human resource deficits across a wide range of functional areas need to be urgently addressed.
  • A comprehensive framework and strategy for improving the relationship between the public and private health sectors needs to be developed and serve as the foundation for a national health reform programme.
  • The exact sources of financing for the proposed system need to be outlined, and further debate needs to take place regarding decision between the implementation of a single- or multi-payer system.
  • Tax implications a means of funding health care reform need to be clearly outlined.
  • It is an imperative that any reform to the health care system at a national level complies with the Constitution. In particular, the constitutional rights and decision-making powers of the provinces need to be upheld.

Download the Foundation's full submission here - PDF.

Statement issued by the Helen Suzman Foundation, December 16 2011

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