Voices

NHI deam: When polemic triumphs over policy

2019-09-02 12:02

In his luminous tome The Leopard, Giuseppe Tomasi di Lampedusa describes the response of a wealthy Sicilian aristocrat to Garibaldi’s impending Republican revolution thus: “If we want things to stay as they are, things will have to change.”

And so it is with our political life, a visceral unravelling over the past decade of a carefully stitched together political compact has left no one in any doubt that Lampedusa’s muse describes our condition perfectly.

When government released its latest draft National Health Insurance (NHI) Bill, the reaction ranged from outright and, occasionally, genuine joy to outrage. That everyone is now an expert on healthcare is evident from the reams of commentary since. The genesis of this iteration of the NHI is revealing.

The term ‘universal health coverage’ was recently coined by the World Health Organisation (WHO) as a model for healthcare for all nations. The terminological inexactitude of the word coverage in the WHO definition notwithstanding, all the conditions for universal health coverage are already within the remit of the public health service. This appears to have been lost on credulous officials in thrall to global bureaucrats.

Coverage implies insurance, which, on the available evidence, is the worst model for healthcare delivery in terms of equality and scientific rationing.

Moreover, insuring against fairly predictable eventualities seems superfluous when compared with a tax-funded model of comprehensive, cradle-to-grave care like the UK’s National Health Service.

Read: Healthcare needs radical reimagining

There are two white papers on healthcare that are germane. The first one, introduced by the Nelson Mandela administration, produced a sensible plan to fulfil the obligation of section 27 of the Constitution. The second is the white paper spawned 10 years later in the toxic cauldron of the Polokwane conference, evoking a new plan that is a triumph of polemic over policy.

One was the product of struggle, of empirical research and the organic participation of the people in its formulation. Emerging intact after running the gauntlet of the Convention for a Democratic SA, it acquired the prestigious imprimatur of the first true Parliament of the people in 1997. It prefigured a phased approach to universal access to care through a methodical integration of all health resources and may well have been a reality today.

Held aloft as a further rebuke to the administration just ousted, this new policy was born of political expediency. Empirical health policy, not so much.

The white paper emanating from the Polokwane resolution is everything that the former is not. It is the result of a political sleight of hand, with a flimsy pamphlet of questionable provenance, lacking credible research, thorough analysis and proper consultation, rammed through by Jacob Zuma’s triumphalist Polokwane brigade and forever suffering the burden of association with that odious regime.

Held aloft as a further rebuke to the administration just ousted, this new policy was born of political expediency. Empirical health policy, not so much.

A decade later and the NHI is no closer, imminent legislation notwithstanding. And it is not hard to see why. The sum of the endeavours to craft a plan over the past decade is there in the bill, which is faithful to the contradictions and insensible propositions of that post-Polokwane white paper.

HEALTH POLICY INTERRUPTED

The truly remarkable relegation of the public health service to a sideshow in this process is a grave error of judgement by the policymakers.

The public health service is the lodestar of people’s health and the bedrock of a caring state. It is the system of first and ultimate resort for more than 85% of the population.

The well-ventilated predations of state capture reveal wilful damage by a criminal insurgency in the affairs of the ANC government. What is less well ventilated is that the lost decade of the Zuma administration didn’t only cripple the economy, it defenestrated the public health service.

The health department was despatched on a decade-long wild goose chase, wasting billions on failed pilot projects, consultants, committees and international junkets in a vain attempt to retrofit a rational model into an NHI policy that reads like an account of a fevered dream.

The public health service, bereft of the singular focus of the government, deteriorated apace, resulting in a state of crisis and incipient collapse.

To rescue, rehabilitate and reinforce the public health service is the truly noble enterprise and a great act of solidarity with our people. Instead, they are offered the thin gruel of the NHI.

From multiple epidemiological streams of disease to preventable mass deaths in our public health institutions, there is an alarming deterioration across all health metrics, in direct proportion to the degradation of public health services, despite the heroic efforts of front-line health workers toiling under miserable management and decrepit infrastructure.

To rescue, rehabilitate and reinforce the public health service is the truly noble enterprise and a great act of solidarity with our people. Instead, they are offered the thin gruel of the NHI.

The government spin is replete with euphemisms about the NHI while private sector parties engage in alarmist hand-wringing, sincere only in their despair at the financial damage to their brands. Both these narratives are phoney and worthless.

The private healthcare industry is a monster of a special type. The government’s simplistic understanding of its role rests on reflexive suspicions that market mechanisms are inimical to universal access to care.

In fact, the position is worse than that.

The private healthcare industry is a monster of a special type. The government’s simplistic understanding of its role rests on reflexive suspicions that market mechanisms are inimical to universal access to care.

The Health Market Inquiry into private healthcare has now officially exposed its many perversities. The findings have elicited surprise and not a little schadenfreude among those for whom all private healthcare is anathema. But the reaction is disingenuous, since its shortcomings have been known for decades, not least among regulators and legislators.

The reason the private sector is overtraded and incorrigibly expensive leads unerringly to the door of government. Its carefully calibrated regulation was abruptly discontinued through the substitution of existing policy for the NHI, creating a regulatory vacuum.

Markets, unlike nature, love a vacuum. Private healthcare, now unfettered by regulatory restraint, experienced explosive growth in the decade that followed, in tragic contrast to the public health service, where health professionals face diminishing incentives to remain.

The private sector has grown because those with means become hostage to their justifiable fear of public healthcare, remaining hostage instead to eye-watering premiums for access to private care.

A NEW DAWN IN HEALTHCARE, MAYBE

The NHI is depressing in its lack of originality. With characteristics of a Ponzi scheme, its dreary ambition is to replicate, on a national scale, the medical scheme model that is replete with inequality, market failure and a baleful lexicon of benefits, limits, exclusions, pre-authorisation, managed care, designated service providers and other horrors of private health insurance.

To sick this on poor people using public healthcare is simply cruel.

If any fantasies were to be had that voluntary contributions to medical schemes will be a source of funding for the NHI, scheme members will first have to pass a threshold of disbelief that a new government agency will provide all the healthcare they are receiving now if they simply paid over their premiums to NHI Inc.

Public health services will struggle to gain accreditation under the NHI unless standards are appreciably lowered.

Moreover, creating a central fund underwritten by taxes and other levies to finance an awkward insurance model for the whole population is to flirt with disaster. The Road Accident Fund is a salutary lesson going unlearned.

Public health services will struggle to gain accreditation under the NHI unless standards are appreciably lowered. To expect them to compete with an agile and well-capitalised private sector that is inured to the social investiture necessary for healthcare is a mug’s game.

The president and the minister of health are eminently sensible politicians and leaders. If they took a risk-adjusted view of healthcare, they would understand the necessity of directing immediate and massive investment into the public health service, turning it into the healthcare provider and employer of choice and a truly world-class national asset.

Simultaneously, they should abjure populist exhortations and implement careful regulatory reform of the private health market, akin to what was abandoned a decade ago, to integrate it into a system of universal access to all necessary care, free at the point of care for the whole population. This would be the promise of 1997 fulfilled.

The NHI envisages raising a tax as an immediate source of funding for health insurance, but spending billions of tax rands on its fantastical bureaucratic enablement in the face of the existing public health crisis is ethically objectionable.

Raising a tax in the interest of national security is a valid exercise. Rescuing the public health service qualifies as being in the national security interest, the NHI does not.

Dr Dasoo is a convenor of the Progressive Health Forum and a member of the Stalwarts and Veterans of the ANC


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November 10 2019