The National Health Insurance Plan: Why the DA opposes it

If the proposals in the leaked ANC Task Team Report on National Health Insurance (NHI) are implemented, both the quality of healthcare and the economy will suffer.

As always, the poor will be hardest hit, because the NHI does nothing to address the crisis in public healthcare. That crisis has been caused by a shortage of nurses and doctors, inadequate facilities and resources, and weak management systems. The poor bear the brunt of it.

The NHI is not pro-poor. In fact it is anti-poor. It is a sure-fire recipe for the destruction of public healthcare.

The DA recognises that the poor in South Africa get poor service from the health system. Health care in the public sector is affordable but of dismal quality, leaving patients queuing for hours for rushed and inadequate care, or no care at all. Quality health care in the private sector is available to a few, but at a high cost. The potential exists to bring these two sectors together to build a system that suits everyone's needs, and provides quality care to all.

However, the NHI plan the ANC is attempting to push through will not do this. The ANC is attempting to force through, with a highly selective consultation process and a preconceived agenda, a plan which makes no attempt to address the real problems of health care, while adding a massively expensive and cumbersome layer of bureaucracy to a system which is already unstable.

The DA believes that we must fix the problems of the health system on the ground, and that we can do this easily and without massive expenditure on more bureaucracy. We have a system that can work, provided that some basic principles are followed - and these principles would apply to any system we decided to implement. We will fight in every way we can to ensure that ordinary South Africans do not bear the brunt of another ANC spending extravaganza which makes big promises and delivers little.

Process: Secrecy, rushing and selective consultation

The NHI has enormous implications for every single South African, including those who are not within the narrow circle of the ANC and its alliance partners. Yet the process around developing the plan has been shrouded in secrecy from the beginning and has embraced only like-minded interest groups. An ANC document titled "The National Health Insurance Plan for South Africa", prepared by the party's NHI task team and dated 16 February 2009, was yesterday leaked to the media, but would otherwise not have been made public. This is part of a pattern which has been in evidence ever since this matter was placed on the ANC's agenda, several years ago. 

It has been made clear from the outset that the NHI will be presented as a fait accompli to the public, once the ANC has decided on the details. This is indicated, for example, by an ANC press statement released this week asserting that "the ANC is currently allowing internal processes on the NHI to be concluded before a formal public statement is released on the matter".

The ANC task team headed by the former director-general of health, Dr Olive Shisana, is dominated by trade unionists, including Nehawu head Teboho Phadu, and they have made it quite clear that they are pursuing a particular agenda, which is driving the process and determining the outcomes. The dismissal of opposing opinions as those of "narrow interest groups and individuals bent on undermining the introduction of NHI" makes it clear that the ANC is not interested in any real consultation.

It seems, furthermore, that there is every intention to rush this plan into operation despite any objections. ANC secretary-general Gwede Mantashe, speaking on behalf of the ANC national executive committee recently, stated that "the National Health Insurance must be in place within the first year of [the current] term". Timetables in the leaked report suggest that legislation will be drafted within the next nine months.

It is widely reported that former health minister Barbara Hogan's insistence that the NHI proposal be subjected to proper processes and public scrutiny led to pressure from the unions that she be removed from the health portfolio.

Now that the proposals are reaching the legislative stage, the ANC's lack of consultation is running into problems even with its own checks and balances. The DA has been informed that three pieces of legislation published in the Government Gazette on 2 June, and which start to lay the foundation for the NHI, have not passed through parliament's Joint Tagging mechanism, because the bills have not undergone a public consultation process as required. (These bills are the Medical Schemes Amendment Bill, the National Health Amendment Bill and the Medicines and Related Substances Amendment Bill.)

Not only is this process fundamentally undemocratic, but it is also a recipe for bad policy. If the only opinions being seriously considered are those who are already ideologically committed to the idea, then the outcome cannot possibly be as rigorously tested as it would be with more critical voices.

Content: Massive expenditure, disastrous outcomes

The NHI will come at an enormous cost to South Africa; estimates put the cost at an extra R100 billion a year, amounting to a 40% increase in the health budget.

This will come from additional taxes. Calculations emerging from the health department suggest that raising the amount required will require taking an additional 9% of current gross household remuneration from every family. However, the question of the consequences of the enormous additional burden on the tax base does not appear to be of great concern to the ANC. According to new health minister Aaron Motsoaledi, speaking to the SABC recently, it is simply a case of "those who earn more will pay more". The implication of this is that the ANC understands there to be a limitless source of income from the already overburdened taxpayers.

Particularly in the current economic crisis, this assumption is dangerous and potentially catastrophic. It may well spiral South Africa's already precarious economy into free fall, as higher tax burdens cut jobs, reduce expenditure on South African products, and increase immigration as skilled workers flee the likelihood of being forced into a low quality public health sector and denied the services they now have.

Instead of improving the quality of health care for all, it will merely decimate the current capacity in the system and leave the poor worse off than they already are.

But these consequences do not seem to have formed part of the planning around the NHI.

At the same time, what is also notable about the information available to us is how little attention has been placed on the current problems facing the health system. The assumption is made that more money will solve all problems. But in fact, the problems of the health system are not primarily about money, but performance. Critical problems such as bureaucratic mismanagement can be addressed without increased expenditure, and would result in far more efficient use of available money and a much higher quality of care.

The DA's alternatives

South Africa has a health system has many qualities which could be improved and developed. We do not need to start again from scratch. The government holds in its hands the means to make this system work for all without using money which could be better spent on doctors' salaries, social grants or housing.

In particular, the DA proposes:

• A comprehensive review of the qualifications and experience of hospital managers. It is not acceptable that we have situations where the management of hospitals is handed over, for example, to ANC councillors with degrees in politics. Managing a hospital is highly specialised and requires people with specific training and experience. The report that the DA finally managed to obtain into the astonishing number of baby deaths in Ukhahlamba in the Eastern Cape last year pointed not to a lack of money, but to the simple failure to follow basic procedures, to monitor patients, and to provide the most basic medication.
• A review of the structure which governs hospitals. Where there are good hospital managers, they are severely constrained by an antiquated management structure. This structure requires them, for example, to obtain approval from the MEC for senior hospital appointments - which often takes months. They are also not entitled to retain the fees they collect, which means there is no incentive to do so and millions of rands go uncollected. Good managers must be given the authority they need to manage their hospitals.
• Improve quality management. The National Health Act makes provision for many innovations that would make quality management in the public sector much more viable. But many of these have simply not been implemented, including one for the establishment of an Office of Standards Compliance. All hospitals need to be monitored on a regular basis to determine how well they are meeting specific quality standards.
• A change in the attitude towards the private sector. The private sector offers enormous potential to improve the quality of the public sector, and it has offered its services in many different areas in this regard in various areas. These offers have largely been ignored.

Conclusion

The DA will not accept the unilateral imposition of a policy which heralds only further decline for the health system at enormous expense. We will be taking the following steps in the short term:

• Requesting that the health committee schedule a series of meetings to discuss this question, and that the minister of health be requested to attend such a meeting to explain the NHI. 
• Scheduling meetings with various other groups who have raised concerns about the process and the substance of this scheme, and where possible work with them. 
• Ensuring that parliamentary requirements for the processing of various pieces of legislation that form part of the NHI are followed rigorously. In particular:
  • Ensure that proper public consultation is undertaken. 
  • Ensure that all legislation introduced is accompanied by a clear, comprehensive costing report, as required.  

• Asking questions in parliament about the details of the scheme, the members of the committee and any possible conflict of interest involved.
• Finally, exploring legal avenues to take this matter further. For example, legal precedent makes it clear that consultation on legislation must be thorough and meaningful. But the process followed so far suggests that the ANC has no intention of engaging in substantial consultation.

Statement issued by Mike Waters MP, Democratic Alliance shadow minister of health, June 10 2009

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