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South Africa reveals health bills

The much-awaited bills were met with criticism by those who think that an effective reform of the health system will require a different approach. Andrew Green reports.

South Africa’s health minister presented two bills last week that would substantially overhaul the country’s health-care system in a bid to move the country closer to universal health coverage. Under the new scheme, all accredited health facilities, whether public or private, will be required to provide a package of services at a price set by the government. The legislation would also abolish copayments to health insurance companies and set up a cross-subsidisation system to ease access to coverage.

“[The bills] put the spotlight on the challenges in the entire health system”, Laetitia Rispel, a professor of public health at the University of the Witwatersrand, told The Lancet. “We simply cannot continue the way we are. There is no doubt in my mind that we need serious reform.” She is among many who doubt that the proposals in the bills presented by the government are the right approach, given concerns that these bills might not necessarily improve the public sector but could destabilise the private health system in the country.

The move to overhaul South Africa’s health-care system was driven by major gaps in coverage for large swathes of the population. The country’s public health system is embattled and overstretched, especially in rural areas. More than 70% of the country’s doctors work in private facilities, according to government statistics, and although South Africa spends 8.7% of its gross domestic product on health care, less than half of that goes into the public system, with the rest going to the private sector.

Access to private health care is limited to people who can afford to pay out of pocket or who have access to health insurance—known as medical aid—which is often provided by employers.

“As it is now generally accepted, the cost of private health care is out of the reach of many citizens, even the well-to-do ones”, Health Minister Aaron Motsoaledi said in the speech introducing the two bills.

“‘There is an assumption that if more money flows into the system through NHI funds, that will solve the problems. But the problems are really of a different kind of calibre.’”

One of the two bills presented by the administration, the Medical Schemes Amendment Bill, looks to overhaul the country’s health insurance system and make it easier for everyone to access medical aids.

The bill also calls for the introduction of a package of service benefits at each facility. The package would be geared toward primary health coverage, including pregnancy and immunisations.

The other bill, the National Health Insurance (NHI) bill, provides for the creation of a government-administered fund that would establish the services provided at both public and private facilities—and set prices for patients. Service users would still be able to pay for complementary services out of pocket, without subsidisation.

It would reach full implementation by 2026.

“The essence of NHI, which must start now, even with the present medical aid schemes, is that the rich must subsidise the poor, the young must subsidise the old, and the healthy must subsidise the sick”, Motsoaledi said.

The proposal lacks detail about what services will be covered, what oversight mechanisms there will be for the bodies tasked with controlling prices and services, and how the government plans to pay for services under NHI.

There is also no guarantee that public health providers will be able to implement the services required under the proposed legislation.

“They are not doing anything to improve the quality of public health care”, said Anthea Jeffery, the head of policy research at the South African Institute of Race Relations, an advocacy organisation. “There is an assumption that if more money flows into the system through NHI funds, that will solve the problems. But the problems are really of a different kind of calibre.” She mentioned issues of the promotion of unqualified people to management positions, a shortage of skilled health workers, and overall quality and hygiene concerns.

Private providers are worried that the proposals will ultimately drive them out of business. Henru Kruger, the chief operating officer of the Alliance of South African Independent Practitioners Association, told The Lancet that many of the small providers represented by his association are already struggling to survive on the current rates that they are charging for services. A reduction in fees will make it impossible for many of them to remain operational, he said.

Private providers are “made out to be the villains”, Kruger said, “the guys exploiting the system and making it expensive. But they’re only just surviving and now they see this as a real threat to their survival.”

The bills are now open for public comment for 3 months.

Andrew Green

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