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2019/08/152019/08/20 10:05 AM
Cape Town - Long lines and hours spent waiting to access emergency specialist healthcare at public hospitals could be a thing of the past if the government’s National Health Insurance (NHI) Bill becomes law.

At the core of the NHI is a National Health Insurance Fund that will pay private hospitals and healthcare practitioners a prescribed fee for services rendered to those that otherwise cannot afford it.


Expert opinion on the NHI Bill before Parliament is divided between those who are wholeheartedly in support and others who are adopting a wait-and-see attitude.

Implementing the NHI may fulfil the government’s constitutional obligation to provide quality universal healthcare for all, but the system has caused debate, with people arguing both for and against it ever since the idea was mooted.

Introducing the bill in Parliament, National Health Minister Zweli Mkhize said: “For too long has our healthcare system operated in an unsustainable and unjust manner: the public healthcare system shoulders the lion’s share of disease burden in this country, looking after 84% of our population with less resources than the private health system that services only 16% of the population.”

n Wednesday, Damian McHugh, head of health marketing at Momentum Group, said that while the medical aid supported universal healthcare (UHC) and there was no debate that inequalities existed in the health system as it was at present, “how we go about achieving UHC is the question”.

McHugh said Momentum was busy studying the bill before saying anything about it, but was ready to support any system that “delivers more healthcare for more South Africans at a lower cost”.

Meanwhile, the Mediclinic Group, which operates a range of multidisciplinary acute care private hospitals across the country and comes under a grouping known as #FriendsOfNHI, put out a statement that said the bill was “a major step forward in the introduction of UHC”.

“The private sector has a valuable contribution to make in this regard.”

President of the Health Professions Council of SA (HPCSA) Kgosi Letlape meanwhile said in a statement: “We hope that as we engage with the NHI Bill, we will persuade the authors (of the bill) to talk about NHI contracting with providers, rather than accrediting them.”

Letlape said: “We don’t want the NHI to become the new medical aids that are choosing who can live and who can die.”

At the same time, Anele Yawa, general secretary of the Treatment Action Campaign (TAC), said the organisation would wait until the bill was enacted, before commenting on it.

However, he said: “In South Africa we have a population of about 57 million of whom 42 million are dependent on the state for healthcare, but the workforce in the health system is only about 400 000 people. How can they cater for 42 million people?”

On the subject of affordability, Ronelle Burger, an economist and researcher in the Faculty of Economic and Management Sciences at Stellenbosch University said: “According to the household surveys, the main constraint to having insurance is affordability. There are many people who would like to have insurance, but simply cannot afford it.”

Burger pointed out that there were no user fees for using primary health clinics and fees at hospitals were means-tested and seldom enforced and that this was echoed in the surveys, which showed that affordability was not a constraint to access to public care. “The demand for private care, amid free public care is interesting and important, and part of what we as researchers are trying to understand in more depth.”

The SACP, which is part of the #FriendsOfNHI, said: “We will continue pushing for the successful introduction of NHI in the interest of quality healthcare for all.”
  
2019/08/152019/08/20 10:11 AM
The National Health Insurance (NHI), the ANC government’s grand plan for improving the nation’s health, is sending all the wrong signals to potential investors.

For evidence of this, look no further than SA’s health stocks, some of which took a severe knock in the wake of last weeks’ publication of the National Health Insurance Bill.

SA’s biggest health and life insurer Discovery led the dive, but other companies that have interests in private health care, from hospitals to medicines, also went down. There are certainly multiple factors at play with these stocks, but for skittish foreign investors, it doesn’t matter that the bill’s sweeping reforms could well take decades to come to fruition.

Negative headlines about its chilling effect on the private health-care sector are enough to trigger a sell-off or make them think twice about putting their money into SA.

NHI has already done harm. For the past decade, it has distracted the national health department from getting on with fixing the public health system and allowed it to abdicate its stewardship of the poorly regulated private health-care sector. The publication of the bill, which is about to begin its passage through parliament, is only going to deepen the damage.

NHI is being positioned by the health department as the panacea to the problems gripping both public and private health-care. But this is a government with a dismal track record in implementing many of its own health policies, ranging from the provision of abortions to mental health services. And the state has proved so vulnerable to corruption that investors are rightly worried NHI may do more harm than good.

They fear NHI will break what little still works in health-care, and are horrified at the prospect that their staff may be compelled to use a state-run service with no scope to purchase better care.

The bill proposes setting up a central fund, overseen by the minister of health, which will pool finances to purchase services on behalf of patients.

Everyone will be expected to contribute to the fund, according to their means, so that the rich and the healthy subsidise the poor and the sick. Medical schemes, which currently enable 8.9-million people to pre-fund their access to private health-care, are to be relegated to providing only “complementary cover” when the NHI is fully implemented, leaving their future and that of their administrators in doubt.

And while the fund promises to contract with private hospitals and doctors, unless it has the money to offer attractive rates, their willingness to do so is an open question.

The bill comes in the wake of repeated revelations of government’s failure to manage its own businesses, ranging from the debt-ridden electricity-generator Eskom to the serially bailed out state-owned airline SAA. Things are so bad, the national broadcaster, the SABC, cannot even guarantee coverage of local soccer matches.

Public trust in the government is at a low, the fiscal environment is bleak, and yet the ANC is stubbornly pushing through expensive reforms that the country simply cannot afford.

The last time the Treasury modelled the cost of NHI was in 2011, when the economy was in a far better state than it is now. At that stage, the Treasury was forecasting that NHI would cost R256bn by 2025-26 in 2010 prices, and would face a funding shortfall of R72bn if the economy grew at 3.5% a year, rising to a shortfall of R108bn if the economy weakened to 2% growth.

It proposed various options for raising revenue for the fund, including a payroll tax and a surcharge on income, and scrapping medical scheme tax credits. The Reserve Bank is currently forecasting economic growth of just 0.6% in 2019, Eskom’s latest bailout has blown a massive hole in the budget and taxpayers simply cannot take any more pain.

If President Cyril Ramaphosa is serious about attracting $100bn in investment over the next five years, NHI needs a serious re-think.
  
2019/08/152019/08/20 10:16 AM
Does the National Health Insurance (NHI) Bill, tabled in parliament last week, herald the demise of medical schemes? Don’t bet on it happening anytime soon.

While it may be political suicide to say so publicly, several senior government officials privately say the reforms proposed in the bill are so ambitious that they are likely to be decades in the making.

The proposed law seeks to breathe life into the government’s plan to provide universal health coverage, which it calls NHI. It aims to establish a central fund that will purchase services from public and private sector players on behalf of eligible patients, who will receive free care at the point of delivery.

The envisaged reforms require huge restructuring of the health-care system, the creation of an enormous bureaucracy to register the entire population, new systems for contracting and paying service providers, and the accreditation of thousands of hospitals, clinics and private sector health-care professionals, ranging from GPs to neurologists.

That will all supposedly be in place within seven years.

For the medical scheme industry and those who rely on it to prefund their access to private health care, one of the bill’s crucial sections is clause 33, which states that once NHI has been fully implemented, medical schemes "may only offer complementary cover to services not reimbursable by the fund". That gives the schemes a lifeline until at least 2026 and, in all likelihood, a good deal longer.

Exactly what health-care benefits will be provided by NHI and how they will be funded remains murky. What is, however, clear is that the government is determined to be seen to be tackling the problems gripping the health-care sector. Even the best public hospitals and clinics are buckling under the demand for services, and the dwindling proportion of the population that can afford medical scheme cover for private health care faces annual premium increases that consistently outstrip consumer price inflation.

The number of medical scheme beneficiaries has remained stagnant for years, despite population growth. There were 8.87-million medical scheme beneficiaries in 2017, compared with 8.53-million in 2011. The population grew from 51.55-million to 56.84-million over this period, meaning the proportion with private cover fell from 16.55% to 15.61%.

Patients who use private health care face a number of challenges. They are buying blind, with no independent oversight of the quality of services they purchase, and no way of knowing whether they are being ripped off or offered unnecessary procedures.

Over-servicing in the private sector is evident in SA’s extraordinarily high rates for Caesarian sections (about 60% of all births in the private sector in 2017, according to the Council for Medical Schemes) and even for the more mundane tonsillectomy (1,888 per 100,000 people aged 19 or under in 2012). Both rates are among the world’s highest.

The problems are even worse for those who rely on public facilities. Patients currently face a five-year wait for hip and knee replacements at Chris Hani Baragwanath Hospital in Soweto, while it takes on average seven hours to see a doctor and collect a prescription at Pretoria’s Steve Biko Academic Hospital.

The government’s plan for fixing these deficiencies is to merge SA’s two-tier system into a single one, centred on an NHI Fund that will pool finances to purchase services for the entire population.

While few people would take issue with the social solidarity principles that underpin the fund — namely that everyone should contribute only as much as they can afford to the fund, and that the rich and healthy should subsidise the poor and infirm — the problem lies with how the policy will be executed.

Many aspects of the bill are vague, ranging from the role of the provinces to the interplay between the new district management offices and units that will contract with service providers.

The provisions that affect medical schemes are equally confusing. For example, while the bill says medical schemes will ultimately only be able to provide complementary cover, it also states that NHI will provide "access [to] health-care services within a reasonable time period", without defining "reasonable". If cataract surgery is covered by NHI, but the waiting period is three years, would that be deemed unreasonable and could a patient then have cataract surgery covered by a medical scheme?

Similarly, the bill says patients must follow the correct referral pathways to be covered by NHI, which means they must first consult a GP, who will direct them to a specialist. What happens if a pregnant woman decides to skip the GP and go straight to her regular gynaecologist or obstetrician? NHI won’t cover the costs, but does that mean a medical scheme can?

What is clear is that the crafters of NHI envisage a sharply diminished role for medical scheme administrators, who are not mentioned in the bill.

When pressed on the issue, Aquina Thulare from the presidential NHI "war room" says the fund will be publicly administered, and there is no plan to outsource any part of this function to the private sector.

Public confidence in the state’s capacity to run large institutions is at a record low, thanks to the growing evidence of public sector corruption and the financial crises gripping state-owned entities such as Eskom and SAA. Yet the bill does nothing to assuage fears that the NHI Fund will create a new pot of money for the unscrupulous to plunder.

None of the governance concerns raised when the first version of the draft bill was released for public comment last June appears to have been addressed, and the new bill deepens the health minister’s control over the fund and its operations, says Sasha Stevenson, head of health at advocacy group Section27.

The bill gives the minister extensive powers to make key appointments, including members of the board, the CEO, the advisory committees responsible for determining what benefits patients will get and how much service providers will be paid, and a new procurement office that will manage lucrative tenders for medicines and equipment.

This arrangement leaves the fund wide open to corruption, says Wits School of Governance’s Prof Alex van den Heever. "It creates a conflict of interest between operations and accountability: if your appointment is political, you are accountable to the appointer and the governance structure means nothing," he says. "And if the minister doesn’t like what the CEO is doing, he can simply remove them."

The pool of money being eyed by the state as potential income for the fund is enormous: in 2019/2020, SA’s total health-care spending will be about R490bn, or close to 9% of GDP, by Treasury estimates. Of this, R222bn is the consolidated public health budget; R11bn is donor money; and R250bn is private sector spend, which includes R207bn in medical scheme contributions, R35bn out-of-pocket spending, R5bn in contributions for health insurance products, and R2.6bn spent by employers providing health services to their workers.

Though the bill does not say it will draw on the funds currently spent on medical scheme contributions, that assumption is implicit in the government’s rhetoric around NHI. People will not want to pay medical schemes to cover services they receive under NHI, so the argument goes, and as medical scheme membership drops, so more money will be available to fund NHI.

For now, however, the bill says the NHI Fund is to be financed by shifting money already in the public health budget, including redirecting conditional grants earmarked for programmes such as HIV/Aids. At a later stage it envisages absorbing the portion of the equitable share earmarked for provincial health, which stands at about R150bn a year.

The bill also proposes several new taxation options for raising additional revenue, such as a surcharge on income and a payroll tax. Here, again, there is a hint that things may not move as fast as the government hopes, as there is an acknowledgment that the current fiscal environment doesn’t lend itself to raising taxes.

Given that the central bank’s most recent forecast shows the economy growing just 0.6% this year, 1.8% in 2020 and 2% in 2021, it could be a very long wait indeed before the required revenue can be raised.

NHI at a glance
• What is NHI?

National Health Insurance (NHI) is the government’s blueprint for changing SA’s health sector so the country has a single system providing services that are free at the point of care for eligible patients: no demands for hair-raising deposits upfront, no big bills afterwards.

• Why is the government pushing it?

Because both the public and private health-care sectors have deep-seated problems. The public sector is overstretched and cannot meet demand. The private sector is unaffordable for a growing proportion of the population. The government wants to put an end to the health-care lottery, where your wealth and where you live determine what care you receive.

• How will it work?

Everyone will choose a GP or nurse as their primary health-care provider, close to where they live or work. This will be their first port of call when they are sick, and they will be referred to a specialist or hospital when required. These health-care services could be provided in the public or private sector. Follow the “referral pathway” and the state will pay for everything. Break the referral pathway and you’ll have to dig into your own pocket.

• Who’s eligible?

All SA citizens. Undocumented migrants, asylum seekers and foreign visitors get limited benefits.

• What does it mean for private health-care providers?

Private providers will contract with the NHI at rates determined by the government. For the time being, they will be able to continue providing services to patients who pay out of their own pockets or via medical schemes. Over time, the state expects the medical scheme market to dwindle, and private providers will see an increasing proportion of their business coming from NHI-funded patients.

• What will happen to medical schemes?

Nothing just yet, but in time their role will change. When NHI is fully implemented, they will be limited to providing “complementary cover” for services not reimbursed by NHI.

• What will it cost?

The government isn’t saying. The last time it published figures was in the 2017 NHI white paper, which updated modelling done in 2011. At that stage, the National Treasury forecast it would cost R256bn in 2010 money by 2025, assuming the economy was growing at 3.5% a year. The Reserve Bank is predicting economic growth of 0.6% this year.

• Where will the money come from?

Tough one. The economy is in a parlous state, which makes it difficult to raise taxes. And the government has already decided to fund free higher education, as well as provide huge bailouts to Eskom, blowing a hole in the budget. There simply is no money.

• When will all this happen?

That depends on who you ask. The government says NHI will be fully implemented within seven years. But privately, officials say the reforms could take decades.
  
2019/08/142019/08/19 03:04 PM
There is already evidence the NHI is set to fail and that it would ultimately drive healthcare professionals away, the SA Private Practitioners Forum says.
A better economy can make universal healthcare a reality, but South Africa needs more time to make the National Heath Insurance (NHI) Bill work, according to a market expert.

Private healthcare lobbyists and other interest groups are intensifying their warnings on the economic dangers of sidelining private healthcare and effectively shrinking its market – a common interpretation of what the NHI would effectively do.

Head of capital markets research at Intellidex, Peter Montalto, said even if South Africa sorely needed NHI, it simply couldn’t afford to make it work.

Estimates from the Davis Tax Committee’s last report on the NHI suggested that the system would cost an additional R165 billion to the fiscus, according to Montalto. But for all intents and purposes and given a better economic outlook for South Africa, there was reason to believe that it could work.

Partially modelled on the British national health system, the NHI had some key political differences in its inception, Montalto said.

“The British system obviously had a much earlier start and one of the differences is that [South Africa] already has a well developed private healthcare system which is an established market and is meeting needs.

“Private healthcare had not been built up in the UK, so there is a different dynamic.

“In SA, it means replacing something that is already there with something of better quality, so that will be more of a political problem. In England, most people don’t have private healthcare so that makes the comparison a bit harder.”

The South African Private Practitioners Forum (SAPPF) suggested there was already evidence the NHI was set to fail and that it would ultimately drive healthcare professionals away.

SAPPF said it remained concerned with the ability of government to successfully implement the Presidential Health Compact to radically improve the quality of the public sector.

“Failure of the health compact to turn around every facility in the public healthcare sector will mean that the public sector facilities will not be of sufficient quality to contract with the NHI fund. The continued implementation of NHI, without confirming that the Presidential Health Compact was successful, could do immense damage to the healthcare system and could result in a shortage of public sector service providers for the NHI fund to contract with.”

The group was also concerned with the lack of clarity around the compensation of private practitioners, leaving it up to the executive to make regulations on such reimbursement models.

Yesterday, Freedom Front Plus blamed healthcare giant Discovery Group’s historic dip in share price on the recent tabling of the NHI Bill.

The party suggested the effect on the economy was already being felt, with Discovery Group’s shares falling 8.5% on the JSE last week.
  
2019/08/142019/08/19 03:07 PM
President Cyril Ramaphosa on Tuesday vowed that the National Health Insurance is here to stay.

Ramaphosa was speaking a week after health minister Zweli Mkhize made public the NHI bill, which has been the subject of a lot of criticism.

Most of the critics have pointed out a lack of clarity about its funding, questions over the future of medical aids and fear that health professionals and specialists would leave the country.

But addressing an ANC Women's League event, dubbed a "Conversation with the President" on Tuesday night in Johannesburg, Ramaphosa came out in full support of the NHI.
  
2019/08/132019/08/19 10:35 AM
The National Health Insurance bill was finally introduced last week, and – despite many, many concerns - it looks as if government will be pushing ahead to start implementing the new healthcare regime.

In a nutshell, this is what will happen: medical schemes as we know it will disappear, and your doctor will be paid by government.

Instead of paying your monthly membership, you will pay a similar amount of extra tax on your income. The government will use that money, and some of its health budget, to buy healthcare for all South Africans. That means that even those without medical schemes may be treated by private doctors and in private hospitals.

Most healthcare – including doctors’ visits, medicines, operations and hospital stays – will be free, for everyone.

Government says the aim of the NHI is to help medical scheme members with their high out-of-pocket costs. At the same time, it also acknowledges that state medical staff and hospitals can’t cope with treating the 83% of South Africans who don’t have medical aid.

There is a general acceptance that South African needs national, universal healthcare, says Dr Ernst Marais, COO of ICON Oncology (ICON), which represents more than 80% of oncologists in SA. Currently around 8% of South Africa’s GDP is spent on healthcare, with roughly 50% of that amount going towards the nine million people who are on medical aid, while the other 50% is spent on 51 million people.

“The healthcare system remains unsustainably lopsided.” Also, Marais says, there is an oversupply of private sector hospitals, which can help government treat patients without medical schemes.

But there remain huge reservations about whether government can afford, and manage, its NHI plans.

While the latest bill remains a bit sketchy, here’s what we now know with some certainty:

1.       You will become a member of the NHI Fund.

The fund will be a massive state-run medical scheme, and all South Africans will be members – you won’t have a choice.

2.       If you earn an income, you will contribute towards the NHI Fund.

Government will levy an extra tax on your personal income, and use the money it will save by not giving you tax credits for being a member of a medical scheme. There may also be a tax levied on your employer. Previously it was speculated that an “NHI tax” of between 3.5% and 5% could be levied on your salary.

3.       All contributions will go into a pool.

Government will use your tax money, as well as some of its healthcare budget, to buy services from public and private doctors, specialists, and hospitals that are accredited with the state.

4.       The fund will cover a range of medical services, treatments, and procedures.

All of these will be for free, without any co-payments. However, the fund will not cover treatments if  it’s not a “medical necessity” and where there isn’t a “cost-effective intervention”. If the fund refuses to pay for a health care, it will issue you a notice of the refusal and give you reasonable opportunity to appeal this decision.

Every year, government will determine what prices will be paid for by specific services.

5.       You will probably have to register with a GP who is contracted with the state.

While this was not clearly stated in the bill, it is expected that each contracted GP will have a set number of patients who they will “service” for the NHI Fund. You could be limited to how often you see a GP.

6.       There will be strict rules about seeing specialists.

You won’t be able to go directly to a specialist, but will have to get a referral first. A visit to specialists, like paediatricians or gynaecologists, may require longer waiting lists, as all South Africans – including the 83% of the population who are not currently medical scheme members – will now have access to private-sector specialists.

It could also, for example, mean far fewer Caesarean sections in South Africa, as the health system is expected to rely more on non-specialists like midwives. In 2017, some 69% of South African babies were delivered via C-section in private hospitals. (The World Health Organisation advises a maximum of 15%, and in public hospitals, only 26% of births are C-sections.) Also, you may not be able to get easy access to a private hospital that is accredited with the state, given that more people will be admitted.

8. The state will buy medicines for everyone

Instead of the private sector buying medicines for its patients, and the state securing treatments for public-sector patients, government will buy medicines for all patients.

9. Medical schemes may disappear

Marais expects that instead of the current medical schemes, medical insurance will become more common. To ensure that they will still have direct access to a specialist, and no waiting times for treatments, wealthier people will - on top of their NHI contribution every month – probably take out medical insurance.

New specific types of top-up medical insurance– for orthodontics, or for cancer treatment – will probably be created.

9. Foreigners won’t be covered

Adult asylum seeker or illegal foreigner will only get emergency medical services; and “services for notifiable conditions of public health concern”. The children of asylum seekers and illegal foreigners will be entitled to basic health care services.

Foreigners visiting South Africa must have travel insurance to receive health care services through the NHI Fund.

10. You will have access to all your medical records

You will be able to access any information or records relating to your health kept by the fund.

11. The fund will be run by a CEO and a Board

The fund will be managed by a CEO, who will be appointed by the minister of health, and can serve for a maximum of ten years. He will be supported by a board of 11 persons, also appointed by the minister.

 
  
2019/08/132019/08/19 11:44 AM
The looming spectre of Medi-Eskom, optimistically named National Health Insurance (NHI), is a relief in one respect: as the first major piece of legislation put together by Cyril Ramaphosa’s government, and potentially the last, it has allowed us finally to dispense with the childish but persistent belief that Ramaphosa has a plan.

We all understand the algebra of dysfunction in the ANC; that there are a great many things Ramaphosa can’t do for fear of embarrassing the made men eating spaghetti and meatballs around the kitchen table. His statements about land reform and Eskom have been so densely hedged you could carve them into topiary.

When it comes to NHI, however, Ramaphosa has been as vocal a cheerleader as any politician who ever shook a pompom and cried: “Gimme a T! Gimme an A! Gimme an X! Whaddaya get? Nothing!”

Of course, some pundits believe NHI will never arrive, ending its life in legislative limbo or euthanased by the courts. If this is the case, and Ramaphosa knows it, it would make sense for him to trumpet the rhetoric of socialised health care, pocketing some man-of-the-people cred while knowing he will never have to deliver. This might also explain his enthusiasm: invertebrate politicians are always keen to commit wholeheartedly to things that seem to have no political price tag.

Still, by backing NHI Ramaphosa has invoked a comparison that demands to be made loudly and clearly. Four years ago Jacob Zuma’s government told us that it wanted to spend R1-trillion on nuclear power stations. The response was unanimous horror. Even if all that money wasn’t stolen, and even if the power stations worked, it was patently obvious to anyone who could read that raising R1-trillion in extra taxes would wipe out the struggling middle class, collapse the economy and erase SA from the map. The proposal went straight to the top of the list entitled “Things Mad Kings Do To End Countries”, and we all rolled our eyes at the nihilistic absurdity of Zuma and his government.

A year ago it would have felt unfair and faintly boorish even to suggest that our current president might contribute to this list. Everywhere we looked, op-ed pieces and hastily published paperbacks were telling us Ramaphosa was not Zuma. Where Zuma was essentially a rustic patriarch who was ignorant of the basics of finance, Ramaphosa was an urban modern and an astute businessman. Ramaphosa was charming. He jogged. He didn’t sing songs about machine-guns.

Best of all, he understood how money worked. It was a story that rubbed up nicely against our unconscious belief that wealth implies virtue or at least competence. He would never, we assumed, support the idea of spending trillions of rand we didn’t have on systems the ANC could never administer honestly or efficiently.

And yet here we are. Zuma’s plan, which so astounded us with its ignorance of basic reality, was to spend R1-trillion, once, on a system built by engineers. Ramaphosa’s plan is to spend almost R1-trillion every two to four years, on a system built by the same people who brought you Life Esidimeni, Charlotte Maxeke Hospital, corpses in ceilings and pensioners chained to beds.

Task teams and cautious optimism and jogging be damned: it is a fact of simple arithmetic that Ramaphosa’s NHI hallucination is a far worse idea than anything Zuma ever dreamed up in his most Caligula-esque fantasies.

The thing that depresses me, however, is not the crude idiocy of the ANC’s endless schemes to crush SA’s economy. I’m used to that by now. What gets me is the cynicism — and inevitable success — of low-grade cons like the nuclear build and NHI.

Because that’s what they are. Long before they are bricks and mortar, even before they are angry headlines, they are money in the bank for connected cadres. The nuclear build was never going to happen. The NHI might evaporate. But simply by stating its intention to pursue them the state sprays money at consultants, lawyers, auditors, even catering firms to feed the people roaming around empty veld doing half-arsed feasibility studies. Ramaphosa doesn’t have to build a single clinic for intergenerational wealth to flood through the patronage system.

It’s a perfect bait-and-switch. While we stare in horror at impossible figures they quietly pocket improbable figures; and when the whole thing goes away, we’re too busy bracing for the next crisis to do the sums. After all, what’s a few hundred million spent to decide that trillions weren’t feasible?  Hell, that sounds like a win for the common people.

So on they go; the same players, playing the same game. Some say: “Heh heh heh”. Some say: “Watch this space”. But in the end they’re all saying the same thing: pay up, suckers.

• Eaton is a Tiso Blackstar Group columnist.
  
2019/08/132019/08/19 03:01 PM
The new National Health Insurance (NHI) Bill, tabled in parliament on 8 August, sheds some light on the new universal health coverage will be funded.

The main question for medical aid members and other taxpayers is whether they can still belong to medical aids and if so, whether they will be forced to pay not only their medical aid contributions, but to also contribute towards the NHI.

According to Aneria Bouwer, partner at law firm Bowmans, the answer to both questions is ‘yes’, although the details have not yet been released.

Bouwer said that the NHI will be funded by way of:

General tax revenue, which will include transferring funds from provincial health budgets to the NHI Fund;
A payroll tax (employer and employee); and
A surcharge on personal income tax.
Taxpayers’ medical scheme fees tax credit will be reallocated to the NHI Fund;
Tax credits

The proposal that Taxpayers’ medical scheme fees tax credit be reallocated to the NHI Fund has previously been mooted as a way for funding the NHI.

“However, it seems more certain that taxpayers will no longer receive medical scheme fees tax credits, which for a family of four, currently provides relief of just more than R12,000 per year,” Bouwer said.

This amount is determined annually by SARS which states that the taxpayer who paid the medical scheme contributions is entitled to R310 per month in rebates.

This rises to R620 per month for the taxpayer and one dependant; or R620 in respect of two dependants.

Taxpayers are also entitled to R209 per month for each additional dependant on the scheme.

Total cost to taxpayers?

“There is as yet no indication as to how much this will cost taxpayers,” Bouwer said.

“The taxes will be imposed by a money Bill to be introduced by the minister of Finance. According to the memorandum, these tax options will only be evaluated as part of the 6th and final stage of implementation, which will presumably not be before 2022.

“Interestingly, it refers to the evaluation of the new tax options ‘in a favourable economic environment’,”.

Bouwer said that the NHI bill also envisages that the payroll tax will be ‘small’ although there is no indication as to what this means.

“In the part of the memorandum dealing with the financial implications for the state, it refers to the various financing options, and then states that ‘due to the current fiscal conditions, tax increases may come at a later stage of NHI implications’,” she said.

“It thus appears that further taxes will only be imposed at a later stage after evaluation of the potential impact thereof, taking into account the economic and fiscal environment.

“There is no doubt that taxpayers will find the additional tax burden a bitter pill to swallow,” she said.
  
2019/08/122019/08/19 10:17 AM
Medical aids as we know them will disappear by 2026 under the National Health Insurance (NHI) Bill released today. Health Minister Zweli Mkhize unveiled the Bill today in Pretoria. Under the NHI, the government will provide a package of comprehensive health services for free at private and public health facilities as part of its bid to more equitable access to quality healthcare.

Medical aids will eventually be relegated to providing top-up cover under the NHI — or coverage for procedures or treatment that fall outside government’s package of care. The government will, in turn, become the single largest purchaser of health services in the country, buying them from accredited private and public facilities with a centralised NHI Fund.

While comprehensive medical aids are still around, they will also be shifting to standardise a basic coverage package across the industry in line with what’s already on offer in the public sector, Mkhize revealed earlier this week at a Bhekisisa editor’s forum. “We are working with the Council for Medical Schemes to ensure that every medical scheme pays for the same package of primary health care services as that provided by the public sector”, he explained. “This is part of the process to revise the Prescribed Minimum Benefits that the council is working on.”

Prescribed Minimum Benefits (PMBs) are a list of 270 conditions and specified treatments that all medical aids must cover, including emergency medical care and chronic illnesses. The changes to PMBs are one of the early signs — at least publicly   — that the government is moving on recommendations made by the Competition Commission as part of its four-year investigation into the spiralling costs of private healthcare ahead of government’s plans to begin buying services from the sector. The commission found that not only were consumers paying more for less when it came to private healthcare, but that the array of packages made it impossible for people to compare offerings between schemes. Standardising a basic option ahead of the NHI will likely cut down confusion, the commission said in its preliminary report, but would not necessarily address high costs

South Africa’s healthcare system remains highly unequal. When expressed as a proportion of gross domestic product, roughly the same amount of money is spent on catering for the roughly 16% of South Africans who have medical aid as the other 84% who rely on the overstretched public health system, according to a review of World Health Organisation data recently published by the Mapungubwe Institute for Strategic Reflection. The health department expects the final NHI Act to come into effect before March 2020, according to its latest annual performance plan.
  
2019/08/122019/08/19 10:21 AM
In a statement on Monday, the opposition Democratic Alliance (DA) invited the media to attend a press conference on Tuesday at which they planned to announce how they would stop the implementation of government’s controversial National Health Insurance (NHI) Bill.

DA leader Mmusi Maimane would outline the party’s next steps to prevent the new legislation as, in the DA’s view, the Bill in its current form threatened to not only “collapse SA’s health sector, but place our entire economy at risk”.

Maimane would be joined by fellow MP Siviwe Gwarube.

Health Minister Dr Zweli Mkhize on Thursday announced the NHI Bill was being handed to the National Assembly for debate.

It could already be made law by July next year and is looking to improve healthcare for more than 80% of the population who are not covered by medical aid and generally don’t have access to superior private healthcare services.

The bill has been published for the public to view. It runs to 88 pages. It aims “to improve the quality of life of all citizens and to free the potential of each person”.

If it gets adopted, the laws governing the health system in South Africa are due to be vastly changed, with the full implementation of the new universal healthcare system set to be completed by 2026. Medical aids as they currently exist will also probably disappear, or at the very least be vastly changed.

The project is set to be one of the most expensive ever undertaken in South Africa, and government intends to introduce a single national pricing regimen for health services and fund it by increasing personal income tax (it uses the term “mandatory prepayment”) and employer tax, among other measures. Medical scheme tax credits that are currently still being paid to medical aid members will now also go towards funding the NHI instead.

Government’s health fund will become the single purchaser of all healthcare services, to pool finances and strategically buy healthcare services, medicine and products from accredited service providers who will have to meet “high standards” in order to be reimbursed for their work.

Patients will in future also only be able to access specialist healthcare after accessing the primary healthcare system through a doctor or nurse.

The plan envisages huge centralisation of healthcare. Academic hospitals will be run by national government and not provincial health departments. All patient information will be kept on a single database, to be called the National Health Information System.

Emergency services will be paid “capped case-based fees”.

Healthcare professionals, particularly in hospitals, will have to keep to prescribed treatment protocols and guidelines as determined by the minister and the fund. They will only be able to prescribe medicine and health products from a government-approved list and all medical professionals will have to keep to a single national pricing regimen.

Asylum seekers and undocumented migrants (which government calls “illegal” people) will only be able to get treatment in emergency situations or if they have conditions “of public health concern”.

Medical aids appear to be largely dismissed by the proposed new law, with the plan apparently to limit their role to only being able to offer complementary cover for the kinds of health services not covered by the NHI Fund. In effect, this means they will only be a top-up service.

The NHI will be implemented over three phases. The first was for “health system strengthening activities”, which apparently already took place between 2012 and 2017.

We are now in the second phase, which ends in 2022. The third phase is meant to happen between 2022 and 2026, at which point the fund will effectively be the only entity that can buy healthcare services in South Africa.
  
2019/08/122019/08/19 10:30 AM
Most healthcare – including doctors’ visits, medicines, operations and hospital stays – will be free, for everyone in South Africa if the National Health Insurance (NHI) is implemented.

The government has introduced the National Health Insurance Bill which has sparked a debate about feasibility and the cost attached to providing universal healthcare for citizens.

The government says the aim of the NHI is to help medical scheme members with the high costs attached to medical aid. At the same time, it also acknowledges that state medical staff and hospitals can’t cope with treating the 83% of South Africans who don’t have medical aid.

Speaking on POWER Drive on Monday, healthcare economist Paula Armstrong says: “The level of inequality and access to high-quality healthcare in South Africa is highly problematic.

“The private healthcare services about 15% of the population and the rest of the population are reliant on a largely dysfunctional public healthcare sector.”

Asked why the public healthcare sector is malfunctional, she replied: “I think it is largely a legacy issue of South Africa’s past. Any country hoping to provide universal access to high-quality healthcare needs to rely on both the public sector and the private sector.”

A consultant of the South African Private Practitioners’ Forum (SAPPF), Johann Serfontein, says it is still not clear what the NHI will cost the government.

“We are ten years down the line and we have no idea what this [NHI] is going to cost. And yet in the bill itself, says that it’s sustainable and affordable for South Africa.”

South Africa needs to look at healthcare models that can work in South African environment, he adds.
  
2019/08/122019/08/19 10:32 AM
The National Health Insurance (NHI) Bill, tabled last week in Parliament, has been forwarded to the chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo.

Dhlomo said the committee will meet and discuss the programme of the NHI Bill, which will have an extensive public consultation process.

Analysts and economists meanwhile, have been digesting the plan and its implications for the economy.

While the bill lays out the groundwork for the NHI and how it will be funded, it still lacks much-needed detail, particularly when it comes down to exactly how much the scheme is going to cost each year.

The original NHI white paper estimated that the scheme would cost the economy around R256 billion a year – however, former health minister Aaron Motsoaeldi admitted that this was a “guesstimate” that was thumb-sucked by a local firm.

The Department of Health said that National Treasury plans to release a revised paper with a revised costing estimate.

According to Intellidex analyst Peter Attard Montalto, NHI is expected to cost an additional R165 billion to the fiscus in current prices, per year from 2026, based on PwC estimates used by the Davis Tax Committee (DTC) in 2017.

In its findings on the NHI and its implications for South Africa, the DTC said that even at R256 billion a year, in a 3.5% GDP growth environment the scheme would still likely hit a shortfall of around R72 billion by 2025. At a growth rate of 2% the shortfall would be R108 billion.

South Africa’s projected growth rate for 2019 is 0.6%.

Deputy director-general for NHI, Anban Pillay has moved to allay fears of immediate taxes – saying that no new taxes will be introduced in the short term, and will only be introduced in the ‘late stages’ of the scheme’s rollout, once it is up and running.

However, the bill was explicit that its funding will come from taxes in the end.

This includes:

General tax revenue, including the shifting funds from the provincial equitable share and conditional grants into the Fund;
Reallocation of funding for medical scheme tax credits paid to various medical schemes towards the funding of National Health Insurance;
Payroll tax (employer and employee);
A surcharge on personal income tax, introduced through a money Bill by the Minister of Finance and earmarked for use by the NHI fund.
Attard Montalto said that no specifics for these taxes were given in the published report, but the DTC previously determined an option that included many of the taxes that the department has now said it will eventually be implementing.

These early projections included a 2% increase to payroll tax on employers and employees, a 2% surcharge on taxable income and a 2.5 percentage point increase in VAT.

However, these figures were based on 2010 pricing, Attard Montalto said, and overestimated fiscal buoyancy.

“Overall the DTC outlined that NHI would only be feasible with strong growth in the economy, and seeing new revenues directed towards NHI,” he said.

In line with current buoyancy rates, the DTC’s original figures would result in a shortfall of around R45 billion a year, and a negative impact on wider tax collection maybe of the order of R50-75 billion.

“This would mean by our calculations the funding wrapper would need to be more like 2.7% payroll tax, 2.7% surcharge on taxable income and 3.5 percentage point increase on VAT – and that is only to address the NHI hole, not the wider revenue shortfalls,” he said.

Attard Montalto said that Treasury likely wants to avoid a tax ‘doom cycle’, and is thus focusing more on the expenditure side than revenue side (ie, funding by reprioritising budgets), but the wider risks of the scheme still persist – specifically medical workers salaries under NHI, and emigration of skills.

“Overall we think NHI is unworkable in the current economic and fiscal context, even if sorely needed. Indeed it can do more harm than good at a macro level,” he said.

“The implications need to be thought through.”
  
2019/08/082019/08/14 11:20 AM
Parliament is set to release the National Health Insurance (NHI) Bill by 9am on Thursday morning. Here is how healthcare in South Africa is likely to change.

1. Will you be able to have a comprehensive medical aid?

No. Once the NHI has been fully implemented, your medical scheme will not be allowed to cover any health services that the NHI offers. You will have to use the NHI for those services. Your medical aid will only be able to provide you with complimentary cover, in other words, services that the NHI doesn’t cover. By when will your medical aid, in its current form, disappear? According to the Bill, the NHI Fund needs to be up and running by 2026 through a system of "mandatory prepayment". Many experts, however, argue that the NHI will take much longer to take off. 

2. What services will the NHI cover?

The Bill doesn’t specify what services the NHI would cover, but it does mention that there will be "comprehensive healthcare services".  A benefits advisory committee, appointed by the health minister, will decide which services will be offered. The Bill says these services will be available for free, so there will be no co-payments. The NHI won’t pay for treatment when it can demonstrate that "no medical necessity exists for the healthcare service in question", when the medicine or treatment is not included in the NHI’s list of medicines, also known as the formulary, and when "no cost-effective intervention exists for the healthcare service".  According to the Bill, the NHI will start to buy healthcare services for children, women, the elderly and people with disabilities by 2022.

3. Will you be able to go to a specialist directly?

No — if you do, the NHI won’t pay for it. You will have to register at an NHI-accredited primary healthcare facility, and, each time you need healthcare, you will have to go to that facility. You will only be able to consult a specialist if the doctor or nurse at your primary healthcare facility deems it necessary to refer you to one. If you’re travelling and fall ill, you’ll be able to go to an accredited facility in the area you’re visiting.

4. What happens if you’re an asylum seeker or an undocumented migrant?

You will only be able to access emergency medical services and services for 'notifiable conditions of public health concern', such as TB. HIV treatment is also likely to be available to asylum seekers and illegal immigrants, as HIV is infectious and it is in the best interest of the country to treat everyone who is infected with the virus to prevent its spread. The children of asylum seekers and migrants, however, will be entitled "basic healthcare services" provided for in the Constitution. If you’re a registered refugee, you will be entitled to all services, provided that you have registered for the NHI by using your refugee identity card.  The NHI will also cater for 'individual foreign nationals' determined by the home affairs minister, after consultation with the minister of finance.

5. Who will pay for the NHI?

In short, taxpayers. The Bill says the money will be collected "in accordance with social solidarity" through payroll taxes for employees and employers, a surcharge on personal income tax, the reallocation of medical scheme tax credits and general taxes. Money that Treasury currently allocates to provinces through the 'provincial equitable share' and 'conditional grants' will be shifted to the NHI Fund. 
  
2019/08/082019/08/14 11:29 AM
The National Health Insurance Bill is one step closer to implementation.

If government gets its way, the Bill could be law by July next year.

Health Minister Zweli Mkhize is set to hold a media briefing on Thursday morning to take South Africans through the Bill before it is tabled before Parliament.

It was adopted by Cabinet last month, and still needs to be debated in the National Assembly.

Mkhize said there will never be a perfect time to implement the NHI.

He believes it will go a long way in improving the country's ailing health system.

"The reality is that if you look at the nature of health services, there is a lot of work that needs to be done.

"We can still do a lot even in the absence of the number of specialists that have been reported," he said.

"You can get a cover from specialists in a way that would not compromise the health services.

"It is something that can be managed and until we have a full NHI, we will be able to deal with it," the minister exhorted.

  
2019/08/082019/08/14 11:47 AM
The government's much-vaunted National Health Insurance (NHI) will be paid for, largely, by increased taxes.

This includes taxes paid by employers and workers, as well as an increase in personal income tax.

This is according to a leaked version of the National Health Insurance Bill, set to be officially released on Thursday morning. TimesLIVE is in possession of the leaked copy.

The NHI Bill is set to be debated in parliament after being approved by cabinet.

The bill explains that a single fund will buy healthcare, medicines, supplies and pay doctors and hospitals for all South Africans. It will be called the National Health Insurance Fund.

Users will have to register to receive the service, which will be free of charge.

Providers - doctors, nurses, specialists, pharmacies, hospitals, private and clinics - will have to register to provide their services. They must be accredited to provide care and pass standards set by the Office of Health Standards Compliance (OHSC).

The bill says an NHI Fund that buys all the health services in the country will be paid for by an increase in taxes and money from existing taxes. It suggests a payroll tax, paid by employer and employee. It also says there will be an increase in personal income tax.

On top of this, the medical aid tax credits currently given to people on medical schemes - who do not generally use state services - will be stopped and paid into the NHI Fund.

The bill also says provincial funds for healthcare will be moved to a single fund.

It says users will get healthcare in a “reasonable time period” - although this was not specified.

If people want to have a medical aid, they will be allowed to - but it will only be for services not covered by the fund or if one doesn’t qualify for NHI, for example if one is an illegal immigrant.

Once NHI is fully implemented after 2026, and when the health minister decides so, medical schemes "may only offer complementary cover to services not reimbursed by the fund".

General practitioners will refer patients to specialists. Patients will have to see nurses and GPs first for an assessment and cannot go directly to a specialist for healthcare.
  
2019/08/082019/08/14 11:52 AM
Health workers, nurses, doctors, dentists, specialists, physiotherapists, paramedics and hospitals will be subject to price control and guidelines if the NHI bill is passed.

Theses prices will be set by a pricing committee.

TimesLIVE has had sight of the bill, which health minister Zweli Mkhize is releasing publicly on Thursday. It has been sent to parliament.

The NHI aims to provide high-quality free healthcare to all and will only pay hospitals, doctors and other staff who provide quality service and meet standards.

The NHI Fund can refuse to work with doctors and hospitals that do not adhere to a "national pricing regimen".

The bill states the fund can refuse to work with establishments or workers that:

Have failed to or are unable to adhere to treatment protocol and guidelines;
Fail to adhere to national pricing regimen for services delivered; or
Deliver services that are not acceptable to the fund.
Various committees and teams, with medical professors, will decide what protocols doctors can follow, what treatments they can administer and what lists of drugs and technology can be used.

Health workers and hospitals will have to be accredited and meet quality standards every year to be paid by the NHI Fund.

Medical aids will not exist as we know them.  They will only be allowed to pay for services not paid for by the fund when NHI is in full force.

More than 10 different acts need to be amended to allow the bill to be passed.

The bill also gives the minister and provincial MECs huge powers.

They can make regulations on:

All the medical practices and procedures followed by health workers (which include doctors, nurses, dentists, dieticians, and so on) and hospitals or clinics paid for by the fund;
The relationship between medical aids, insurance policies and the fund;
The development of the formulary of approved treatments and medicines;
The monitoring of the fund;
Fees payable to the fund;
The levels of reserves kept in the fund for stability;
How the extra NHI funds must be invested;
How doctors and hospitals bill/invoice the fund, and what medical codes they use on invoices;
How the state buys private health services from private hospitals and private doctors' practices;
How doctors, therapists, health workers and hospitals are paid;
The accreditation of doctors, hospitals and health workers, like optometrists and speech therapists, by the Office of Health Standards Compliance;
The budget of the fund;
The information that must be provided to the fund by the national database and by doctors and hospitals; and
The registration of every user (every citizen and legal immigrant) of the fund.
The bill will be debated in parliament after its public release.
  
2019/08/082019/08/14 11:54 AM
The long-awaiting National Health Insurance (NHI) Bill was introduced to parliament on Thursday. The bill is important because it is the first piece of enabling legislation for the government’s ambitious plans for implementing universal health coverage, which it calls NHI.

“NHI seeks to optimise the available resources by pooling existing public funds and engaging the entire quantum of the health sector, so that in the end there is a single purchaser of services,” health minister Zweli Mkhize said at a briefing in Pretoria.  A draft NHI Bill was released for public comment in June 2018, and then revised before being submitted to cabinet. The updated version was approved by the cabinet on July 10.

Read the bill here: https://www.scribd.com/document/421162240/National-Health-Insurance-Bill

The bill contains potentially contentious measures, as it is expected to signal the government’s view on the future role of medical schemes and that of provincial health departments. Observers will also be scrutinising the governance measures put in place to protect the NHI fund from corruption. Mkhize said on Thursday that medical schemes “will have no trouble” adapting to the changing environment, “by developing products and services that provide complementary cover”. Once the bill has been tabled in parliament, it will be considered by both the National Assembly and the National Council of Provinces, which are both expected to undertake a process of public consultation.
  
2019/08/082019/08/14 12:07 PM
Health Minister Zweli Mkhize on Thursday said expenditure in health should be a crucial investment in the country.

Mkhize was speaking in Pretoria where he officially released the National Health Insurance (NHI) Bill.

Cabinet approved the bill last month, which paved the way for the process of universal health coverage to be put into legislation.

Details of the bill were made public, including its beneficiaries and how it would be funded.

Mkhize said the NHI aimed to transform the country’s struggling health sector and give citizens quality healthcare.

“This is a very important moment wherein we are making a conscious decision to end the inequality in access to healthcare services,” he said.

The Health Department said the NHI would be funded through a mandatory prepayment system that aimed to achieve universal access to health. It said a board would be established to oversee the system.

While questions were asked of how this massive insurance would be funded, the main source would be appropriations and general tax revenue.
  
2019/08/082019/08/20 10:25 AM
Your medical aid, in its current form, will cease to exist if the National Health Insurance (NHI) bill introduced to parliament today becomes law. The bill stipulates that, once the NHI has been fully implemented, “medical schemes may only offer complimentary cover…[ for]… services not reimbursable by the Fund”. 

The NHI will be funded “in accordance with social solidarity” through payroll taxes for employees and employers, a surcharge on personal income tax, the reallocation of medical scheme tax credits to the fund and general taxes.

According to the Bill, which was signed off by Health Minister Zweli Mkhize in July, the NHI Fund will be fully operational by 2026. By then, the fund will be the single purchaser of both public and private healthcare services in the country through a “system of mandatory payment”.

Medical aids will only be permitted to provide top-up cover to their members; the bill, however, doesn’t specify what services the NHI would cover.  A benefits advisory committee, appointed by the health minister, will decide on what will be offered. The services will be available for free, so there will be no co-payments.

Private-sector health professionals who participate in the NHI will be paid in fundamentally different ways: they will only be able to charge prescribed NHI rates for their services. Currently, doctors and dentists practising privately can charge whatever they like, because there are no set fees. For more than a decade, the government has tried to impose such rates, but, each time, the private sector has instituted court proceedings and won.

The rationale behind the NHI is to provide the same quality healthcare to all South Africans, regardless of their ability to pay for it. The cross-subsidisation between rich and poor will be quite significant: according to the Council for Medical Schemes, the body that regulates schemes, only 16% of South Africans can afford medical aid premiums. The rest of the country relies on a dilapidated public healthcare system, although some of them also visit private doctors, for which they pay cash.

Through the NHI, the medical aid contributions of the 16% will be used towards the NHI to help to subsidise the cost of care for the 84% of the population. The country is currently in its second phase of the NHI’s implementation (2017-2022).

During this phase, legislation will be put in place for the NHI to be implemented. The fund will also start to buy healthcare services for vulnerable groups such as children, the elderly and people with disabilities. 

In order to access a healthcare facility through the NHI, South African citizens, permanent residents, refugees, inmates and “certain categories of foreign nationals” would need to register at an NHI-accredited primary healthcare facility in their area.  Each time they need healthcare, they would have to first visit that facility. NHI members will only be able to consult a specialist if the doctor or nurse at their primary healthcare deems it necessary to refer them to one.

A contentious issue in the Bill, that is likely to be fought in court cases driven by civil society, is that undocumented migrants and asylum seekers will not be able to access the NHI in full: they will only be allowed to access emergency medical services and services for “notifiable conditions of public health concern”, such as TB.

Although the Bill doesn’t refer to HIV services, migrants and asylum seekers are likely to be provided with HIV treatment, as HIV is infectious and it is in the best interest of the country to treat everyone who is infected with the virus to prevent its spread. A 2007 national health department directive also guarantees free TB and HIV care to anyone regardless of immigration status. 

The NHI Bill doesn’t specify how much the scheme will cost. It does, however, specify that a “health benefit pricing committee” comprising of between 16 and 24 members with “expertise in actuarial science, medicine, health economics and financing”, among other fields, will recommend prices of health services.

Mkhize told Bhekisisa: “The question should not be whether South Africa can afford the NHI. That is the wrong question. The question should be: do we have an option?”

The Bill will now be debated by the National Assembly as well as the National Council of Provinces. It will also navigate a process of public consultations.

This article was amended on 12 August 2019. The term illegal immigrant was changed to undocumented migrant in line with internationally accepted language.
  
2019/08/072019/08/14 11:01 AM
Health Minister Zweli Mkhize says there's no problem in the public health sector the National Health Insurance system can't fix.

Mkhize comments come despite a severe lack of hospital staff, including specialists.

A 200-page report shows outreach teams didn’t even meet their target of improving care for infants and pregnant women due to a lack of paediatricians and gynaecologists.

The findings were made by private consultancy firms and Wits University, following the NHI pilot projects.

Mkhize is assuring the country that the NHI is the panacea to all the problems in the health sector.

“We can still do a lot even in the absence of the number of specialists that have been reported,” Mkhize said.

“You can get a cover from specialists in a way that would not compromise the health services. It is something that can be managed and until we have a full NHI, we will be able to deal with it.”

Mkhize also believes the alleged racial profiling of doctors by medical aid schemes will be eradicated by NHI.

“Going forward into the future, there will not be a need for profiling because we are hoping NHI will embrace people who are professionals coming from various disciplines to deal with issues of health promotion. Including specialist care,” Mkhize said.

The NHI Bill is before Parliament and must still be debated in the National Assembly and National Council of Provinces.

  
2019/08/062019/08/14 10:12 AM
Taxpayers should be concerned about the recent announcement by Dr Zweli Mkhize, the minister of health, that the final National Health Insurance Act (NHI) will come into effect before March 2020. The implementation of this law will in effect mean that the ruling ANC will have the power to decide what treatment you need, who should provide it and where you should receive it. It is also widely expected that it will result in a shocking tax increase.

The NHI envisages a national, single-paying health system for South Africa that will dictate the service levels, price and scope of healthcare. According to Mkhize, in terms of the NHI, healthcare will be the same for everyone and healthcare workers will be available to provide services on an equal basis. If this intended equal level were of a high standard, the NHI might not have been so undesirable, but the level of public sector healthcare is so appalling that very few facilities will qualify to provide services in terms of the NHI. According to a report by the Health Standards Compliance Office, only five of 696 state hospitals and clinics that were surveyed in 2016-2017 complied with the health department’s norms and standards to achieve an 80% pass rate.

According to the June 2017 NHI White Paper, this scheme will apply to the treatment of cardiology, dermatology, neurology, oncology, psychiatry, obstetrics, gynaecology, paediatrics, orthopaedics, and surgery – including organ transplants. This means that the ANC will be able decide who a woman’s gynaecologist should be, as well as where and by what method her baby should be born. At the primary healthcare level, the NHI will provide, among other things, sexual and reproductive healthcare, the rehabilitation of oral health, and mental health treatments.

This can mean that the state will decide on your behalf what contraceptive you should use, whether your child needs orthodontics or not, as well as whether you really need to use antidepressants. Is this the type of power we want to put in the hands of the state? Especially in light of the distinction the current government is making between races?

Furthermore, about 8,3% of the population will be obliged to fund the NHI for the benefit of the entire country. According to SARS, in the 2018 tax year there were only 4.8 million registered taxpayers, while South Africa’s population figure (during this period) was 57.7 million. When one considers the high levels of poverty, unemployment and this disproportionate small tax base, it is difficult to imagine how a government-funded system of “free healthcare for all” can work in South Africa. South Africans will be obliged to belong to the NHI system and taxpayers will be required to pay for it, even if they choose to make contributions to a private medical aid fund as well. All health revenue generated by the NHI will be paid into a central fund from which payments will be made.

According to a study by AfriForum, the NHI can cost taxpayers up to R446.8 billion a year (and not R30 billion, as Mkhize argues). Yet, the health minister still cannot explain where this money will come from. His only vague answer is that the NHI is the solution to the current lack of funds in the health system. Considers that the health department received one of the worst audits of all the departments in the 2017/2011 financial year, however, it is clear how these deficits in the healthcare sector came about.

For many poor people, the implementation of the NHI sounds like the answer to their current health problems (by implication, the dire conditions in state hospitals and clinics). By the time people realise that the NHI cannot live up to the health minister’s golden promises, however, the health system in South Africa, as we know it today, will already have been destroyed. This is why citizens should oppose this system with all their might and give civil organisations their mandate to protect free market principles.
  
2019/08/062019/08/14 10:34 AM
Yet another positive article about the future of the NHI appears in your newspaper, this time by Ms Phumla Williams and, yet again, the writer is out of touch with reality.

Let writers stop living in Disneyland and come down to earth and face reality. Let us first look at how South Africa manages the current health care system. Bad news. It’s a complete cock up. Since Mandela ended his walk to freedom and the ANC took power, the state of our health system has gone down the drain. Yes, like all systems, there are little pockets of excellence, but generally the hospitals are failing on a daily basis, medicine is stolen, then sold to patients at higher prices, many patients spend most of their stay in the corridor, rather than the ward. It’s fairly normal for sick people to sleep on the floor and it’s not unusual for patients to die while waiting months for treatment. Can this be true? Just read The Star.

Many, many South Africans make the silly mistake of thinking that, because the more wealthy pay thousands per month to belong to medical aid companies and because they get treatment at far superior hospitals (where they are not asked to bring their own bedsheets!) many believe that this is unfair to the poor and the government should  take from the more wealthy people and their hospitals and give some to the poor. This is really, really stupid because all you then do is weaken the successful system and cause more business people to move overseas.

The same mentality is often used by people who think that the private and independent schools (paid for by parents at fees many times higher that those paid by less-well-off parents) are to blame for the terrible standard of education offered to the majority who are, generally black. So, the less intelligent of our members of parliament, in particular, want to force the successful schools to enrol more of the poor population who, generally don’t pay their school fees. It sounds pretty stupid when you say it like that. That’s because it is pretty stupid. You don’t improve the poor schools by damaging the private schools! What you do is concentrate on improving government schools and attempt, where possible, to learn from the private and independent schools.

The same applies to the health sector. Walk through the average government hospital and then compare it with the well-run, clean, efficient private hospitals. Then ask yourself how can I improve the government hospitals and health service to benefit the poor of South Africa? Why do the private hospitals work and why do the government hospitals fail? Why is the paint peeling off the walls of the government hospital? Why are the sewers backed up? Why is it the staff in many government hospitals don’t care if you die while you wait? Why does the government doctor ask for a donation in order to  serve you sooner? (Yes, it happened to me).

What do the private and independent schools succeed where, generally, the government schools fail? Why is the  Matric pass rates so high in private schools and so low in most government schools? Why do we set the standard so low in government schools resulting in the Matric certificate having little or no value in the workplace?

Wake up South Africans and face reality. You cannot wave a magic wand and make the NHI system perfect by building it on a foundation that is failing, that is corrupt. You can’t make the NHI service work without, wait for it, deducting money from the salary of every working black person, down to the maids and the gardeners! Did you hear me? Everyone will have to contribute money, every month, for the whole of their working life in order to pay for the NHI. How do I know? Because every NHI system in the world makes everybody pay towards the NHI system. You, the average to low earner may say, but why should I pay? Well, think about it: The current South Africa health system does NOT work. It’s a sad joke. Don’t lie to yourself by pretending it works. It does not.

Ms Williams says, in her wisdom: ‘Through the NHI, the government envisages that private and public health care can equally share resources to accommodate all South Africans who need medical care without compromising quality and service standards’. Wrong! This is another way of saying, let the poor patients go to the private hospital and pay nothing to punish the private health care system from being successful. That’s just plain stupid. Think about it (please!); How many private hospital groups and medical aid schemes would leave South Africa if they are forced to share their money and fascilities with the poor people (however deserving)?

All that would happen is that the standard in the private medical system would drop while the government health system would remain exactly where is is today. In addition, once a fund is created from the monthly fees deducted from the population, you and I know that many of the people in charge of spending those funds would steal much of the money. Why do I say that? Read The Star! Watch the news!Ms Williams hints that the new healthcare system will “reverse the inequalities in health care inherited from the apartheid system.” Rubbish. The ANC have had about a quarter of a century to improve health care and have totally failed.

You don’t improve a failing healthcare systems by punishing a successful one. You don’t improve government schools by taking away from the success of private and independent schools. Wake up South Africa before you fail, as many other African countries have failed. South Africa can lead Africa. South Africa can show the rest of the world that is can be a great success story. All it takes is common sense and NOT lying to the people.


Richard Stewart is the Production Manager of the Fleet Street publication ‘The Law Society Gazette’. He came to Africa in 1975 and have spent most of my life marketing health and educational films on behalf of companies such as Encyclopaedia Britannica, BBC and National Geographic. He made many bulk film sales to SABC and other TV stations across Africa and around the world.
  
2019/08/052019/08/14 09:54 AM
There are few things more devastating than being denied quality health care because of one’s socio-economic status. This, sadly, is a reality faced by the majority of South Africans.
The country’s health-care system has over the years resulted in disparities in how it is administered. It is based on both the private and public health systems. Up to 84% of the population receive services through public health facilities which are inadequately resourced, while only 16% have access to the private health-care system, which is highly resourced.

More so, the unfortunate reality is that even those who are members of private medical aid schemes often find themselves in a quagmire as medical aid savings and benefits are exhausted before the end of the annual financial contribution cycle. This is always attributed to the exorbitant price structure in the private health system. This, then, cannot be a fair system. In redressing this anomaly, our National Development Plan (NDP) envisages a health-care system that works for everyone. It provides for several key elements aimed at putting programmes that will meet the constitutional mandate which instructs that the government provide health-care services to all South Africans, irrespective of their socio-economic background, and within the available resources. One of those elements in the NDP proposes that the government implements a financially-sound health system based on universal health ­coverage. It is a system that will pool funds to provide access to health services for all South Africans. This system is the National Health Insurance (NHI), which will be implemented in phases to tackle the unacceptably high levels of inequality, particularly as they relate to the health-care services in the country. Addressing the country during his recent State of the Nation Address, President Cyril Ramaphosa said: “By introducing the NHI together with a multi-pronged quality improvement programme for public health facilities, we are working towards a massive change in the health-care experience of South Africans.”

As the president indicates, the programme to change how we provide health-care services to all of South Africa will be multi-pronged. This will, among many interventions, deal with the country’s preventative programmes, improve the quality of our health infrastructure and human resource capacity in our health facilities, strengthen the partnership between the private and public sectors and strengthen our governance structures and information system. Through the NHI, the government envisages that private and public health care can equally share resources to accommodate all South Africans who need medical care without compromising quality and service standards. It will draw in hospitals, clinics, doctors, specialists and dentists from across the health sector. Work has already begun to strengthen this sector and to engage stakeholders through the Presidential Health Summit convened in October last year. Last year the Cabinet approved the NHI Bill for release for public comment over the 90 days ending in September that year. The bill proposes the establishment of an NHI Fund Entity in terms of Schedule 3 of the Public Finance Management Act. This structure will oversee the funding and procurement of the health services of all registered beneficiaries. Out of the public consultations last year, this bill was enriched with inputs from various communities. Last month, a revised bill was presented for consideration by the Cabinet. It was approved for submission in the National Assembly to also go through another rigorous parliamentary process. The process will again entail public consultations and will be debated in both the National Assembly and National Council of Provinces. The bill will only be passed into a law that will serve its intent once all of us have made our inputs, which will be canvassed through those public consultations. In line with Section 27(1) b of the Constitution, the NHI will be implemented in various phases depending on available resources. An implementation plan will also be put in place to ensure transparency. The implementation plan of the NHI, together with several key elements still to be put in place, will help reverse inequalities in health care inherited from the apartheid system.

Before 1994, health services were racially segregated and black people were provided with an inferior public health service compared to that of their white counterparts. There have, understandably, been many varying opinions about the proposed NHI, with some claiming that it will harm the private health-care sector. It is therefore important to state that the NHI will create space for the private and public sectors to complement each other in serving the health needs of our people.

Phumla Williams is the acting director-general at the Government Communication and Information System (GCIS)
  
2019/08/052019/08/14 09:58 AM
Gauteng MEC for Health Dr Bandile Masuku convened an Inaugural Health Conversations set to take place on Wednesday at Emoyeni Conference Centre in Parktown, Johannesburg.

The conversations will be held under the theme “The Health Market Inquiry and its implications for universal health coverage (NHI).”

The NHI, which stands for National Health Insurance, will rely on unified collaborations and effective political will.

NHI is a culmination of a collaborative effort by government, civil society, business, private providers, academia and health professionals to develop a plan that includes clear objectives, timelines, indicators and financial resources to effectively address challenges in the sector

These Healthy Conservations will be held bi-annually over the next 5 years.

MEC Masuku will be inviting speakers from various backgrounds and sectors to exchange ideas with Gauteng Department of Health on various aspects of public health and public policy issues.

The Competition Commissioner of South Africa, Mr Tembinkosi Bonakele, will address the Inaugural Healthy Conversations event.
  
2019/08/052019/08/14 10:10 AM
Taxpayers should be concerned about the recent announcement by Dr Zweli Mkhize, the minister of health, that the final National Health Insurance Act (NHI) will come into effect before March 2020. The implementation of this law will in effect mean that the ruling ANC will have the power to decide what treatment you need, who should provide it and where you should receive it. It is also widely expected that it will result in a shocking tax increase.

The NHI envisages a national, single-paying health system for South Africa that will dictate the service levels, price and scope of healthcare. According to Mkhize, in terms of the NHI, healthcare will be the same for everyone and healthcare workers will be available to provide services on an equal basis. If this intended equal level were of a high standard, the NHI might not have been so undesirable, but the level of public sector healthcare is so appalling that very few facilities will qualify to provide services in terms of the NHI. According to a report by the Health Standards Compliance Office, only five of 696 state hospitals and clinics that were surveyed in 2016-2017 complied with the health department’s norms and standards to achieve an 80% pass rate.

According to the June 2017 NHI White Paper, this scheme will apply to the treatment of cardiology, dermatology, neurology, oncology, psychiatry, obstetrics, gynaecology, paediatrics, orthopaedics, and surgery – including organ transplants. This means that the ANC will be able decide who a woman’s gynaecologist should be, as well as where and by what method her baby should be born. At the primary healthcare level, the NHI will provide, among other things, sexual and reproductive healthcare, the rehabilitation of oral health, and mental health treatments.

This can mean that the state will decide on your behalf what contraceptive you should use, whether your child needs orthodontics or not, as well as whether you really need to use antidepressants. Is this the type of power we want to put in the hands of the state? Especially in light of the distinction the current government is making between races?

Furthermore, about 8,3% of the population will be obliged to fund the NHI for the benefit of the entire country. According to SARS, in the 2018 tax year there were only 4.8 million registered taxpayers, while South Africa’s population figure (during this period) was 57.7 million. When one considers the high levels of poverty, unemployment and this disproportionate small tax base, it is difficult to imagine how a government-funded system of “free healthcare for all” can work in South Africa. South Africans will be obliged to belong to the NHI system and taxpayers will be required to pay for it, even if they choose to make contributions to a private medical aid fund as well. All health revenue generated by the NHI will be paid into a central fund from which payments will be made.

According to a study by AfriForum, the NHI can cost taxpayers up to R446.8 billion a year (and not R30 billion, as Mkhize argues). Yet, the health minister still cannot explain where this money will come from. His only vague answer is that the NHI is the solution to the current lack of funds in the health system. Considering that the health department received one of the worst audits of all the departments in the 2017/2018 financial year, however, it is clear how these deficits in the healthcare sector came about.

For many poor people, the implementation of the NHI sounds like the answer to their current health problems (by implication, the dire conditions in state hospitals and clinics). By the time people realise that the NHI cannot live up to the health minister’s golden promises, however, the health system in South Africa, as we know it today, will already have been destroyed. This is why citizens should oppose this system with all their might and give civil organisations their mandate to protect free market principles.

Natasha Venter, Campaign Official at AfriForum.
  
2019/08/052019/08/14 12:10 PM
1.    Growing litigations against the Department

Litigation against the department is growing at a fast pace which DENOSA has hinted to the Department some of the contributory factors. In our view, gross shortage of health workers contributes about 70% of these litigations that the department is faced with. We proposed to the department and asked a fundamental question: why does the department not fill vacant posts instead of paying lawyers these exorbitant amounts?

2.    Safety of health workers not addressed

The safety of health workers in institutions was not taken care of, except for ambulances. We note this with concern because both nurses and patients are not safe in the health institutions. The recent incident at Ngwelezane Hospital where one patient killed another patient is a case in point that highlights the need to strengthen safety in the workplace. We thought MEC would come up with solutions in this regard.

3.    Implementation of NHI in the pilot districts

The implementation of the National Health Insurance (NHI) in the pilot districts in the province has failed dismally. The pilot unearthed many infrastructural and backlogs in the districts which have not yet been addressed. Despite this, however, the national department of health is still adamant that they are ready to start NHI. DENOSA reiterates that the NHI must not be met with the same challenges that exist today which, like the filling of vacant position created by retirement of resignation, should easily be resolved.

4.    Poor infrastructure

Infrastructure of the department in almost 80% of institutions is a disgrace and unsafe for both health workers and patients.

5.    Moratorium on junior category posts

The continuing moratorium on appointment of personnel to junior category posts is a problem because if a staff nurse retires or resigns their posts are not filled, which leaves the burden of workload with those remaining behind. The situation is dire and needs great leadership.
  
2019/08/052019/08/14 01:20 PM
Nursing union, Denosa, has expressed concern about the budget vote put forward by KwaZulu-Natal Health MEC, Nomagugu Simelane Zulu. Last week, the MEC delivered her maiden budget vote at the KZN Legislature.

According to Denosa provincial secretary, Mandla Shabangu, issues relating to the growing number of litigations, the safety of health workers, the failure of the National Health Insurance pilot projects and the failure to fill staff vacancies were of major concern to them. 


"In our view, gross shortage of health workers contributes about 70% of the litigations that the department is faced with. We proposed to the department and asked them to fill vacant posts rather than pay lawyers exorbitant amounts," he said.

Shabangu said the safety of health workers in institutions was not taken care of, except for ambulances.

"We note this with concern because both nurses and patients are not safe in the health institutions. The recent incident at Ngwelezane Hospital where one patient killed another patient is a case in point that highlights the need to strengthen safety in the workplace," he said.

He said the failure of NHI in pilot districts highlighted the plight of the issues with the department.

"The pilot unearthed many infrastructural and backlogs in the districts which have not yet been addressed. Despite this, however, the national department of health is still adamant that they are ready to start NHI," he said.

"Another fact is the continuing moratorium on appointment of personnel to junior category posts is a problem because if a staff nurse retires or resigns their posts are not filled, which leaves the burden of workload with those remaining behind. The situation is dire and needs great leadership," he said.
  
2019/08/022019/08/06 01:25 PM
Winston Churchill once said “Failure to plan, is planning to fail”. Planning is, however, not a guarantee of success. The SA government has proved itself quite adept at drafting plans and policies to fix everything from SAA and Eskom to the ailing economy. What has proved elusive is the capabilities to implement these plans.

Now a grand plan to solve the public health system crisis has been launched with much fanfare. But it remains a plan, one that will only succeed if it can be implemented successfully. It seems the future of the entire health system is being bet on the government being able to implement its plan and turn the public health system around, without even waiting to see if it makes any difference.

President Cyril Ramaphosa is indicating that the success of this plan will lead to the implementation of National Health Insurance (NHI), and the government is proceeding with the legislation to enable an NHI fund to be established. The question remains: what happens if the presidential health compact fails to fix public health care?

SAA has had 10 turnaround strategies in the past 15 years and is still nowhere near profitability. Strategic plans at Eskom and the SABC are being hamstrung by unions that are concerned with job losses and the retrenchments required to implement the tough, unpopular strategies required to turn these entities around from the brink. It seems those same unions are oblivious to the fact that the implementation of NHI will move almost all health service delivery out of the provincial responsibility sphere, making most administrative staff at provincial health departments redundant.

The same union members who receive treatment for injuries on duty in the private sector will be expected to use state facilities for future treatment, along with the waiting times prevalent in the state sector. The fact that union federation Cosatu has been largely silent on the NHI Bill being approved in parliament might be an indication that its members have started raising concerns about the project to their union leadership.

As much as one would not plan to fail, in the instance of the SA healthcare system it would be prudent to start looking at alternatives to NHI prior to the presidential health compact failing in its aims. Actually, I don’t believe it’s a question of “if it will fail” but rather “when it fails”.

A great many of the proposals in the compact are things that already should be happening in the health system, and others that are legislated and regulated to happen. It is wishful thinking to assume that the same management personnel who have been failing to apply regulations and doing their jobs for years are miraculously going to become competent and efficient because this document has been signed.

Currently, 95% of public facilities do not attain the required standards for contracting with the NHI fund. The government is going ahead with the NHI Bill despite this. If the compact fails to radically improve the quality of state facilities to levels where they qualify to contract with the NHI fund, which facilities are going to render services to South Africans under NHI? The NHI white paper has stated that public facilities will form the backbone of NHI service delivery. If the backbone is missing due to not being able to contract with NHI, it will leave the entire health system totally paralysed.

The government is putting all its eggs in one basket with the presidential compact/NHI plan, with little thought being given to a scenario where the compact fails to completely turn around every failing facility in the entire public health system, and NHI therefore cannot be implemented. Little consideration seems to be given to all the small, interim measures that can be implemented to improve public health quality and reduce costs in the private sector. Why must government policy always rely on grand, ideologically driven systemic changes, rather than focusing on the small, practically implementable steps that can be taken to fix problems?

If — or when — the presidential health compact/NHI fails, the systemic damage caused by its attempted implementation will be so severe that it will take decades to fix. The NHI pilot projects have shown that success is unlikely, and yet the government is blindly rushing forward with NHI, every devastating step taking SA health care closer to the abyss.

• Dr Serfontein is a member of the Free Market Foundation health-care policy unit.
  
2019/08/012019/08/06 01:30 PM
The government’s controversial controls on private-sector medicine prices delivered immediate and sustained savings after they were implemented in 2004, according to research published earlier this week in peer-review journal PLOS ONE.

The study found there was a significant drop in prices of innovator drugs and generic copies of those that were no longer patent protected.

The health department introduced the single-exit price (SEP) regulations in an attempt to make private-sector medicines more accessible by regulating prices and introducing transparency along the entire supply chain, from manufacturer gate to pharmacy shelf. The SEP is the ex-manufacturer price of a medicine combined with the logistics fee and VAT, and is the same for all customers, regardless of volume bought. The regulations also cap dispensing fees pharmacists and dispensing doctors may levy.

When the SEP regulations came into effect, a new price was calculated for each private-sector medicine, based on the weighted average of all of the previous year’s sales, including all the discounts and off-invoice rebates enjoyed by key customers. Since then, manufacturers usually get only one price increase a year at a ceiling set by the pricing committee that advises the health minister.

Until now there has been little hard evidence of the effect of this policy. But in a study published in PLOS ONE this week, researchers showed that there were significant and immediate price cuts for the majority of medicines, and that in many cases prices continued to fall.

“This research shows the SEP had a real impact, even on generic pricing, which came down remarkably,” said study co-author Fatima Suleman, who is professor of pharmaceutical sciences at the University of KwaZulu-Natal.


The researchers selected three baskets of drugs, and examined prices between 1999 and 2014. In one of the baskets, dubbed the “global” core and drawn from a list of World Health Organisation-approved medicines, they found 10 out of 14 originator molecules showed a significant price drop in 2014. Twenty six out of 28 generics also saw a sharp price cut, and two-thirds of the medicines (65%) saw a sustained drop in prices.

The SEP regulations were immensely controversial when they were first flighted. Pharmaceutical manufacturers warned that the government’s plans to cut medicine prices threatened their viability. Retail pharmacists launched a legal challenge that went all the way to the Constitutional Court, but ultimately saw their dispensing fees regulated. 
  
2019/07/312019/08/06 12:25 PM
Paying for unlimited doctor’s visits could save patients and medical schemes thousands in medical bills, says Stan Moloabi, the chief operating officer at the Government Employees Medical Scheme (Gems).

Moloabi was speaking at the annual conference of the Board of Healthcare Funders of Southern Africa (BHF) held in Cape Town last week.

When people have to pay for visits to a general practitioner (GP) out of pocket one in three of them will go directly to more expensive specialists even when they have a basic ailment,  Gems data presented at the conference show. Patients who snub their GP in favour of a specialist pushed up the cost of care by 12%.

But, Moloabi argues, just because people can go to the doctor for free, doesn’t mean they’ll go when they’re not sick. "People don’t like queuing," he quips.

'A magic combination'

On top of unlimited trips to the GP, members of Gems’ sapphire package — the cheapest package that the scheme offers — are also completely covered for preventative services, including screenings for sexually transmitted infections, breast or ovarian cancer as well as cholesterol.

It’s proven to be a magic combination – but there’s a catch.

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