The recent HASA 2017 Conference brought together top leaders from the private healthcare sector to discuss what’s needed to move forward in the successful implementation of National Health Insurance (NHI). One message was clear: as a country we need to stop talking about universal access to healthcare and start implementing projects and programmes that will make a real difference in people’s lives now. Almost all of the invited speakers made note to this, something which has been referenced to at every NHI themed conference or gathering of healthcare professionals since the private sector accepted the fact that NHI is inevitable to rectify the healthcare system that’s failing the majority of South Africans.
Public-private collaboration a must
Following the opening of the HASA 2017 Conference, delegates heard from the CEO of Beneficência Portuguesa de São Paulo, Denise Soares dos Santos, and CEO of Instituto de Estudos de Saúde Suplementar, Luiz Augusto Carneiro, about how the public and private sectors are co-existing under the Brazilian universal health system. Universal health coverage, called SUS (Brazil’s Unified Health System), was implemented in 1990 to ensure all Brazilians have access to the public system without any payment. The private sector and medical aid schemes remained in place to provide supplementary healthcare cover, of which 99% consisted of employment benefits.
Despite the success stories that we tend to hear about the Brazilian system, the two presentations pointed out that we in fact share a lot of similarities with them. For example, the Brazilian public system covers 76% of the population, but as with here in South Africa it lacks funding and resources, has extensive waiting lists for medical procedures and is plagued by inefficiencies and mismanagement. Therefore despite the public system being available for free, Brazilians have to rely on private healthcare facilities for quality care. In fact, as Soares dos Santos pointed out, 74% of Brazilian healthcare facilities are private.
Soares dos Santos’s final message was that under NHI the South African public and private systems have no choice but to coexist. “Public health is a challenge, and joining efforts with the private system to overcome difficulties is the only way to deliver quality care to the underprivileged population,” said Soares dos Santos.
Public education isn’t sustainable
On the second day of the HASA 2017 Conference, Vice Chancellor of Manipal University in India, Dr Hattangadi Vinod Bhat, took to the stage to present the work his private medical teaching institution is doing in India. His presentation’s theme focused on how the private sector has an important role to play in overcoming the shortage of healthcare professionals in any country.
Manipal University was established as the first private medical teaching facility in India in 1953 and over the last six decades the institution has expanded its network to six universities across 10 campuses worldwide, with over 220,000 students enrolled in different faculties. Manipal University is now one of many private medical teaching facilities in India that has helped the country to produce tens of thousands of doctors per year.
Using Manipal University as an example, Dr Bhat explained how the establishment of private medical schools has helped to combat brain-drain by retaining medical students who would otherwise have gone on to study abroad, and stay there. In light of South Africa’s on-going brain-drain, along with a shortage of medical professionals graduating from South Africa’s limited public medical schools to meet the country’s large disease burden, there has been a growing demand from the South African private sector to introduce accredited private medical schools.
While South African private hospitals have the resources available to help with private medical education, Manipal University has also expressed its interest in partnering with South Africa to unlock opportunity. However, the move towards implementing private medical schools can only happen once government revises legislation.
Focus on quality instead of financing
During her presentation at the HASA 2017 Conference, Director of health economics practice Econex, Mariné Erasmus, explained why the discussion around NHI financing is the biggest distraction from what we really need to be focusing on, and that is quality healthcare. According to Erasmus, South Africa spends a lot of money on healthcare – the wealthy and other tax payers are contributing funds to our health system and the government’s healthcare expenditure is getting larger and larger. Yet despite this, overall we aren’t seeing any results and the poor population continues to get punished.
Based on this reality, Erasmus argued that healthcare funding isn’t the biggest issue in our healthcare system; it’s rather structural issues around governance, management, accountability and lack of service delivery. Erasmus went on to make reference to the 2014/2015 Office of Health Standards Compliance (OHSC) compliance results of 417 public facilities which found that two thirds of the facilities failed in quality – 27.8% were non-compliant and a staggering 39.8% were critically non-compliant. Examples of poor quality included sedated patients left on the floor unattended; expired drugs; empty emergency trolleys and unsterile instruments used on patients.
According to Erasmus, it’s counterproductive to throw money at the problem if the inefficient structures are still in place. For example, if government removes tax credits and/or increases taxes to help finance NHI then more people will be at a higher financial risk and will have less disposable income to contribute to the economy, thereby reducing GDP growth. Not to mention that the cost of employment will increase and there will likely be a negative impact on ratings agencies’ assessments of South Africa. And even then an increased taxation financing model wouldn’t fix the quality issue previously discussed because it isn’t only a money issue.
“Structural problems need structural solutions. We may require some funding along the way, but for now it is a great distraction. The real solution we need is likely to be less costly and produce better outcomes for all,” said Erasmus.
What we need to focus on instead of the financing debate is how leadership can be strengthened to ensure they are accountable in ensuring quality services at their healthcare facilities. “There’s no reason why we can’t do it,” said Erasmus. Instead of starting from scratch the government can utilise the private sector to improve management and service delivery in the public sector. There are even a number of existing resources in the public sector that can be improved on and harnessed, such as the innovation behind the world’s first penile transplant, which happened at Tygerberg Hospital, a public facility.
What’s more, to alleviate the burden on the public system, Erasmus noted that South Africans should be incentivised to pay for themselves in the private sector because if more people use private healthcare then prices will become more affordable. South Africans have an important role to play in the development of NHI by taking part in policy review and voicing their opinion. With NHI we still face a lot of uncertainty and government is still trying to figure out the best way forward. So even though there may seem to be a trust deficit between the two healthcare sectors, the government requires opinion and guidance from all sides to ensure NHI is successful.