NHI a bonanza for bureaucrats, a gift for looters

Di McIntyre’s comments in support of the National Health Insurance (NHI) system, “We can build NHI, and we should” (August 25), are a mix of snide insults to the “privileged”, false claims about NHI benefits and costs, and blithe assumptions about how “vigilance” can safeguard the new system from corruption.

Her assertions are also misguided. On the contrary, the NHI is not needed to achieve universal health coverage. Instead, this requires much more efficiency and accountability in public health care. It also needs increased access to private care, to be achieved by allowing low-cost medical schemes and empowering poor households to access these via tax-funded health vouchers.

Major additional taxes (at least a 3% payroll tax, a 3% surcharge on income tax, and a 20% VAT rate) will be required at the start, and are likely to increase as the population expands.

Medical scheme members may pay just as much in increased taxes as they do now for their monthly contributions, while the benefits they receive are likely to be less.

In addition, high contributions could be reduced by allowing low-cost medical schemes and introducing compulsory enrolment for all formal employees, which would spread risks and further bring down contributions.

There will be no major cost savings from “strategic” NHI purchasing. Instead, comprehensive state controls will rule out competition and innovation, while the purchase of every item needed for 59-million (and more) South Africans will be subject to escalating BEE requirements. Yet already these rules taint some 40% of state procurement with fraud and inflated prices. They also spawn violence and intimidation by those demanding “their” 30% “share” of subcontracts.

Tens of thousands of deployed cadres will be needed to implement all the NHI’s controls, even with a simplified payment structure for health professionals (lump sums instead of the fee-for-service system). Many bureaucrats will be needed to certify and accredit all health facilities and professionals every five years.

Many more cadres will be required for the annual setting, evaluation and resetting of NHI controls over medicines, products, and technologies and their recommended prices. More still will be needed to staff

NHI sub-units, advisory committees and governance structures, along with health management offices in all municipal districts and primary contracting units in all sub-districts.

The NHI is likely to fuel an exodus of health professionals. This will lengthen treatment waiting times while crippling growth, reducing tax revenues and constraining state spending in every sphere.

Instead of benefiting from the NHI, the poor will suffer the most.

In addition, the “vigilance” for which McIntyre calls has not prevented a massive waste and/or looting of tax revenues through cadre deployment, BEE procurement and a narrower “Zupta” state capture. “Collapsing” all medical schemes into a single state-run medical aid and then giving the state the power to control every aspect of health care will expand the opportunities for capturing and looting all the NHI’s new entities.

To endorse the NHI proposal, thus, is to confirm that the key lessons of “how the state was allowed to be captured” (to cite McIntyre’s words) have yet to be learnt.

Dr Anthea Jeffery, head of policy research, Institute of Race Relations

Let’s not rush it

Many South Africans support health-care reforms towards achieving universal health coverage (UHC). According to the World Health Organisation, UHC is a health-care system that gives all citizens equal access to effective, good-quality health care without financial hardship. Our government is proposing NHI as a mechanism of achieving UHC.

NHI as an insurance can only address the funding needs of the UHC but not the delivery of health care. I support the need for NHI but it is a risky and enormous project to embark on given the following challenges: economic pressure, shrinking tax base and lack of trust in government.

The department of health lacks the track record for successful regulation and implementation, besides its HIV and TB programmes. Many blame the department for failed regulation of the private sector and lack of price controls. Nonexistent health-care information and inadequate immigration control make it difficult to plan. Many who can afford private health care or to pay for public health care are able to avoid contributions.

In the private sector there is a nonexistent pricing structure in which health-care professionals can charge any fee, yet medicine pricing is well regulated. Why not regulate the pricing of health-care professionals, hospitals and clinics similarly? We would reduce the cost pressure on medical schemes that leads to above-inflation premium increases. The Competition Commission and the department of health must resolve this.

Simplify and standardise medical scheme options so that all citizens understand what is covered or excluded. Drive transformation of the medical funding industry and hospitals/clinics.

I think NHI is a great idea but there is no need to rush the implementation. Embarking without the confidence of the troops is not good change management.

Dr Khaya Gobinca, Cape Town

Will they jump the queue?

My question about the NHI: will I be seeing the politicians who vote for it in the same queue as the rest of the population?

Dr Leon Jacobson, Sasolburg

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