SECTION27 and the Treatment Action Campaign (TAC) welcome the release of the Green Paper on National Health Insurance (NHI) for public comment. As organisations committed to the realisation of the right of everyone to have access to health care services, as guaranteed in section 27 of the Constitution, we value the opportunity to participate in what appears to be a clearly defined and well-considered policy development and implementation process that is to be accompanied and underpinned by legislative reform.
While we are still busy studying the detail of the Green Paper and consulting with our partners, we would like to make a number of initial comments. SECTION27 and TAC support both the underlying principles of NHI – access as a right, social solidarity, effectiveness, appropriateness, equity, affordability and efficiency – as well as its objectives. In summary, these are –
- Improving access to quality services for all;
- Pooling risks and funds to achieve equity and social solidarity;
- Procuring services on behalf of the entire population;
- Mobilising and controlling key financial resources in an efficient manner; and
- Strengthening the public health sector.
We support a system of NHI that is designed to draw on the strengths and address the weaknesses of both public and private health sectors, with all health care services being unified on the basis of constitutional rights and the obligations they place on them. In particular, as the Minister of Health has stressed, “NHI is not a war between the public health sector and the private health care sector”; rather, its objective is to “get the best out of both systems for the benefit of the public.”
We recognise the size of the challenge in maximising the available financial and human resources currently expended on the provision of health care services. In part, this will require the taking of reasonable legislative and other measures designed to ensure the transparency of tariff structures and the reasonableness of prices. It will also require significant improvements in the quality of public health services in terms of a quality control system to be developed and implemented by the proposed Office of Health Standards Compliance.
With this in mind, we commit ourselves to defending the Minister’s right – essentially a constitutional obligation – to take all reasonable evidence-based measures necessary to restructure the health system. Given the challenges outlined in the Green Paper, some of these measures may in fact need to be particularly radical; health is a fundamental right, not an ordinary commodity.
The Green Paper is lacking in some detail, such as information on the source(s) of funds for health financing, the future role of medical scheme administrators and the various packages of benefits to be available at different levels. But it proposes a clear way forward to gather evidence on and consider how best to address some of the unanswered questions. In particular, it proposes a well-considered piloting stage starting in 2012 that is to be funded by way of a conditional grant. Importantly, reasonable criteria will guide the selection of the initial ten districts: the result of facility audits; demographic profiles and key health indicators.
We have, however, also identified a number of concerns that we will investigate further and consider in our written submission. Amongst others, these include –
- The proposed complete exclusion of those who are not citizens, permanent residents, refugees or asylum seekers (such as undocumented migrants), raising concerns about their constitutional rights and the public health implications of a system that does not offer essential services to all;
- The somewhat ambivalent status of asylum seekers (and refugees to a lesser extent), whose rights of access to health care services may not be sufficiently clarified in the Refugees Act 130 of 1998; and
- The nature and governance structure of the proposed National Health Insurance Fund, which does not appear to be have an adequate level of structural and operational autonomy necessary to discharge its mandate efficiently, effectively and in the public interest.
We are encouraged by the Green Paper’s honest and sober reflection on the state of health and health institutions in South Africa, its commitment to evidence-based interventions and its recognition of the need for reasonable planning at all stages of the policy development and implementation process. We congratulate the Minister of Health, his Director-General and their staff on its development and publication. In the coming months, we will consult with our partners, prepare a comprehensive written submission and actively engage in the broader consultation process.