Sara Gon |13 August 2019

Compromised accountability, and administrative headaches, promise to be essential features of the controversial National Health Insurance (NHI) scheme.

Among the range of troubling issues the NHI bill throws up are the implications for provincial governments’ constitutional role in organising local health services, and the increasing centralisation of health functions the scheme entails.

It seems clear that the NHI Fund would manage and oversee the distribution of funds to ‘district-level units’, which will identify the services needed, and specify who will provide them, and who will manage their contracts and payments.

These units’ direct line of management will be to the National Department of Health, and yet they’ll operate in areas serviced by provincial hospitals, though without the provinces having any authority over them.

The most contentious issue will be which level of government will ultimately ensure that the money to be spent on the new system will be well spent, and insulated from corruption.

The NHI Fund will have an 11-person board – one of whom will represent the health minister – which is accountable to the health minister. The board will be recruited through a public nomination process; then a minister-appointed ad-hoc panel will conduct interviews and make their recommendations to the minister before board members are appointed for a five-year term. They must be found to be free of any conflicts of interest. The board will, in turn, appoint the fund’s CEO.

Alex van den Heever, the chair of Social Security Systems Administration and Management Studies at the School of Governance at Wits University noted that ‘(this) approach to governance leaves wide scope for extracting patronage’.

‘Such practices have resulted in the failure of provincial health services and in South Africa’s state-owned enterprises,’ Van den Heever added. ‘No justification is provided for why the ministry of health should have such powers of appointment and removal within a domestic context where the experience demonstrates that it runs counter to the public interest.’

The Western Cape has warned that the NHI will introduce deep uncertainty about the role of provincial health departments and could diminish the amount of money available for service delivery.

While the purse strings may be in the hands of the national government, the provision of services will still be the responsibility of the provinces. Western Cape Head of Health Beth Engelbrecht has expressed the concern that ‘we will have a fragmented system, that accountability will be a challenge and that the complexity of the administrative processes in a province will be very difficult’.

Engelbrecht says further that the ‘premier and provincial government will have less capability to influence the well-being of our communities, because you will be depending on somebody up there [Pretoria] to buy services’.

Chapter Four of the National Health Act sets out the current responsibilities of the provinces. The important ones are to:

  1. provide specialised hospital services;
  2. plan and manage the provincial health information system;
  3. plan, co-ordinate and monitor health services and evaluate the rendering of health services;
  4. co-ordinate health and medical services during provincial disasters;
  5. conduct or facilitate research on health and health services;
  6. plan, manage and develop human resources for the rendering of health services:
  7. plan the development of public and private hospitals, other health establishments and health agencies;
  8. control and manage the cost and financing of public health establishments and public health agencies;
  9. facilitate and promote the provision of port health services, comprehensive primary health services and community hospital            services;
  10. provide and co-ordinate emergency medical services and forensic pathology, forensic clinical medicines and related services,                      including the provision of medico-legal mortuaries and medico-legal services;
  11. control the quality of all health services and facilities;
  12. provide health services contemplated by specific provincial health service programmes;
  13. provide and maintain equipment, vehicles and health care facilities in the public sector;
  14. consult with communities regarding health matters;
  15. provide occupational health services;
  16. promote health and healthy lifestyles;
  17. promote community participation in the planning, provision and evaluation of health services;
  18. provide environmental pollution control services;
  19. ensure health systems research; and
  20. provide services for the management, prevention and control of communicable and non-communicable diseases.

The NHI bill provides that in future provinces will ‘provide health services which “the Fund would purchase”’ in addition to:

(a) co-ordinating health and medical services during provincial disasters;

(b) co-ordinating emergency medical services and forensic pathology, forensic clinical medicines and related services, including the provision of medico-legal mortuaries and medico-legal services;

(c) providing and maintaining equipment, vehicles and healthcare facilities in the public sector; and

(d) protecting and promoting environmental health.

Clearly provinces will no longer play a role in performing most of the functions currently required of them. The lack of clarity as to how national government is going to operate vis-a-vis provincial is unclear; it seems that the line of reporting is going to be direct between national and district officers, by-passing the provinces.

Section 35(3) of the NHI Bill provides that at provincial level the Fund must transfer funds directly to certified, accredited and contracted provincial, regional, specialised and district hospitals based on a global budget, or to Diagnostic Related Groups as determined by the Minister in consultation with the National Health Council and the Board from time to time, as required.

There are two overarching concerns about the proposed system. First, that the bureaucracy needed to administer it is just not imaginable. It would have to be enormous in an era where reducing the current public service is crucial to reducing government debt.

The second is that there is absolutely nothing in the economic destruction wrought by the ANC over the past 12 years that suggests it could even contemplate running a system as complex as this will be.

Sara Gon is the head of strategic engagement at the IRR.

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