National Health Insurance
Universal Coverage
In a description of NHI in July 2009 the ANC said: The National Health Insurance will: ... Expand health coverage to all South Africans [emphasis added]. This means there will be no financial barrier to access health care. All South Africans will be equally covered to access comprehensive and quality health care.”
The June 2009 NHI proposal says that “The goals of the national health insurance include... providing universal coverage for all South Africans, irrespective of whether they are employed or not”. “The introduction of a national health insurance system has been on the agenda of government since 1994. The key objective of such a system is to address the problems of the dual health system by promoting social solidarity in order to achieve universal coverage” [emphasis added].
The two graphs below from Prof Servaas van der Bergh show what is known about access to healthcare in South Africa by income group.
Figure 1: Proportion of those ill that consulted a health worker and reasons why not.
Source: Prof Servaas van der Berg, Stellenbosch University, using GHS2002-2007
Figure 2: Health workers consulted by those who were ill.
Source: Prof Servaas van der Berg, Stellenbosch University, using GHS2002-2007
It seems though that there is confusion in the debate between universal coverage for healthcare and universal coverage for health insurance. It is estimated that only some 16.4% of South Africans had health insurance cover in 2008. However everyone in the country has access to healthcare, either in the public sector or through medical schemes, bargaining council funds or other employer-based arrangements.
Figure 1 shows that across all income groups about 80% of the population who needed care were able to access care. A further 9-14% decides they do no need to see a healthcare practitioner. Physical constraints (the distance that needs to be travelled), affect 5% of the lowest income group, reducing as income increases. Financial constraints affect only 6% of the lowest income group and this does not vary as much by income as might be expected.
The area of greatest difference is the type of healthcare practitioner consulted. The highest income group seldom see a nurse and have become used to going to a GP or directly to a specialist. Among the lower income groups, a nurse practitioner is the most common point of entry to the health system. Prof van der Berg makes the point that dissatisfaction with the current national health system is dissatisfaction with the quality of the care provided in the public sector. Demand projections indicate that satisfying public preferences would require double the current number of doctors’ visits, as the public presently interprets quality care as access to private facilities and doctors.
The debate around universal coverage thus needs to be recast: we do have universal coverage for healthcare. The question is whether it is feasible to equalise the quality of service as we do have differential access to GPs by income level. There is currently substantial research being conducted on the numbers of GPs and specialists practicing in the country and on the numbers needed by the health system. The graph below, from the Development Bank of South Africa (DBSA) Roadmap process projects the shortage of GPs under various scenarios.
Figure 3: Scenarios for dealing with the shortage of GPs
Source: Alex van den Heever, DBSA Roadmap process, 2008
Note that the figures above are for the health service as it has been, with nurse-based clinics. The figures did not include the effect of the NHI promise that people would be able to choose a clinic or GP in their area: “All South Africans can then choose which primary health care provider (which would generally include a number of different public sector clinics/community health centres and accredited multi-disciplinary practices) in the district they would like to register with and utilise health services.”
|
