South Africa has a two-tiered, and highly unequal, healthcare system. The public sector is state-funded and caters to the majority – 71% – of the population. The private sector is largely funded through individual contributions to medical aid schemes or health insurance and serves around 27% of the population. The public sector is underfunded while most South Africans can’t afford the exorbitant cost of private care. To balance the scales, the government tabled the National Health Insurance Scheme. The proposal was to provide universal healthcare by buying services from health professionals through a National Health Insurance Fund. These services would then be delivered at private and public facilities. But there are many unanswered questions about how exactly this scheme will work and many doubts about it. Russell Rensburg is the director of the Rural Health Advocacy Project, which champions equitable access to quality healthcare for the country’s rural communities. He shares with The Conversation Africa how the gaps may be plugged.
What has the pandemic exposed about South Africa’s healthcare system?
Firstly, South Africa’s biggest problem is that the health needs of its people exceed capacity.
Secondly, the vast majority of people actually don’t know their health status which delays access to care.
Thirdly, the way the system is funded perpetuates inequality.
What are the solutions?
There’s a massive opportunity to reform the system. The biggest lesson that’s been learned from COVID-19 is that if there is poor health utilisation at the lower levels, people are at increased risk of severe illness and death due to COVID-19. Comorbidities are a risk factor for COVID-19. If the health sector did a better job of diagnosing and treating people living with diabetes at the community level, for example, the outcomes would be better.
If the country had a strong primary health care network with competent well-trained community health workers, it would have had a better chance of containing the spread of COVID-19 as well as linking people to care sooner so that deaths could be reduced.
We also need to look at the efficiencies of hospitals. Some fundamental questions need to be asked, such as are we doing the work that should be done in a hospital? Yes, it’s hard to turn people away. But so much is being done poorly in public sector hospitals. Many are falling apart.
Another area that needs close attention is explicit prioritisation. Given the levels of poverty and inequality in the country, there should be explicit priority setting in determining who accesses key services such as surgery and when. Who benefits from that at the moment? Is access based on how close someone is to the system? For example, people who live in Cape Town or Johannesburg have a better chance of getting elective surgery like a hernia repair.
The World Health Organisation says those people with the least coverage need to be prioritised before expanding access to others with more access to care. While everyone has the right to health, there is not equal enjoyment of that right. For example in the current response to COVID-19 how quickly people can access testing, care or even vaccination is determined by their ability to pay. This is neither just nor fair.
As the country considers the development of a comprehensive primary health care package, it should look at prioritising services where lower-income groups enjoy the least access.
South Africa should also consider universal pricing and admission criteria.
Access to medical schemes shouldn’t lead to over-enjoyment of capacity. The Competition Commission conducted a five-year investigation into the country’s private health sector. One of its findings was that South Africa admitted more people to ICU than other countries with comparable data.
Patients shouldn’t be treated better simply because they can afford to pay more. The high cost of private care has detrimental effects on public health care. If most doctors work in the private sector, there will be a limited number of doctors working in the public sector. These two markets affect each other. If the cost of private healthcare isn’t reduced, the costs will increase for everyone. This means that the public health sector will suffer over the long term as it struggles to keep up with the cost of care.
How should South Africa manage the unequal nature of healthcare provision?
The country has to find a way to make sure the availability of care is spread more evenly throughout the system. We can’t look at the private and public sectors separately. One has an impact on the other.
South Africa’s healthcare system is inefficient – both public and private. The cost of healthcare is too high. In the long term, improving the quality of care in the public sector would balance out people’s need to have expensive medical insurance.
South Africa’s institutional frameworks perpetuate inequality, rather than address it. Publicly-funded healthcare is not allocated based on need but determined by each province’s relative share of the population. In this scenario, funding for the Western Cape and Eastern Cape provinces would be roughly the same – despite vastly different implementation contexts. When you consider the vast area covered by the Eastern Cape, it is clear the current arrangements do not address inequality of access.
When health services were officially desegregated in 1988, South Africa’s spending in the former mainly white provinces was R172 average per capita. Public sector healthcare expenditure was R55 in areas designated under apartheid for black people. Known as the “homelands”, it’s where most black South Africans were forced to live.
Many of these inequities have persisted with disproportionate spending on health infrastructure in large metropolitan areas. This has lead to an underinvestment in primary health care where 80% access services.
The system needs to be more responsive at the levels where the majority are likely to access it. This means moving services out of facilities and being proactive in engaging with people through lower-level workers such as community health workers.
Doing this would ease the burden on facilities and health diagnose people at early stages of disease and infection – before they get sick.
South Africa has followed this approach with community testing of HIV. It saw also saw the effectiveness with the community screening and testing at the being of the COVID-19 pandemic in March 2020.
There are no simple solutions to South Africa’s health crisis but we have a once a generation opportunity to begin addressing the crisis. The improved electronic vaccine registration system can contribute to a better understanding of where people are, the investment in diagnostics can lay the platform for expanded screening and diagnostics and the introduction of reforms like the NHI can facilitate better cooperation between the public and private sector. Failure to act on these opportunities will show our disregard for the lives and living of the 80% of the population trapped in poverty and underdevelopment.