Cometh the Healers?

The Creator’s default assumption about any decision taken by the Zuma administration is that it is a) stupid, b) corrupt and c) will make matters worse for the general public. This was originally an assumption driven by hostility to the Zuma administration’s personnel, but it has been borne out by virtually everything we know about the consequences of virtually every decision taken by the Zuma administration. In other words, as usual, the Creator was right.

Of course one might sometimes be wrong. For instance, er, the Libyan rebels might have been the good guys. The fact that they weren’t does not reflect anything on the Zuma administration, because the decision to support the Libyan rebels was not taken by Zuma; the Zuma administration took office on the understanding that they would do what they were told. If Obama had decided to support Gadaffi instead, the Zuma administration would have supported Gadaffi.

And again, sometimes we know very little about what’s going on. Health insurance, for instance. Virtually nothing has been said about this issue in public — virtually nothing of substance, that is. The official line is just “Health Insurance Good!”, and as a corollary, “Critics of Health Insurance Bad!”. This line is generally echoed by the money-men who control our public discourse and pay our intellectuals and the pharmaceutical-company shills who are encouraged to play at doctors when they strut on the public stage. (Wearing white coats, naturally, like actors in old toothpaste advertisements.)

So why not have a look at what is being actually said? One might find something interesting, as we did when we had a look at the Protection of State Information Bill and discovered that (gosh, what a surprise) everything said about it by the media and the foreign-hired “civil society” organisations was bullshit. Or maybe one might find a confirmation of the sum of all fears. Let’s check out the “National Health Insurance in South Africa Policy Paper” promulgated by the Department of Health in August 2011.

The first thing it admits is that National Health Insurance was vaguely talked about for years, but for some reason unspecified was stalled, until it was suddenly adopted as a policy at Polokwane. Unlike almost all the other policies adopted at Polokwane, with the exception of abolishing the Scorpions, this one has been taken forward. No doubt the policy paper won’t say why, but at least it may give us some hints. A Ministerial Advisory Committee was established in August 2009 to figure things out. (Who was on that committee is unspecified.) The mandate is: “NHI will ensure that everyone has access to a defined comprehensive package of healthcare services. The covered healthcare services will be provided through appropriately accredited and contracted public and private providers”. OK, so that means that it’s a public-private partnership. Since the private sector charges six times more than the public sector, which is already supposed to provide universal access but doesn’t, how is this going to work out? They also say that there must be efficiency and value for money. To which the Creator says, uh-oh, that doesn’t sound good. But who knows?

There’s certainly a great deal of argument that National Health Insurance will solve all the problems of the country, increase GDP, extend lifespan and generally provide answers to all questions. That is, national health insurance will. But will National Health Insurance? Ban-Ki Moon says it will, but what does a Korean glove-puppet of the Americans know?

The kick-off is supposedly Primary Health Care. This was the pet project of Nkosazana Dlamini-Zuma, and was torpedoed by her opponents when they smeared her and hounded her out of the Health Ministry. It’s a good thing in principle; you provide small-scale healthcare at local level in order to a) prevent small problems from becoming big ones and b) identify big problems while they are still treatable, so that you can refer the victims of big problems to places with more substantial healthcare infrastructure. This, of course, requires a network of skilled, dedicated professionals covering the country, one which was envisaged by Dlamini-Zuma (and had been provided in, for instance, the KwaZulu homeland) but which has never come to pass, despite the plethora of clinics.

The idea is to provide 10 primary healthcare workers in every ward — that is, if there are about 10 000 wards in South Africa, we would need 100 000 primary healthcare workers. That’s a hell of a lot of them. How skilled and trained are these workers to be? Not clear at this stage. Then, there will be a nurse in every school, with a team of trained primary healthcare workers under that nurse. If there are about 30 000 schools in South Africa, that’s over 100 000 primary healthcare workers in schools. Then, there’s a district team, focussing on maternal and child health, consisting of the following doctors: an ob/gyn, a paediatrician, a physician, an anaesthetist, a midwife and a professional nurse — this is the minimum, and there will be support staff under them. How many such teams must exist? A thousand? Then that requires 4 000 doctors, plus 2 000 people with midwifery and nursing qualifications, and very considerable support staff, probably another 5-10 000 qualified people. So, all in all, we are talking about a quarter of a million trained medical personnal, although only 2-3% of those would be doctors and another 20% would have nursing training.

This is a gigantic project, well worth the effort in the Creator’s view, but it will be extremely expensive; it will cost at least R20 billion a year in salaries alone, and then there is the infrastructure needed and the cost of the equipment, medication and administration. We are probably looking at somewhere around R400 billion over ten years, or an eighth of our unaffordable infrastructure programme currently envisaged to kick-start the neocolonisation of South Africa. Is anyone intending to spend that much on healthcare? At present, the plan is to spend about half of 1% of that in the next year or so on the project, which doesn’t look promising. (About a billion rand earmarked, out of the 7 billion called for by the project.)

A problem acknowledged by everyone who has looked at the project is that South Africa doesn’t have the medical personnel to staff such a project, nor do we have the medical education structures to generate the staff for such a project — in the case of the primary healthcare workers, we have essentially zero structures. At present there are no plans to set up effectual training programmes towards this absent end. Another problem is that there is no sign of any administrative structure to oversee this system. The present primary healthcare clinc system, and the rural hospital system, are beset with maladministration and corruption. How is this to be prevented from replicating itself in the new system? Nothing in the document seems to even acknowledge that these are problems.

Nevertheless, this all looks much better than the rhetoric which preceded it — although unfortunately even here the rhetoric/reality ratio is painfully high. Meanwhile, there is a call for the delivery of district primary healthcare through private providers, to be paid by the state. How this will work in districts where there are no private providers is not specified.

We move on, however, to hospitals. The plan is to change the classification of hospitals, to District Hospitals, Regional Hospitals, Tertiary Hospitals (national ones which don’t have a medical school attached), Central Hospitals (with a medical school attached) and Specialised Hospitals (self-explanatory). Basically, this is what already exists to a large extent, so this is wind and verbiage. There is to be an Office of Health Standards Compliance, which provides accreditation and inspection to healthcare facilities throughout the country. In short, the quality assurance programmes which have done so much harm to educational and healthcare facilities throughout the country in recent decades are to be beefed up. Presumably nurses will have to fill in more forms.

None of this seems to matter much in regard to NHI, because NHI is supposedly all about paying for the programme. How are people going to pay? Where does this “insurance” come in?

Well, “accredited providers will be reimbursed using a risk-adjusted capitation system linked to a performance-based mechanism”. Ah, so an accountant wrote this. Also, “accredited and contracted facilities will be reimbursed using global budgets in the initial phases of implementation with a gradual migration towards diagnosis related groups (DRGs) with a strong emphasis on performance management”. An accountant wrote that, too. Then, “In preparation for contracting with private providers, mechanisms for achieving cost-efficiency will be investigated including international benchmarking from countries of similar economic development that have successfully implemented such processes”. This is all New Public Management jargon, which seems to boil down to finding excuses for giving private contractors more money without providing better services.

In case you were wondering, “the public and private health providers contracted by the National Health Insurance, will be assisted in controlling the expenditure through recommended formula, and adherence to treatment protocols for all conditions covered under the defined package of care. This will be necessary to ensure the appropriate level of service provision and avoid under-servicing which is a common characteristic of many capitation-based systems”. They really are concerned, very strongly, with finding ways to control expenditure, but also with bringing in the private sector. How is all this money to be got?

Aha: “universal coverage to affordable health care services is best achieved through a prepayment health financing mechanism. To achieve universal coverage, pooling of funds requires that payments for health care are made in advance of an illness, and these payments are pooled and used to fund health services for the population”. Well, duh; that’s what insurance is. The trouble, however, is that at present the money comes out of tax revenues to sponsor a large but apparently inadequate public healthcare system. Bringing private healthcare into the equation means that a lot more money is needed. They say “the revenue base should be as broad as possible”, presumably meaning that the poor will have to pay more. Also, there will be private “co-payments” — the rich will be able to get better treatment by coughing up, just as they do now, outside the NHI system.

The proposal is to just over double healthcare spending, from R125 billion in 2012 to R255 billion in 2025.  This will be funded by a tax, administered by the Revenue Service. This will be paid into a National Health Insurance Fund. Everybody will be obliged to belong to NHI.

What about existing medical schemes? Well, “There is existing expertise residing in the health sector in the area of administration and management of insurance funds. Where necessary and relevant, this expertise may be drawn upon within the single payer publicly administered National Health Insurance, to ensure that adequate in-house capacity is developed”. So that’s all right then, so long as the medical schemes don’t take charge. But what if they do?

Yes, it actually seems all right. A great deal of policy frameworks developed by this government seem all right. After all, one appoints noisy idealists to write the policy frameworks, because they won’t shut up unless they can, and by getting them to let off steam one can diminish their effectiveness to struggle for their goals.

However, it’s worth looking at the table at the end of the paper, which presents a timeline for implementation, and see that virtually all the deadlines have been missed. The ones which have not been missed are the ones which involve virtually no additional work for anyone outside the existing healthcare system (like auditing hospitals, which basically involves making overworked nurses, doctors and healthcare administrators fill in more forms). However, absolutely essential ones which have been missed include the training of the first 5000 primary healthcare agents (which was supposed to start in September last year) and their appointment (which was supposed to have happened last March), the establishment of school-based primary healthcare which was supposed to have been on the ground last November, and the refurbishment of 72 nursing colleges which is supposed to be completed by the end of this year, but which has not even been begun. Instead, a few areas with relatively good healthcare have been put forward as flagship areas and offered very little money to supposedly improve their healthcare. One skill which the present government possesses in full measure is massaging and making up statistics, so we may assume that these pilot projects will be presented as “successes”.

Without the primary healthcare system in place — which is the most expensive part of the National Health Insurance project, but also the part least likely to make a lot of money for consultants, corporations and medical aid schemes — the whole rest of the system crumbles away as an effective entity. It seems evident, therefore, that NHI is doomed to be a good idea which was destroyed by the corruption and incompetence of the present government and the hostile lobbying of the medical-industrial complex.

Which should come as no surprise to anybody. But the Creator has to admit that NHI seemed like a scam from the first — and it probably was. But it now seems that it wasn’t a complete scam, since there were some people who wanted to make it work. The tragedy is that they’ve been co-opted and the system is almost certainly doomed to fail, and be taken over by the medical schemes which were supposed to be sidestepped.

The poverty of optimism, alas.


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