The pilot phase of South Arica’s National Health Insurance (NHI) kicked off in 11 districts around the country in April. It will be phased in over a period of 14 years. This will entail major changes in healthcare service delivery structures, administration and management systems.
The NHI will offer all South Africans and legal residents access to a defined package of comprehensive health services. The package will offer care at all levels, from primary healthcare to specialised secondary care and highly specialised tertiary and quaternary levels of care.
There is much anxiety in South Africa about the proposed changes to the healthcare system. It is not yet clear how the private sector and medical schemes will operate in the new environment. The South African government has also not yet clearly indicated how the NHI will be funded.
South Africa can learn valuable lessons from other countries that have similar healthcare systems in place or that are also battling to implement healthcare reforms.
Healthcare in the USA
At a NHI conference in December last year, several countries shared their experiences with South African health experts.
A representative from the US said the country has a “highly fragmented healthcare system”1. The US has the most expensive health system in the world, spending about R20 trillion in 2010. This translates to approximately 20% of GDP.
Healthcare in the US is pro-rich and unfriendly to the poor. Americans who are older than 65 years are covered by Medicare. Healthcare for the elderly is relatively good. Employers, private insurance and Medicaid cater for people younger than 65. However, private health insurance is very expensive for both employers and employees. Individual insurance companies often refuse insurance to the sick or the likely to be sick.
Each of the 50 states has its own schemes which stipulate categories such as poor, pregnant, and mentally ill. Accessibility to doctors is challenging and limited under Medicaid and a significant number of Americans, approximately 50 million, are without any insurance at all and are mostly catered for by charities.
The average cost for a consultation with a doctor is $200 (R1 600). The average cost for treating a heart attack is $20 000 (R160 000).
The Affordable Care Act (“the ACA” or what most people call simply “Health Reform”) became law in March 2010. While some changes regarding insurance regulations and coverage have occurred (or will occur) between 2009 and 2013, most large improvements will not take place until 2014. The Affordable Care Act does not uproot the health insurance system in the US, but builds on existing public programmes and private insurance. When it is fully implemented, it is projected to provide insurance for an additional 28 million people.
Health reform is politically very controversial. All President Barack Obama’s possible Republican opponents in the 2012 elections said that they will work to repeal health reform. It will most likely be one of the most debated topics of the presidential election.
Healthcare in the UK
The UK’s National Health Service (NHS) was launched in 1948. For the first time, hospitals, doctors, nurses, pharmacists, opticians and dentists were brought together under one umbrella organisation to provide services that were free for all at the point of delivery. The principles were clear: the health service will be available to all and financed entirely from taxation, which means that people pay into it according to their means.
With the exception of charges for some prescriptions, and optical and dental services, the NHS remains free at the point of use for anyone who is resident in the UK. That is currently more than 62 million people. It covers everything from antenatal screening and routine treatments for coughs and colds to open heart surgery, accident and emergency treatment and end-of-life care.
Although funded centrally from national taxation, NHS services in England, Northern Ireland, Scotland and Wales are managed separately. While some differences have emerged between these systems in recent years, they remain similar in most respects and continue to be talked about as belonging to a single, unified system.
The NHS employs more than 1,7 million people. Of those, just less than half are clinically qualified, including 39 409 general practitioners (GPs), 410 615 nurses, 18 450 ambulance staff and 103 912 hospital and community health service (HCHS) medical and dental staff.
The NHS in England is the biggest part of the system by far, catering to a population of 52 million and employing more than 1,4 million people. The NHS in Scotland, Wales and Northern Ireland employ 155 312, 85 252 and 65 016 people respectively. Around 3 million people are treated in the NHS in England every week.
The NHS has not been without problems. The Guardian2 recently reported that district nurses and health visitors are facing job cuts, rising workloads and less time to care for patients, despite promises by ministers that community services would receive more support to relieve the pressure on overstretched hospitals.
“A dossier of evidence assembled by the Royal College of Nursing (RCN), which represents the UK’s 400 000 nurses, reveals that NHS services outside of hospitals are struggling to cope with growing demand brought on by the ageing population, hospital bed shortages and staff cutbacks,” the paper reported.
According to The Guardian the union also claimed that 61 113 posts in the NHS have been lost or placed at risk since April 2010, as the NHS undergoes a financial squeeze.
Healthcare in Brazil
Brazil’s healthcare system is similar to the UK, with national or state control of hospitals under the auspices of the Minister for Health. It is funded by the government, but the system relies on private provision much more than in the UK. Private hospitals perform more than half the medical procedures in the country and are reimbursed by the government. State health services are funded by taxation and provided free at the point of care. The country’s healthcare system owes its achievements to the Constitution of 1988, later developed in the Unified Health System (SUS) Act of 1996. The 1988 Constitution declared healthcare to be the right of the citizen and its provision the duty of the state.3,4,5
Under a later health reform in 1996, Brazil established a health system based on decentralised universal access, with municipalities providing comprehensive and free healthcare to each person in need financed by the state and federal government.6 Primary healthcare was key to this strategy. According to the World Health Organisation primary healthcare remains one of the main pillars of the public health system in Brazil today.6
South Africa’s reengineering of its primary healthcare system incorporates some elements of Brazil’s primary healthcare system. The three main streams of South Africa’s reengineered system are:
District clinical specialist support teams: These teams will consist of four specialist clinicians: A paediatrician, family physician, obstetrician and gynaecologist, and an anaesthetist. An advanced midwife, advanced paediatric nurse and an advanced primary healthcare (PHC) nurse will be deployed in each district.
School health services: This programme aims to address basic health issues among school-going children such as eye care, dental and hearing problems, as well as immunisation programmes. Contraceptive health rights, teenage pregnancy, HIV/Aids and issues of drugs and alcohol will also form part of this initiative. The programme for each group of schools will be led by a qualified nurse.
Municipal ward-based primary healthcare agents: This team will be based in a municipal ward and will involve about seven PHC workers per ward. It will comprise six community health workers and a specialist PHC nurse. This method is used successfully in Brazil where community healthcare agents have been deployed to various communities.
According to The Economist5 there is a gap between the SUS aim and reality. Family doctors reach only half of the population. Another quarter has private-health insurance. The rest of the people, who are mostly poor, live in remote rural areas or violent urban slums where the service is less easily accessible. They must either pay out of pocket or take their chances in packed hospital emergency rooms.
1. Report on conference on National Health Insurance: Lessons for South Africa. Available from: http://www.doh.gov.za/docs/reports/2012/nhiconfrep.pdf
2. Campbell, D. 2012. NHS community care struggling to cope with demand, survey shows. Available from: http://www.guardian.co.uk/society/2012/may/14/nhs-community-care-struggling-survey
3. Gold, S. 2011. .BRICs build healthy economic growth but uncertain healthcare. Available from: http://www.guardian.co.uk/healthcare-network/2011/jul/13/brics-health-services-brazil-russia
4. Pallot, P. 2011. Expat guide to Brazil: Healthcare http://www.telegraph.co.uk/health/expathealth/8737945/Expat-guide-to-Brazil-health-care.html
5. An injection of reality (2011) http://www.economist.com/node/21524879
6. World Health Organisation. Flawed but fair: Brazil’s health system reaches out to the poor.