Why is the South African health system failing?

South Africans associate good quality healthcare with exorbitant prices, said Health Minister Aaron Motsoaledi during a “Leaser’s Angle” panel discussion in Cape Town last week.

The event was focussed around the pending National Health Insurance (NHI), which, once implemented, will offer universal health cover for all South Africans.

Motsoaledi explained how the NHI will prevent good healthcare from being synonymous with money, and how it aims to protect citizens from all socio-economic backgrounds.

Both Dr Boshoff Steenekamp, strategic project manager at MMI Health, and Prof. Ronelle Burger, economist at Stellenbosch University, spoke alongside the health minister.

During the event, the three panellists answered the following questions:

What is wrong with the current healthcare system? – By Prof. Ronelle Burger.

“In the NHI preamble they talk about distributing resources in ways that are more equitable, efficient, and effective. Currently, of course, we do not have this kind of health system. We have a health system that’s broken, fragmented, divided, and often wasteful - in both the private and the public sectors.

“As an illustration of this deep divide, I want to cite recent research by colleagues of mine using the 2011 census. They looked at the 1-year mortality rate of males between 40 and 59. The research compared men living in affluent communities, like Bishop Court, with those in poor communities, such as Bishop Lavis.

“They found that the men living in poor communities are six times more likely to die over the next year than those in affluent communities. And I think that just makes the challenge of what we are facing and the problem of the current health system very real.  In fact, I think it’s these types of contrasts and these types of divides that Dr Martin Luther King spoke of when he said: ‘Of all the forms of inequality, injustice in health care is the most shocking and inhumane.’

“We know that if individuals do not have decent access to healthcare that it’s going to affect their health, which in turn will affect their productivity, and thus their labour market income, causing individuals and communities to be trapped in poverty, reinforcing old patterns of privilege and poverty.

“From a growth-inefficiency perspective, we can also argue for greater health equality because of the tragedy of wasted human potential. Individuals who die at the age of five, a mother who can’t look after her children, all those things are clearly not in the best interest of our country, and we need to avoid unnecessary suffering, sickness, and death.

“If we look at who constitutes the portion of our population who have health cover, you’ll see that it’s the employed. As soon as I get a job, my likelihood of having insurance goes up from 17.5% to 50%. If you get a well-paying job (such as becoming part of the top 10% in South Africa), it goes up much higher, to 81%.

“In the general households surveyed in 2009, roughly 9 out of 10 households that did not have access to health cover said that it’s simply an issue of cost. There were other reasons, but they were overshadowed by households claiming they just can’t afford it.

“We found that if someone in a poor community goes to a clinic and their medicine is out of stock, they don’t go to another clinic. Instead, they go without their medicine. This means that when there’s a shortage of stock in poor communities, it affects individuals in a far more severe way because they tend to go without their medicine. 

“Many patients test for TB, but then they don’t return to collect their test results and start their treatment. We find that this is based on vulnerability – women and the poor tend to delay coming back, or don’t come back at all.

“Moving over to the solution, I think there’s a lot in the NHI to be excited about.”

Why is the public healthcare system failing? - By Dr Aaron Motsoaledi.

“The World Health Organisation (WHO) recommended that countries spend at least 5% of their GDP on health in order to create an improved healthcare system. Similarly, the Abuja Declaration, which was implemented by the African Union (AU) in 2001, stated that countries must spend at least 15% of their GDP on health. And although some African countries have achieved this, it has changed nothing.

“They can spend to 20% or 30% of GDP on health – it won’t change anything, unless we change the fundamental way healthcare is financed. Many organisations make the mistake of believing that health problems can be solved by looking at the GDP. But it’s not the same as the budget for healthcare in a country.

“The problem in South Africa is that we are far beyond the 5% mark. We are spending 8.7% of GDP on health this year, compared to the average European country that’s spending 9% of their GDP on health. Using the lingo of the youth, I’d say South Africa is in the same WhatsApp group as Europe. But if you compare the healthcare systems, it’s like two different planets.

“In 2015, within BRICS countries, Russia spent 5.4% of GDP on health, China spent 4.6% of GDP on health, and India spent 4.2% of GDP on health – less than half of that of South Africa today. Although we spend much more than them, their health outcomes are better than ours.

“People will say it’s because of corruption, mismanagement, inefficiency, and poor leadership. And I am not denying that they are there. But I can assure you, they are secondary causes of the problem.

“The problem is that the GDP for health is divided unequally. South Africa is spending 4.5% of GDP on 16% of the population, and the remaining 4.2% is spent on 84% of the population. And people believe that as long as there’s no corruption or mismanagement that 84% of the population can manage to run their healthcare on that amount. And people believe this is justifiable, scientific, and it can be explained economically, politically, and socially – no it can’t! This is gross inequality!

“Who forms part of the 16% of the population that receives 4.5% of GDP? It’s people who are on medical aid. It’s the teachers, the nurses, the doctors, the police, the army, members of parliament, the judiciary, CEO’s, and the leaders of the trade union movements.

“It’s a law of nature that money follows people. If we as a country continue pouring money into the 16% of the population, then of course everybody who’s got a scheme, whether it’s medical or financial, will run to that centre. Why would anyone go to where there’s no money? Why would you want to be a health administrator or a surgeon here if you know the money is elsewhere? “

How could the NHI be financed? - By Dr Boshoff Steenekamp.

“In 1993, there were 77 mothers who died during childbirth for every 100,000 births in the country. By 2015, this number had increased to 138. Instead of decreasing, it has increased.  The worst part is, even our neighbours, such as Zambia, which is a country that’s far less resourced than South Africa, has a decreased maternal mortality rate. And other countries like Thailand, which spends about the same amount of money on healthcare as we do and has a similar population size, are also seeing a decrease in their maternal mortality rate.

“This rate is important because it gives an overall assessment of a country’s health system, because a range of specialists are required to successfully deliver a baby. We’re spending lots of money, we’re spending it unequally, and we’re getting very poor outcomes for what we do.

“So, with that background, what is universal health coverage? And what are we doing with it? Countries that have achieved universal health coverage make use of different mixes of financing and different mixes of service delivery mechanisms. There is not a single one-size-fits-all solution.

“The first important principle that must not be forgotten is vertical and horizontal equity. Vertical equity means young and healthy people must cross-subsidise the sick and old. If you are sick and old, you cannot take care of yourself, and the young and healthy must take care of you. Similarly, low-income people can never earn enough to take care of their own healthcare, so you always need high-income people cross-subsidising low-income people. Those two elements are critical in any design of any system.

“It doesn’t happen spontaneously. No one is going to voluntarily fund someone else’s sick grandmother. There must be compulsion, and that’s the role of the state – to ensure we have a system that requires the vertical and horizontal funding.

“The second critical element is that health systems reform must be passed systematically. We need to take the necessary steps to move towards universal health cover. We must take steps that move us towards healthcare. We must focus on one or two of the difficulties. We must identify problems and address those in a structural way that keeps the long-term vision in mind. It’s a direction, not a destination – the minister said it himself!”

READ MORE: Funding universal healthcare in South Africa