December 15, 2019

Yet another take on National Health Insurance fund

South Africans across the board will be comforted to know that the NHI pilot projects that were reported to have failed were in fact “not NHI pilots” at all. They were “health system strengthening projects” implemented in the NHI pilot districts, according to the Minister of Health in response to a question in the National Council of Provinces in September.

The Minister’s response clarified further that the “independent assessments” of the “health system strengthening projects” in fact did not declare them as failures but as projects that “should continue with some amendments in some cases”.

Sceptics of the pending NHI Fund will also be pleased to hear from the minister that: “The NHI policy was finalised after widespread research and consultation with local and international experts prior [to] its finalisation. We therefore believe that the NHI will certainly be successful. We have had the benefit of the experience of several countries before us that have had positive and negative lessons relating to their Universal Health Coverage implementation experiences.”

Failed NHI pilots were 'health system strengthening projects'.

The Minister replied to several questions which could help establish the current state of the public health service in the run-up to the introduction of the controversial NHI Fund. Asked how public health facilities in the Republic have been assessed for compliance with international health standards, the minister replied that for the financial year from April 2018 to March 2019, the Office of Health Standards Compliance inspected a total of 730 clinics, community health centres and hospitals, and 379 were found to be compliant.

The Department of Health has developed a National Improvement Plan to address the findings of the Office of Health Standards Compliance and to ensure the facilities meet acceptable standards R300m has been budgeted during the Medium Term Expenditure Framework period, over and above allocations for infrastructure, to improve the quality of human resources and the building of health information systems. Quality Learning Centres are to be built over an 18-month period throughout the country to improve current capacity.

In another question DA MP M R Bara indirectly raised the vexed problem that parliamentarians, and citizens, often grapple with, which concerns whether social services fall under the responsibility of national government or provincial governments. More specifically, Bara asked: “What are the envisioned powers of the provincial departments of health under the new National Health Insurance (NHI) Bill ... how will (i) provincial heads of departments and (ii) Members of the Executive Council be held accountable for poor health outcomes and/or service delivery?”

The Minister confirmed that Provincial Departments of Health will continue to have powers to manage healthcare services in their province as prescribed by the Constitution and the National Health Act. For example, the South African Constitution allocates to provinces the responsibility of providing emergency health services.

As it happened, at around the same time another DA MP, Mrs E R Wilson, put a question to the Minister on the state of provincial emergency health services. The minister’s reportback on this aspect of health care does beg the question: will provinces be able to provide emergency services to the entire population, including refugees and immigrants?

New EMS facilities have been built in three provinces; a brand new EMS headquarters at the Dora Ngiza Hospital in Port Elizabeth, Eastern Cape; another base in the Northern Cape; and five EMS bases are presently being built in Limpopo.

That will not be nearly enough to meet demand. In addition, no provincial budgets have provided for expansion in the EMS workforce. Some existing posts have been filled, such as 159 in the Free State and 14 in Limpopo, and KwaZulu-Natal Province is said to be “currently finalising” the recruitment process for 120 emergency care officers. Some provinces have requested additional budgets to expand their emergency care workforce without any success. But most provinces have not even tried because they have so many existing vacant posts. It was reported that not one province has received any funds “to move towards achieving the requisite number of personnel”.

The Northern Cape is suffering from a dire shortage of staff. It responds to emergency calls with only a single person. It has said it needs 960 more to meet the demand. The last time the programme received an injection of funding was in the 2014/15 financial year after a presentation was made to provincial treasury indicating the need for more personnel.

The minister included the report from Northern Cape in his reply: “Based on the norms and standards and the vastness of our province we have worked out an ideal number of operational personnel to the order of 1800. This would comfortable (sic) run 184 ambulances at any given time. The program is presently standing at 769 emergency care officers including all categories who are currently operating with 75 ambulances across the province due to breakdowns and road accidents. This number needs to at least increase to 120 to improve our response time.”

The Northern Cape, Limpopo and Mpumalanga provinces are non-compliant with the EMS Regulations due to shortages of staff and/or equipment.

Aside from being made responsible for coordinating health and medical services during provincial disasters, proposed amendments to the National Health Act also allocate additional direct powers to provinces, such as providing specialised hospital services for illnesses such as infectious disease and mental health.

Despite the obvious lack of resources at provincial level, national powers may also be delegated to provinces for the management of provincial tertiary and regional hospitals and district health services, including district hospitals.

In March 2019, South Africa renewed its exchange programme with Cuba for training and recruitment of medical doctors, in part to bolster medical capacity at provincial level. According to the latest agreement, South Africa intends to recruit a total of 112 Cuban doctors to the Republic to assist in the public health sector. These Cuban doctors will be employed by the provinces, who are responsible for their costs and salaries.

Its aim is to send 10 would-be doctors from each province in South Africa for training in Cuba. However, it seems that so far the only province that has students ready to send to Cuba for the 2019/2020 academic year is the North West, which has recruited 15 students.

The programme has trained about 2,500 students since its inception, and about 600 have fully qualified, despite complaints from students that, among other obstacles, Cuba’s medical training does not teach them to deal with health conditions in South Africa and they are not prepared for their final year, which has to be done in South Africa.

Each student is granted a full bursary, but it been estimated that it costs about R2.3m to train a South African doctor in Cuba, and it takes longer, compared with about R1.5m to train a student doctor in South Africa in a shorter time. Asked in another question how many of these students make the grade, the Minister confirmed that 326 students had dropped out of their courses. A contract is entered into between each student and the Provincial Health Department which stipulate that those who do not complete the course have to repay their bursaries. However, it has proved very difficult to recoup any funds lost due to the incompletion of their studies as these students come from the poorest of families. This suggests the exchange programme is a drain on the provinces’ fiscus.

Moira Levy

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  • Author: Moira Levy
Last modified on Friday, 20 September 2019 20:11

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Notes from the House is an independent online publication that tracks and monitors Parliament’s role in fulfilling its constitutional responsibilities to improve the lives of South African citizens. Published by Moira Levy with the support of the Claude Leon Foundation.

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