Can NHI be implemented without alienating health professionals in South Africa?

Updated: Oct 25, 2019

The Inaugaral HPCSA Conference came at the right moment in healthcare conversation.

On the 18-20 August 2019, the Health Professions Council of South Africa ( HPCSA) held it's first ever conference, coming after over a century of the organization's existence in various forms. The HPCSA is tasked with regulating the main health professions in South Africa , protecting the public by ensuring ethical practice and as the ultimate registrar of health professionals, does play a role in ensuring adequate human resource supply in the country. It is also a legislated entity, that is funded by health professionals themselves , thereby maintaining independence while liaising directly with the Minister of Health of South Africa.

To this point, healthcare professions have been tightly regulated in a one-sided relationship, with primary engagement being around medical malpractice events. To use the words of Dr TKS Letlape, the current President of the HPCSA, the approach of the organization in the past has been largely reactive rather than proactive, and it has not played as much of a role in creating environments that enable ethical conduct within a challenged health system. For the first time in the history of South Africa, there is an opportunity in the landscape for healthcare professionals to directly interface with the HPCSA as an entity and for the HPCSA to engage stakeholders with certain kinds of ideas, discussions and content and become an influencer in this regard. The power of this development cannot be underestimated in light of looming changes on the horizon in the form of the proposed and somewhat maligned National Health Insurance (NHI) Bill.

Universal Health Coverage, of which the NHI seeks to stimulate with it's financing model, as a principle is a worthy idea. Any professional or citizen who has experienced the health system is more than aware of the wide disparity in access and quality of care between the public and private sectors. To many in the healthcare or social justice space,it has become apparent that the euro-centric approach and business models that underpin our healthcare system are not sensitive enough to a South African context or nor do they sufficiently serve the health needs of our nation. Even in the private sector, while there is easier access and choice, fragmentation of services and overservicing by professionals is a major cost driver of healthcare while quality and effectiveness can only really be evaluated by some medical funders or courts within a litigation process.

What then would NHI mean for healthcare professionals? . Essentially, it aims to move the private health system or part of it away from a fee-for-service model , which serves a small segment of the population at a high price ,into a cost leadership model, where practices would take on a wider patient base at a lower cost. The idea is that a practice ( or rather, a group multidisciplinary practice) would take ownership of the primary healthcare needs of their patient base, including health promotion and preventative health, and would be paid a lump sum for providing this. Care between different levels of healthcare would be managed within more formalized referral pathways and the protocol and design of these pathways will need to be established. Specialized levels of services have to be determined and paid on a fixed fee-for-service basis.

One of the reasons that the Bill has been criticized is that types and value of benefit packages are decided by relatively small committees, and although there is provision for stakeholder engagement, it is a very concentrated power scheme with a high risk of being impacted by organizational dynamics .Furthermore, innovation is always inspired at a ground level, and all kinds of health professionals as well as healthcare users need to be part of creating new solutions and care pathways. For this to happen, open platforms of engagement are needed to promote and develop this as well as the facilitation of stronger entrepreneural and service design skill sets. Traditional professional platforms have mainly been clinically focused, and some key developments, like the adoption of technology towards healthcare outcomes or innovative service design remains on the fringes of conversation and professional development to this day. It is then no wonder that the Bill is met with fear in the healthcare sphere, given that no strong conceptual backing exists towards this in South Africa.

The HPCSA has actively aligned itself to support the NHI Bill and play it's part in enacting the principles of Universal Health Coverage. It is also attempting to engage further with stakeholders through efforts like this inaugural conference. This ecosystem has not ever existed before in South Africa and it is more important than ever for others to follow in its steps. Regardless of opinion on the NHI Bill and the implementation thereof, the government cannot fix healthcare alone, it needs partnership with the private sector, and more spaces are needed for important conversations to happen.

*Nabeela Laher is a registered health practitioner who promotes, teaches and consults in Social Innovation for healthcare and rehabilitation. Follow her advocacy platform @RehabForAllSA

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