Delivered by Email 1 September 2018
Director-General of Health,
Private Bag X 828,
Pretoria, 0001
For attention : Deputy Director- General: National Health
Insurance, Dr Anban Pillay
Dear Madam
Draft National Health Insurance Bill
2018
As a South African citizen, and therefore
an interested person, I thank wish to thank The Minister of Health for the
invitation to submit comment on the draft National Health Insurance Bill as
published in the Government Gazette, No. 41725, dated 21 June 2018.
This submission is lengthy because I
refer to several research papers and case studies that contain conclusions
similar to my views, and I quote often from them.
I have read the entire draft Bill, and
in addition, I have read the sections from the Constitution of the Republic of
South Africa No. 108 of 1996 to which reference is made within the document. The
following sections are relevant to my comments:
27.
Health care, food, water and social security.-(1) Everyone has the right to have
access
to -
(a)
health care services, including reproductive health care;
(2) The state must take
reasonable legislative and other
measures, within its available resources, to achieve the progressive
realisation of each of these rights.
(3)
No one may be refused emergency medical treatment
CHAPTER 10
PUBLIC ADMINISTRATION
195.
Basic
values and principles governing public administration.-(I) Public
administration
must
be governed by the democratic values and principles enshrined in the
Constitution,
including
the inter alia following principles:
A
high standard of professional ethics must be promoted and maintained
Public
administration must be accountable.
Good
human-resource management and career-development practices, to maximise human
potential, must be cultivated.
Public
administration must be broadly representative of the South African people, with
employment and personnel management practices based on ability, objectivity,
fairness, and the need to redress the imbalances of the past to achieve broad
representation.
I have
also read the document containing Minister Aaron Motsoaledi’s address to the
audience when the National Health Insurance Bill was released, together with
the Medical Schemes Amendment Bill, at the Press Conference on 21 June 2018. My
comments in this letter concern the former bill only,
We are painfully aware of the fact that some people believe that
even before we open our mouth about NHI, we must sit and fix the ailing public
healthcare system first.
We
are very much alive to the problems of poor quality and lack of efficiency in
the public healthcare system. That is not a matter of debate.
He goes on to say:
The National Development Plan (NDP) has actually flagged it
unambiguously. It said in implementing NHI, South Africa has two problems to
solve, viz -
The existing cost of Private Healthcare; and
The
poor quality of care in the Public Health system
Then he states:
Fixing
the quality of Public Healthcare is never going to be an ending event. It is
rather an ongoing and continuing process which has no end as long as the health
system exists among people.
Then he admits
to the following:
This
was after we had done an audit on 6 key indicators of quality in our healthcare
facilities - these indicators were cleanliness, safety and security of staff
and patients, attitude of staff to patients, waiting times, infection control,
and drug stockouts.
We
were rattled to find that there was an 80% failure rate on our facilities on
the issue of attitude of staff.
Near his conclusion he states the following:
Here we were testing how
private GPs can be integrated into the healthcare system to provide services.
And hence in NHI GPs and clinics will be the 1st point of call and for HIV and
AIDS, we are going to decant 50 000 patients to be under the care of GPs
Despite the Minister’s remarks,
and his admissions regarding the poor quality of the existing healthcare
system, I cannot share his optimism that a national health insurance will solve
the problems regarding healthcare in the country. During my online research on
the subject of healthcare in South Africa, I have come across a range of papers
on the subject and there is a common thread amongst them all, and it has to do
with human resources in healthcare. The most important conclusion reached is
that throughout the country there is no proper record kept of available human
resources in the professional cadres in health care. The bodies responsible for
the registration and for maintaining the registers of the respective
professions, do not keep track of the whereabouts of those on their registers.
Despite the Government’s best
efforts over the years at providing health care for the population as per the
Constitution, the quality of the health care, as mentioned above by the
Minister, has suffered. I do not believe that the introduction of NHI is going
to make any difference whatsoever unless the necessary quality and quantity of
the workforce is first remedied.
It is evident that the Department has been
unsuccessful in achieving its goals over the past two decades, despite having
the financial resources to do so. The introduction of a slew of new boards and
committees will meet with little or no success if the necessary improvements to
the quality and the quantity of the work force currently responsible for health
care are not first given priority. . If attention were to be given to fixing
the existing problems, the current system would work as originally envisaged,
and there would be no need for a new system,
Functions of Fund
6. (1) The Fund –
( h) may
purchase health care related service, medicines, health goods and health
products that are of a reasonable
quality;
for
the purchase, procurement and supply of health care services, medicines, health
goods
and health related products where the health care provider, health
establishment
or supplier is accredited as provided for in section 38 and must -
(a)
demonstrate to the satisfaction of the Fund its capacity to deliver such
services
in sufficient quantity and of sufficient quality to meet the needs of
users;
(b)
guarantee that there will be no interruption to supply for the duration of the
contract;
(c)
conduct its business in a manner that is consistent with the best interests
In support of my argument, I wish
to draw your attention to some, of several, research papers that are available
on line.
The first, (published in Am J
Public Health. 2011 January; 101(1): 165–172.) is entitled:
“Health Care Capacity
and Allocations Among South Africa's Provinces: Infrastructure–Inequality Traps
After the End of Apartheid” and is authored by David
Stuckler, PhD, MPH,
Sanjay
Basu, MD, PhD, and Martin
McKee, MD, DSc.
Their stated
objective was “We assessed the
determinants of health care funding allocations among South Africa's provinces and their effects on health
care from 1996 through 2007”
In their
discussion on the results of their investigation the authors remark :
“We found that health system capacity,
measured by numbers of doctors and hospitals, emerged as a significant driver
of inequalities in health spending. Human resources have been attracting
increasing attention as an important factor when seeking to scale up health
care investment and can be considered a measure of absorptive capacity.
Although the post apartheid government recognized early on that the scarcity of
human resources was a barrier to scaling up basic health services, the measures
put in place to address this problem do not seem to have been effective. Other
research in 3 South African provinces and interviews with Treasury civil
servants suggest that implementation capacity, a function of availability of
managerial staff, is at least as important as a shortage in the number of
health care workers. There is also evidence of uneven distribution of the
limited number of staff available, a situation exacerbated by better conditions
in the private sector and HIV programs.”
The African Institute for Health and
Leadership Development is responsible
for a series of case studies funded through a project “From Brain Drain to
Brain Gain”. These case studies can be
viewed online. In the case study
entitled
“UNDERSTANDING
AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM”
dated March 2017, and authored by Percy Mahlathi and Jabu Dlamini, the opening
paragraph in the Abstract reads:
Background. The provision of health services is
largely dependent on the sufficiency of the health workforce in terms of numbers,
the quality of skills they possess, how and where they are deployed and how
they are managed. With increasing urbanization, the issue of migration
(including immigration, emigration and movement between the public and private sectors)
of health personnel has become a critical factor in the debate about social
justice in health, especially access and equity in the provision of health
services. This case study seeks to better understand the patterns of movement
of medical doctors and the development of associated policies in order to help
health authorities to put in place the necessary systemic improvements for
effective management of health workforce migration.
Data
were collected from the provincial Departments of Health, the Medical and
Dental Board of the Health Professions
Council of South Africa, the South African Medical Association and individual
medical practitioners through a survey. The data utilized were derived from
responses to a survey questionnaire.
The
authors have done a thorough investigation and make comments under many
headings including:
Health workforce context, Policy on the
Recruitment and Employment of Foreign Health Professionals in the
South African Health Sector, Regulation of
medical practitioners, South Africa–Cuba Medical Training Programme, Migration of
the medical workforce.
The
study also sought to identify whether any synergies or gaps existed between the
workforce data systems of
provincial
Departments of Health (the major employer within the health sector), the HPCSA
and the largest
medical
professional association – the South African Medical Association.
TOTAL NUMBER
OF MEDICAL STUDENTS
(FIRST TO FINAL YEAR)
PCSA ACCREDITED AND APPROVED POST
NUMBERS (INCLUSIVE OF ALL TEACHING HOSPITALS (of which
there were none available)
PERCENTAGE SHARE OF EXPATRIATE MEDICAL WORKFORCE
FROM MAIN SOURCE COUNTRIES
HPCSA MEDICAL OFFICER REGISTER
AGE PROFILE OF EXPATRIATE MEDICAL PRACTITIONERS
MEDICAL OFFICER STOCK IN GOVERNMENT HOSPITALS, 2011–2015
PROVINCIAL GP REGISTER AT HPCSA, NUMBER AND % OF NATIONAL
TOTAL
MEDICAL OFFICER RESIGNATIONS ACROSS FIVE PROVINCES (MALE
AND FEMALE), 2011–2015
MOVEMENTS UPON RETURN FROM OVERSEAS EMPLOYMENT
Most include the years 2011 2012 2013 2014 and 2015.
In the DISCUSSION section the authors state:
The
HPCSA is the national custodian of data on the medical doctors in South Africa
regarding registration
and
licensure to practise. It is mandated by the Health Professions Act No. 56 of
1974 (as amended) to set up a
medical
board that regulates accreditation of medical education programmes and registration of medical
students, qualified medical staff and specialists, and to keep an annual register
of all these through the Medical and Dental Board. In the execution of its
duties it must continue to liaise with the national Department of Health.
In
South Africa, public health workers have been permitted+ to work part-time in
the private sector since the early 1990s, initially through the Limited Private
Practice Policy and, since 2001, through the Policy on Remunerated Work outside
the Public Service . Because dual practice is a sanctioned activity, the public
service employer should be able to know who does what work and where. Accurate records
must thus be maintained across all employing agencies of government. In our
study, it was difficult to determine how many medical practitioners work
exclusively in the public or private health sectors. It was also difficult to
determine how many of those appearing in the HPCSA register have emigrated.
This is the essence of the Brain Drain to Brain Gain project2 – updating
expatriate policy, supporting entry/exit processes, and strengthening links between HPCSA registration and
employment status of the physician workforce.
They
opine:
This
requires strong coordination and leadership at the level of the national
Ministry of Health as the chief
steward
of the health system in the country. It must involve the public, private and
nongovernmental or not-for-profit health sectors. The HPCSA is a critical
player in this process as it has the legislative responsibility to
maintain
the credibility of the register and ensure that only competent medical
practitioners can practise medicine in
the country. There is currently no link between the HPCSA registration system
and the government’s system. Any
verification required is done manually, and the HPCSA i-register on the website may be
used for the manual verification of a practitioner’s registration status. While the Medical and Dental Board of the HPCSA may be responsive
to the Ministry of Health’s call for increased numbers of practitioners, the
Board is limited by the number of training places that are available at any given
period.
present
study suggests that many doctors leave for short periods).
2.
The HPCSA needs to be the custodian of the migration monitoring system and
collaborate with its counterparts in other counties
3.
Government-to-government agreements should be encouraged so that the migration
numbers can be better managed without one party losing out.
4.
The South African Medical Association should play a bigger role in monitoring,
as doctors tend to trust
the
organization more than they trust governmental or health authorities.
5.
The Ministry of Health and the HPCSA should actively engage the medical
profession on issues of migration to directly address their perceptions of
being victimized.
6.
The Department of Health and the HPCSA should interact regularly to:
(a)
analyse the recorded movement of medical officers employed in the public health
facilities;
(b) gain insight into the views and
perspectives in South Africa of emigrant medical practitioners; and
(c) identify existing policy instruments and
practices in place to maximize benefits and mitigate negative consequences of
the migration of medical doctors
7.
There needs to be intergovernmental discourse at country level regarding
migration of professionals across the board, including for example engineers, medical
doctors, physiotherapists, among many as these are trained at great expense to the
country. A uniform approach will assist in removing perceptions of
victimization prevalent in the medical workforce.
8.
Increased focus should be placed on migration trends between rural and urban areas of the country.
9.
HPCSA becomes the custodian migration monitoring body whose role should include
the contextual relationship with the Department of Health to meet the reporting
requirements of the Code.
The entire
document can be found using this link:
Given the above, the Minister’s plan
to “And hence in NHI GPs and clinics
will be the 1st point of call and for HIV and AIDS, we are going to decant 50
000 patients to be under the care of GPs” seems overly optimistic and gives
rise to skepticism.
The
same duo from The African Institute for Health and Leadership Development did a
follow-up case study entitled “NURSING AND MIDWIFERY MIGRATION TRENDS
IN THE SOUTH AFRICAN HEALTH SYSTEM”
Both case
studies are of similar design and overlap in some respects.
The link to
the nursing one can be found at:
In
this twenty-eight page document, too, there are numerous informative tables of
statistics.
In
their background discussion the authors outline the health system:
The South African health system is
premised on primary health care (PHC) services that are delivered through a
District Health System. The system is designed to ensure easy access to health
services by every citizen in line with the Bill of Rights as enshrined in the
Constitution of the Republic of South Africa. With effect from 1996, the government
endeavoured to extend access through a massive clinic building programme and
revitalization of hospitals across the country. The public health service is
divided into primary, secondary and tertiary care through health facilities
that are located in, and managed by, the provincial Departments of Health. The
provincial Departments of Health are thus the direct employers of the health
workforce, including nurses, whilst the national Ministry of Health is
responsible for policy development and coordination.
They continue:
There is a realization that the health workforce
plays a critical role in advancing the health system goals, largely driven by a
policy position of improving access to health care for all citizens. In the
mid-2000s, the nursing profession, through their national association, the
Democratic Nursing Organisation of South Africa (DENOSA), made several representations
to the Ministry of Health for the creation of a post at national level that
would be dedicated to nursing issues. The driving force was a realization and
acknowledgement that nursing, being the largest component of the health care
professions, needed coordination at the highest policy level.
Such a post was
created in 2014.
The authors go
into great detail about the training of nurses, various training institutions,
various qualifications. They paint a chaotic picture.
In the final
discussion, the authors point out that South African nurse training is “esteemed for the high standard of training it offers
its practitioners, a quality that renders them prime candidates for
recruitment. The nursing profession, in common with the teaching profession and
police training, has for a long time been easier to access by ordinary South
Africans than other fields of study, such as law, engineering, medicine,
pharmacy, and dentistry. Nursing has over the years been the first point of contact
that patients have with a health system. Nurses are found in every health
facility across the country and play a vital role in the delivery of health
services, from PHC to highly specialized medical interventions.”
What is
alarming, is the following observation:
Despite the high level of training of midwives, the letters of
verification are requested for confirmation of the nurse’s competence as a
general nurse, not as a midwife.
Consequently, it can be assumed that nurses’ movements are based
on their basic nursing competencies, except those of highly specialized
categories such as critical care, intensive care unit and theatre nursing. The
prevalence of the moonlighting phenomenon can be attributed to a desire by
health professionals generally to augment their salaries. This practice also
exists in other professions, such as medicine, where it is termed “remunerative
work outside public service”. All provincial nursing directors reported that
this practice is officially allowed on condition that the services provided in
the private health facilities do not conflict with the nurse’s normal duties.
They however concede that it is a practice that is very difficult to control or
monitor.
Whilst the movement of nurses to other countries appears
insignificant in terms of recorded verifications, it is the moonlighting
phenomenon that must be addressed. The number of persons registered by SANC
forms the largest proportion of all those registered by all three statutory health
councils – SANC, 401 543 (57.93%); Health Professions Council of South Africa,
249 827 (36.05%); and the South African Pharmacy Council, 41 745 (6.02%). This
indicates the need for the implementation of the National Health Insurance
system to be heavily reliant on (a) the continued production of highly
qualified nurses; (b) equitable distribution of qualified nurses between urban
and rural public health facilities; and (c) ensuring that effective retention
strategies for nurse practitioners are in place, especially for rural hospitals
and clinics.
Another notable finding is
the variance between registration of nurses by SANC per province versus the
total employment numbers as supplied by the Vulindlela human resource system in
public service. Vulindlela, a derivative of the payroll system in public
service, provides employment figures relating to financial years. Table 18
shows a number of data gaps that were experienced when extracting figures for
the present study; for example, the North West province did not show any
resignation record for the years 2012 to 2016. This is most likely due to a
system glitch. The 2016/2017 figures could also not be reliably extracted. The
option would therefore be to do a headcount at provincial level to obtain
accurate figures. However, provincial Departments of Health also rely on the
Vulindlela system, which does not make a separation between a registered nurse
and a midwife. This is one aspect that the nursing profession has to work on
and clarify because not every nurse is a midwife, even though many have
midwifery skills. The employment system records a nurse generically as
“registered nurse” and does not separate that from a midwife. This will
hopefully be addressed through the new nursing qualifications and creation of a
nurse specialist register. There is also a need to devise a mechanism for
matching data between SANC, provincial Departments of Health and private sector
employers.
The authors open their concluding remarks with the
following:
Measuring the migration trends of nurses is critical for the
provision of health services in South Africa from a workforce planning and
human resource deployment perspective. Over the years indirect measures have
been attempted, particularly for medical doctors and nurses. However, these
remain inaccurate, as some professionals choose to keep their registrations
active in some overseas countries to facilitate temporary work stints,
Of the eleven recommendations
suggested, I will only list the following, which if they had been introduced
during the past twenty years, could have made a vast improvement to the quality
of the existing healthcare system, and time and money would not have been expended on drafting
a NHI bill:
A mechanism for monitoring migration trends of nurses to be
established through the involvement of SANC, the Ministry of Health and the
Department of Home Affairs. The Department of Home Affairs already has a
mechanism for determining priority skills among immigrants that seek employment
in South Africa.
A separate register for nurses who are not in active practice to
be established at SANC. Calculating the attrition rate due to retirement and
death is important for workforce planning.
A collaboration to be set up with other statutory health councils
for mapping out accurately where registered practitioners are employed
A mechanism to be devised for matching nursing workforce data
between SANC, provincial Departments of Health and private sector employers.
SANC and the Ministry of Health to engage nursing professional
associations to impress on them the need for monitoring migration trends as one
of the mechanisms to positively influence nursing planning and eventually
education, training and deployment
The registration categories to be aligned to the new nursing qualifications such that it is easy to distinguish
midwives from those who may possess midwifery skills but are not applying those
skills in their daily work environment, for example in a mental health facility.
In 2007
the first of a series of articles “Health in South Africa 1” was published in
The Lancet. The authors are Hoosen
Coovadia, Rachel Jewkes, Peter Barron, David Sanders, Diane McIntyre and the article is
titled “The health and health system of South Africa:
historical roots of current public health challenges”.
It is not necessary for me to go into this history of health, it is more
pertinent for me to point out their comments under the headings of
Inadequate
human resource capacity and management (with
the subheadings of historical perspective, human resource challenges, and issues with human resource management) and Poor
stewardship , leadership, and management of the health system.
They point out that
From 1994, the health sector in South Africa has been affected
by a legacy of maldistribution of staff and poor skills of many health
personnel, which has compromised the ability to deliver key programmes, notably
for HIV, tuberculosis, child health, mental health, and maternal health. The
staffing crisis is especially acute at the district level and has persisted,
despite 60% of the health budget being spent on human resources. This situation
has been aggravated by several unfortunate policy decisions—such as the offer
of voluntary severance packages to public sector staff in the mid-1990s that
had the effect of moving (often skilled) staff out of the public sector and
into the private sector, international agencies, or early retirement. There has
been a substantial decrease in the nurse-to-population ratio, from 149 public sector
professional (i.e., registered) nurses per 100 000 population in 1998 to 110
per 100 000 population in 2007. This reduction has resulted from a decline in the
number of nurses graduating because of the closure of many nursing colleges in
the late 1990s, migration from the public to private sectors and to jobs
abroad, and attrition due to retirement and HIV/AIDS (which affects 16% of the
nursing profession). With as many as 40% of nurses due to retire in 5–10 years,
nursing remains the most crucial area for urgent policy intervention.
Under the
sub-heading of issues
with human resource management, they further point out:
A central challenge of the health system has been a reluctance
to strengthen management of human
resources. Part of the problem lies with managerial capacity.
Under apartheid, senior management throughout
the system was male and white, and public sector managerial
competence was centralised and highly
variable. The public sector had been expanded to reduce white
unemployment, with the result that employment was seen as a goal in its own
right. After 1994, a concerted eff ort was made to include women and black
people in senior and top management teams. The changes resulted in loss of
institutional memory and some problems associated with many inexperienced
managers placed in positions of seniority (because competence had not been an
essential criterion for public sector appointments in the past, lack of
experience or expertise was not seen as a necessary barrier to employment).
Inexperienced managers have struggled to
handle the major challenges associated with transformation, and, in particular,
efficient and effective management of human resources. Reports of ill
discipline, moonlighting, and absenteeism are widespread. Additionally, there
is a serious shortage of training, support, and supervision. There has been
insufficient political will and leadership to manage underperformance in the public
sector. There has also been a stubborn tendency to retain incompetent senior
staff and leaders, including (until recently) the former Minister of Health. As
a result, for many years, loyalty—rather than an ability to deliver—has been rewarded
in the public sector and there has been no climate of accountability, apart
from financial accountability of senior managers, which was ensured through the
Public Finance Management Act 1999. This move, however, has meant that
cost-containment has become the dominant determinant of practice in the health
system Incompetence within the public sector is so widespread that it is an
issue that has become very difficult to deal with. Limited capacity is a
problem at every level of the health sector and throughout other sectors of
government. It clearly stems from the historical legacy, but also from the
disastrous education situation, which has resulted in most individuals emerging
from secondary (and often tertiary) education with limited numeracy, literacy,
and problem-solving skills.98 There has been a consistent refusal of government
to face up to the failure of the education system and to consider radical
action to remedy it. A more efficient public sector requires the political determination
to solve the problem of capacity, to deliver public services, and to change the
culture of the public service from one that is oriented towards security of employment
and reward for loyalty, to one focused on accountability and delivery of
services to the public, in which competence and performance are both expected and
rewarded.
The Ministry of Health’s role in providing overall guidance on
activities that contribute to improving levels of health in South Africa has
generally been characterised by good policies, but without equivalent emphasis
on the implementation, monitoring, and assessment of these policies throughout
the system. Neither has the Ministry of Health given priority to these policies
within the resources available. The scarcity of human resources, especially in
rural areas and at lower levels of the health system, have presented one
constraint to policy implementation, but another key constraint is that at all levels
of the health system there has been inadequate stewardship, leadership, and
management. There is an increasing number of studies examining these
deficiencies in different combinations both at different levels of the system
and even between facilities of the same type. The lack of stewardship and
leadership has been evident in the highly variable quality of care delivered within
the public sector. For example, the Western Cape province had tuberculosis cure
rates of around 80% in 2007, whereas for most of the districts in KwaZulu-004Etatal,
the cure rates were between 40% and 60%.
,,,,,,,,,There has been a
notable lack of progress in implementing the core health policies developed by
the ANC, and some disastrous policy choices…………. Moreover, it demands
determined efforts to show leadership and improve stewardship and management in
the health system and to ensure that sound health policies and social policies
are both developed and implemented.
I doubt that their vision included a radical switch to a National Health
Insurance.
I have one further study, and it will be my final one, that I believe
has merit and supports my arguments.It is entitled “Achieving universal health coverage in South Africa through a district
health system approach: conflicting ideologies of health care provision”. I will not lengthen this letter by quoting from it,
except for the conclusion:
We conclude that in South Africa the DHS is pivotal to
health reform and UHC may be best achieved through minimal universal coverage
with positive discrimination to ensure disparities across districts in relation
to disease burden, human resources, financing and investment, administration
and management capacity, service readiness and availability and the health
access inequalities are consciously implicated. Yet ideological and practical
issues make its achievement problematic.
Here is the link it. It is worth
a read, if you have not yet viewed it.
I am sure that by now you would have comprehended why I am completely
opposed to the implementation of a National health Insurance, particularly for
the reasons that are provided in the Preamble to the Bill. The above studies all
provide the evidence and statistics that the existing health service is failing
the citizens of South Africa mainly because of inadequate human resources, the
lack of planning for adequate human resources, and the poor training that some
receive. One study makes damning comments about lack of leadership, and lack of
management skills. How do you envisage that a change in policy, namely the NHI
Bill is going to magically change the situation?
I am
concerned about the vague unelaborated wording in the paragraph preceding the
Preamble of the Bill. How is providing mandatory prepayment health care
services going to benefit the citizens if the current inadequate human resources, with lack of leadership, have to be responsible for doing the work at
the coal face?
Parts 2,
3, 4, 5, and 7 all include lists of committees and other organisations, which
will require the appointment of people who will require expertise.
There is
an entire section regarding the formation of a National Health information Repository and Data System
Then there is a section that refers to the
matter of Payment of service providers.
Yours sincerely
Susan Buekes
