What the NHI won’t fix

Thirty years into democracy, our new administration faces the same challenge it did halfway through — the poor rollout of mostly well-designed policies.

In a series of articles in The Lancet in 2009 — 15 years after the landmark 1994 elections — South African researchers noted that while many of the country’s health system problems had historical roots in apartheid, poor implementation of forward-looking policies had hamstrung progress.

Many fixes have been suggested. The government’s key solution is in the now signed National Health Insurance (NHI) Act; NHI will function like a large state medical aid, likely to be funded mainly through taxes, and which will pay for a predetermined set of health-care services for all South Africans. The idea behind it is to reduce inequities and prevent out-of-pocket payments, so that everyone gets the same health services, regardless of whether they can pay for it.

But the scheme is highly controversial and responses to it have been mixed — with some groups threatening legal action, others saying it’s the roadmap to health equity, and still others arguing that growing the economy, rather than an NHI scheme, is the best way to deal with inequity, and that corruption and bad management in our public health system first need to be fixed for any new system to work.

Something the NHI almost certainly will not fix is how the conditions in which people live affect their health. Unless there’s a real shift to helping people stay healthy, whether through improving their living conditions or preventing disease, continued focus on illness and lip service to prevention will keep draining the health budget.

There have been some gains. For example, South Africans’ life expectancy increased from 57 years in 2009, at the height of the HIV epidemic, to just under 63 years in 2022, Stats SA data shows. Deaths of infants and children under five have both almost halved in this time. These improvements, the analyses show, are likely because of the large-scale introduction of antiretrovirals (ARVs) for treating HIV since 2008. About 5.7-million people are on ARVs in South Africa.

But despite these improvements, a new post-election government will still have many challenges to deal with to get the country to better health.

The challenges

1. Maternal mortality: At 11 per 1,000 live births, South Africa’s neonatal death rate is in line with the 2030 sustainable development goal of 12 or fewer per 1,000. (A neonatal death is when a baby dies before being 28 days old.)

But the country has done less well on getting deaths among children younger than five down to the target of only 25 per 1,000 births and having fewer than 70 out of every 100,000 pregnant women die. National data shows close to 31 out of every 1,000 children die before their fifth birthday and in 2022, 109 out of every 100,000 pregnant women died.

2. HIV and tuberculosis (TB): Though the country is moving in the right direction, South Africa has not met the global commitment for ending HIV and TB. By 2020, new HIV infections had about halved from the figure in 2010, instead of the UNAids target of reducing new HIV infections by three-quarters. TB cases dropped by 14% between 2015 and 2020, but it’s still some way from the 20% cut that had been aimed for in the End TB strategy for that period.

3. Noncommunicable diseases: Since 2010, noncommunicable diseases, such as diabetes, mental health, violence and injuries, have been causing more deaths in South Africa than infectious illnesses, Stats SA data shows. Health problems that stem from these conditions will put tremendous strain on the public sector if they’re not dealt with. For example, treating patients with type 2 diabetes in the public sector cost the government about R2.7bn in 2018, which shoots up to R21.8bn if the cost of treating patients not officially diagnosed with diabetes is included. By 2030, the figure is estimated to jump to R35.1bn.

4. Bad management: Trade unions, independent watchdogs and civil society have all called out the public health sector for failing the poor, who make up the bulk of the population who use state hospitals and clinics. (Over 80% of South Africans rely on the public health sector; only about 20% have the means to pay for private medical care.)

One of the many drains on the system’s budget is lawsuits against state hospitals, with more than 15,000 claims against the health department in 2022 and close to R2.7bn paid out in 2021 and 2022 together.

The fixes

So, what should the new administration do?

1. Build trust: Building trust or tackling the lack of trust — between patients and the health services, between medical aid members and their administrators, between health workers and their managers, and between the public and private health sectors — is key to fixing the South African health system. For this, there have to be conversations in which every level of society can participate — not only those whose voices are typically heard, but also those whose voices are seldom heard, like the youth and the elderly.

To deepen trust in the public health sector, the government should show bold leadership, create clear ways to keep leaders accountable, deal decisively with corruption and build departments that really work.

Building trust means moving away from running the health system in a top-down way, whether in management or how people are served. Instead, delivering health services should be more intentional and creating solutions with local communities should become the norm rather than the exception.

2. Prevention is better than cure: Instead of a system that focuses almost only on illness and curative care, we need one that equally values and invests in wellness and preventing disease.

But more so, we need a system that works. Stable leadership at subnational levels is important for creating a working health system — or any government department for that matter — with the high turnover of high-level managers noted as “prevalent in the South African public service, which has negative outcomes on departmental performance and service delivery” in a 2019 report from the department of planning, monitoring & evaluation. 

Rolling out health management information systems that are practical and stable should become a priority. Such systems should be built on good, reliable data, not only to manage patient outcomes but also to ensure that gaps in service delivery are spotted and fixed in real time. This will be critical for tracking performance and progress, and delivering quality care.

3. Manage money better: The health system is labour-intensive and requires enough well-trained health workers, who are managed well. Training doctors, nurses and other health professionals but then not having the budget to employ them not only weakens the credibility of the system but also impairs service delivery.

At the same time, people in charge of managing staff, facilities or departments need to be suitably skilled and accountable for the services and level of care patients get. This includes upskilling people to roll out NHI.

4. See the bigger picture: How social and economic conditions affect people’s health should become a national conversation. Fixing structural barriers to getting health care can’t be the task of the health sector alone. Every sector — from agriculture and housing to social welfare and transport — has to play its part, so that both structures and policies that will make South Africans’ lives healthier can be put in place. 

The incoming administration will have its work cut out for it. However, by being open to advice and help from skilled and experienced South Africans, those in charge of the health system can make sure that they build one that is strong and trustworthy — and which will serve people best.

Yogan Pillay is the director for HIV and TB delivery at the Bill & Melinda Gates Foundation (BMGF), and extraordinary professor in the department of global health at Stellenbosch University. Prior to his current role he spent more than 20 years in the national health department in various management positions.

René English is a medical doctor and public health medicine specialist. She heads the division of health systems and public health in the department of global health at Stellenbosch University. She is a recent graduate of the Kofi Annan Global Health Leadership Fellowship.

The authors write in their personal capacities.

Bhekisisa receives funding from the BMGF, but is editorially independent. Read more about the nature of our donor relationships.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.