National Health Insurance pilot sites suggest scheme is dead in the water

Over a decade since the National Health Insurance (NHI) was piloted, there has been little or no improvement in the quality of public health service at the test sites, with poor hygiene, drugs stock outs, and long waiting hours still the order of the day.

This despite R5.1 billion spent testing the NHI in OR Tambo (Eastern Cape), Gert Sibande (Mpumalanga), Vhembe (Limpopo), Pixley ka Seme (Northern Cape), Eden (Western Cape), Dr K Kaunda (North West), Thabo Mofutsanyane (Free State) and Tshwane (Gauteng), uMzinyathi, uMgungundlovu and Amajuba (KwaZulu-Natal)

The NHI pilot programme was rolled out in 2014 but failures in core pillars of the scheme, including medicines and medical supplies, cleaning material, and servicing and maintenance of equipment had started to show by 2017.

Yet, in June MPs started clause-by-clause deliberations of the NHI Bill and, if the health committee agrees to the Bill, it goes to the House. 

ALSO READ: NHI this is where we are today

Once fully implemented, the NHI Bill states that medical schemes will not be able to provide cover for services paid for by the scheme.

The health financing system is designed to pool funds to provide access to quality affordable personal health services for all citizens, irrespective of their socio-economic status.

But government’s track record in implementation and capability has been the biggest concern around the NHI, which focuses on the primary health care.

Reality on the ground

At Temba clinic in Hammanskraal, Tshwane, one of the pilot regions, the floor of the patient waiting area was littered with rubbish during The Citizen’s visit this week, bathrooms were without water, while there was also a shortage of drugs and waiting hours of up to three hours.

This flies right in the face of the NHI’s stated goals, which were to improve primary healthcare and sanitation, in order to prevent the need for higher-level care later on.

Chronic patient Jones Ndala said collecting his medication at the clinic was a whole-day affair and many times he has left without his treatment, either because he could not wait any longer or because there was none.

“I do not understand why I have to wait so long just to collect medication. I have been sitting here for over an hour now. From here they will call my name and then go get my file. Then go to pharmacy where I will wait for another two hours,” he said.

A recent Section27 report revealed that 6.9% of patients surveyed at 380 health facilities across seven provinces over three months said they, or someone they knew, had left a public health facility without the medicine, contraceptives, vaccine, dry stock or tests they needed.

To be at the front of the queue when Boikhotsong old clinic in Soshanguve, also in Tshwane, opens at 7am, patients have to wake up as early as 2am to be at the clinic at 4am.

The facility is so small that patients’ vital sign readings are taken outside near the entrance, despite a new facility standing empty down the road.

According to community members, the clinic was supposed to house the old clinic, but work on finishing touches suddenly stopped in March without any explanation.

In Ekangala, also in Tshwane, Rethabiseng Clinic does not have water, leaving the patients in the waiting area with no access to ablution facilities.

Koos Mahlangu said there were three clinics in the area but only one in Dark City opened 24-hours, forcing residents of Rethabiseng and surrounding areas to travel long distances in case of emergencies.

“I thought the NHI was about strengthening the primary health care sector so that people do not have to go to hospitals for ailments that could be dealt with at the clinic. Where are the doctors?” Nothing has changed here,” he said.

Mixed feelings

Public health specialist and activist, Dr Shakira Choonara, was not surprised, saying she has been hearing of similar experiences from patients at different facilities across the country.

She said the assessments of the NHI pilots showed multiple issues but that there was no clarity on how these issues will be dealt with.

“The NHI Bill has become more of a political rhetoric tool versus something which is implementable. It is poorly written and in its current form [will not] resolve the issues we are seeing in the healthcare system,” Choonara said.

ALSO READ: ANC on foreigner blame trail wants to ram through NHI bill

She said the health department recently approved R30 million for close to 44 experts who will design the final form of the NHI, but said they were yet to see how this pans out.

“In my view the principle of the NHI, universal health coverage is what must happen. Too much is being promised, but very little will translate to changes on the ground. That is where we need to focus,” Choonara added.

But Dr Atiya Mosam, Public health specialist and researcher at Wits’ Centre for Health Economics and Decision Science, believes what is important to communicate is that it is impossible for the NHI to become a reality overnight.

She said the SA health system, both public and private, has challenges that need to be addressed systematically.

According to Mosam, the pilots and subsequent assessments were done to prepare the country and start optimising the health system for NHI.

“An endeavour such as the NHI has many moving parts and they all need to be worked on simultaneously and they are happening, even if it is not always apparent,” she said.

Mosam said the newly established NHI directorate, under Dr Nicholas Crisp, was making headway but conceded that the road ahead was long.

Department of Health spokesperson Foster Mohale said the NHI Pilot Programme ended in 2017.

He, however, said the contracting of healthcare practitioners for oncology and mental health services, including doctors, has been expanded to allow the 52 districts coordinated through the provinces

“The pandemic has contributed to delays in Parliament debating the NHI Bill, but Parliament is now debating the Bill through the Clause by Clause Debate.

“The Department has also embarked on strengthening its internal capacity to accelerate preparatory work for the implementation of NHI as recently evidenced by the advertisement in the media of the 44 post for the NHI Branch,” Mohale said.

He added that this additional capacity will ensure that the delays that resulted from the restrictions associated with the pandemic were mitigated.