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Forget NHI: Strengthen what we have, and build what we need — jobs

By Andrea Mendelsohn• 21 August 2019

 Johannesburg, South Africa – February 26, 2019: 23-year-old, Fuzile Jwara, waits on a hospital bed at Charlotte Maxeke Academic Hospital in Johannesburg, South Africa for a colonoscopy and a gastrointestinal endoscopy. Jwara has to be examined at least every six months because he’s living with FAPS (Familial adenomatous polyposis), a genetic disorder that could become cancer. Picture: DANIEL BORN for DAILY MAVERICK  Less


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Medicine alone is rarely the answer to public health crises. Jobs, good education, safe neighbourhoods, housing and healthy food are what South Africans need to rectify the gross health inequalities persisting in our society, not health insurance.

I’d rather be a poor patient in South Africa than uninsured in America.

I’ve worked as a family physician in community health centres in struggling communities in both South Carolina and Cape Town. Without a doubt, my patients in Cape Town have access to much better healthcare than my patients in America.

In South Carolina, at a federally subsidised community health centre, my uninsured patients had to pay $30 for a clinic visit. Each medication at Walmart was a minimum of $4 for a one month’s supply (most people were on 4-5+ chronic medication). Insulin was at least $30 a vial and steroid inhalers for asthma were so expensive (more than $100) that we had to apply to the company for free samples.

Forget elective hip replacements or specialist consults. Emergency hospitalisation? Sure, the cardiologist would treat your heart attack, but would you like a payment plan with that stent? I routinely had patients refuse to go to the emergency centre for serious medical conditions for fear of accruing more debt.

Cape Town might have shocking waiting lists for elective procedures or specialists’ clinics. However, my patients walk out of my primary healthcare consultation room with free ARVs, TB medication, asthma inhalers, insulin, and anti-hypertensives (and so on!), which is certainly nothing to sniff at. For a resource-constrained public healthcare system, I would argue that patients have relatively good access to care.

That is not to say that the public health system cannot be improved. Eliminating the medical aid tax credit would provide a much-needed cash infusion to improve the public healthcare system we have, rather than destroying it for a more complicated and idealised version of what a National Health Insurance (NHI) could be.

Doctors. More doctors would work in the public sector if there were more posts. Each public hospital is budgeted a limited number of medical officer posts.

A recent specialist paediatrician post at Paarl Hospital had 16 applicants. A final-year UCT dermatology registrar from the Eastern Cape told me she couldn’t go home because no public hospital in the Eastern Cape would create a dermatology post, despite the need. My Community Health Centre services 20,000-30,000 patients a month, yet we have one intern psychologist who is currently booked through the end of the year.

My patients’ queue to see me all day, because we book 30-40 patients per primary healthcare doctor daily. There are doctors, nurses, pharmacists, physios, psychologists and social workers ready to work in the public sector. You don’t need NHI to bring more healthcare professionals to much of the population. You just need posts.

Medicines. We currently have stockouts of all first-line anti-depressants on the primary healthcare essential medicine list (EML). Much of the country is switching patients’ ARV regimen because of a national shortage of lamivudine. For a while, we didn’t have enough penicillin to treat syphilis infections.

Before further centralising healthcare, the National Department of Health must fix its current ordering systems to prevent stockouts.

Thank god for private pharmacies because at least now I can offer my severely depressed patients a private prescription for Fluoxetine for about R50 for a month’s supply (if they can afford it). I have no problem with wealthy patients buying a broader range of medication for the same conditions as long as my patients have access to all the essential medicines needed to keep them healthy.

In fact, keep the stock of essential medicines for my public patients and let private patients buy something else. Just fix the government’s medication procurement system to prevent stockouts.

Health insurances. Health insurances create administrative waste, including NHI. Hospital billing departments need to submit claims and then insurances need to process those claims and reimburse healthcare providers for services rendered in a timely fashion. I hate health insurances.

It is a pleasure to practice as a salaried employee without having to fight for reimbursement. If South Africa’s public healthcare system is allocated more money, I want that money spent on equipment, healthcare providers and medication, not billing staff or national insurance middlemen. Fix the public system, don’t create a more complicated system with additional layers of administrative waste.

Private health insurances will cease to function if they are only intended to provide “top-up” services not included in the public system.

For instance, the public healthcare system currently does not offer dialysis for any patient over 60 due to cost constraints. There is no way that private health insurance would exist to provide costly dialysis services for sick patients without being able to offset those costs with healthy young patients. For those patients in renal failure whose family can afford private insurance, I am glad the option to buy better care exists. For the rest of the population, we should offer the most cost-effective essential medical treatments afforded by the public health budget, while continually striving to expand services.

Jobs. My HIV patients who do poorly drop out of care, often because they are looking for work and live stressful, complicated lives. They don’t fail treatment for lack of access to ARVs. When you live on your child’s R400-a-month grant, survival comes first.

Likewise, I had plenty of insured patients in South Carolina who had access to specialists and fancy medication, but still struggled to control their diabetes because of poor diet, obesity and poverty.

Medicine alone is rarely the answer to public health crises. Jobs, good education, safe neighbourhoods, housing and healthy food are what South Africans need to rectify the gross health inequalities persisting in our society, not health insurance. If the medical tax credit is eliminated, we should use the extra funds to strengthen the public health system that we have, and work on what South Africans need most to live healthier lives: Jobs. DM

Andrea Mendelsohn is a senior medical officer working in the public healthcare system. She writes in her private capacity.