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SA’s hospitals falling into disrepair – Is NHI the answer? Certainly not, says Anthea Jeffery
There’s no disputing the fact that vaccines save life. In the UK, where 85% of the adult population has received at least one vaccination, just 117 Britons (according to recent figures) have succumbed to the Delta variant of the coronavirus. Half of those who died had received the vaccine. While not full-proof, it’s undoubtedly saved lives – without the vaccinations, over 1,100 people would have fell victim to the strain. On the other side of the coin, South Africa is currently being ravaged by the highly transmissible variant. Now in its third wave, the country is seeing the highest infection numbers since the pandemic began. This could certainly have been avoided if the government had not dropped the ball on vaccine procurement. As the vaccine roll-out picks up now, it may be too late for many who would have been saved by timeous inoculation. Below, the IRR’s Anthea Jeffery notes that despite barring the private sector from procuring vaccines themselves, they refuse to “accept responsibility for the harm that it has done by insisting on a state monopoly over vaccine procurement.” However, the mishandled roll-out could be seen, somehow, as a forewarning. Government is very keen to go ahead with the National Health Insurance (NHI) proposal. As Jeffery writes, “the bungled vaccine roll-out could have one positive effect if it helps to strip away some of the myths surrounding the NHI proposal. This could save SA’s from an even more destructive government monopoly over every single aspect of healthcare – not simply vaccine procurement.” Below Jeffery’s insightful piece, a commentary on the state of South Africa’s public hospitals. As the author, Professor Daynia Ballot writes, state-run healthcare is in a dire place. “Overcrowding and infrastructural issues negatively affect patient care. Hospital acquired infections with “super bugs” resistant to almost all known antibiotics are a major health challenge. Sewage leaks and inadequate plumbing increase the risk of infections.” Is the solution to our failing healthcare system, highlighted by the Covid-19 pandemic, to give the state even more funding in the form of NHI? If the vaccine roll-out and mismanagement of SOE’s are anything to go by, certainly not – Jarryd Neves.
Lessons from the vaccine roll-out for the NHI
By Anthea Jeffery*
The government’s bungled and tardy Covid-19 vaccine roll-out has predictably led to an upsurge in infections, great suffering among the ill and isolated, and many hundreds of additional deaths that could have been avoided.
Yet the government declines to accept responsibility for the harm that it has done by insisting on a state monopoly over vaccine procurement. Instead, it has deployed Barry Schoub, head of the Ministerial Advisory Committee on Covid Vaccines, to castigate its critics and deny its accountability for a vaccine roll-out so slow that South Africa lags far behind almost all its peers.
However, the bungled vaccine roll-out could have one positive effect if it helps to strip away some of the myths surrounding the National Health Insurance (NHI) proposal. This could save South Africans from an even more destructive government monopoly over every single aspect of healthcare – not simply vaccine procurement.
SACP/ANC propaganda around the NHI repeatedly claims that public healthcare in South Africa is being crippled by a shortage of revenue and other resources. It also claims that, once the NHI has boosted available resources, public healthcare will become just as efficient as South Africa’s world-class system of private medical treatment. The NHI will thus allow the state to ‘level up’ health services so that everyone, whether rich or poor, gets the same free and high-quality care.
This perspective is flawed in at least three ways:
- health revenue is already considerable but is badly mismanaged;
- additional ‘NHI’ tax revenues may not be spent on health at all; and
- the government’s main concern is to ‘level down’ rather than ‘level up’.
Mismanagement of considerable resources
Spending on public healthcare as a percentage of GDP has already risen sharply: from 2.3% in 2002 to 4.5% in 2018, which is not far short of the 5% of GDP the World Health Organisation (WHO) recommends. In addition, the number of GPs in the public sector more than doubled between 2002 and 2020, while the number of specialists went up by close on a third.
Despite increased resources, outcomes often remain poor. Some 85% of public clinics and hospitals fail to comply with basic healthcare norms and standards, even on such essentials as hygiene and the availability of medicines. In addition, South Africa lags many developing countries on under-five mortality rates, while the state’s contingent liability for alleged medical negligence has risen sharply from R28bn in 2014 to R105bn in 2019.
Experience at one Mpumalanga public clinic – which was supposed to have been ‘strengthened’ through its participation in a NHI pilot study – highlights common shortcomings.
Interviewed by The Citizen in October 2019 on whether the pilot study had helped, patients said they ‘continued to be subjected to chronic shortages of medication, rude nursing staff, long waiting hours, and a chaotic filing system’. Many arrived as early as 5am, but nurses either ignored them or ‘ridiculed and demeaned’ them if they complained. Some had therefore given up on even trying to seek treatment.
Why this inefficiency and indifference? Cadre deployment is partially to blame, as party loyalists appointed to posts know that their political affiliations count more than their job performance. Also relevant is the Labour Relations Act of 1995 – which makes it difficult to implement dismissals – and a reluctance among many public service managers to discipline their staff.
According to the Public Service Commission or PSC (a body established under the Constitution to oversee the public service), many ‘managers are too scared of trade unions’ to punish employees for poor performance. Many decline to act even against unlawful conduct, such as blocking operating theatre doors during a hospital strike.
Most managers find it easier to pay bonuses than impose penalties. The upshot, says PSC director general Irene Mathenjwa, is that employees now take the view that ‘they should be given a good score just for coming to work’, irrespective of what they achieve during their working hours.
Corruption is another key factor and goes largely unchecked. State property in hospitals and clinics is commonly ‘stolen, hired out, or resold’, as President Cyril Ramaphosa has noted. Procurement of goods and services is deeply tainted too, with many state tenders marred by ‘false invoicing, collusion,…bribery, and over-pricing’.
Unless these deeper problems are resolved, more resources for public healthcare will not improve performance. On the contrary, expanding the public healthcare budget will simply increase the scope for incompetence, mismanagement, corruption, and theft.
‘NHI’ taxes for general spending, not health
Under the NHI, the SACP/ANC alliance plans to divert much of the roughly R250bn a year that some 18 million people now spend on the private healthcare of their choice into the coffers of the state.
Though the government declines to disclose how much the NHI will cost, the Davis Tax Committee estimated in 2017 that the new system would need R165bn in additional revenue at its start. The committee also cautioned that the NHI was ‘unlikely to be sustainable’ without sustained economic growth.
Assuming R165bn is enough (which seems unlikely), how could this sum be raised? In 2019 Intellidex estimated that this would require a 2.75% payroll tax, a 2.75% surcharge on income tax, and a 3.5 percentage point increase in the VAT rate, which would take this from 15% to a damaging18.5%.
But even if this R165bn can be raised from a population already struggling under one of the highest tax burdens in the world, the money will not necessarily be used for the NHI. In the absence of legislation ring-fencing ‘NHI’ taxes for NHI purposes – which the Treasury opposes – the extra R165bn will be paid into the National Revenue Fund, as the Constitution requires.
Once included in this common pot, ‘NHI’ revenue will be used to help fund all government spending: from public service wages and SOE bailouts to the interest bill on expanding public debt. Most of the extra ‘NHI’ taxes will go, in short, to paying cadre salaries, covering inflated prices on many BEE tenders, and otherwise oiling the patronage machine that keeps the SACP/ANC alliance in power.
The assumption that the government wants to ‘level up’
The government repeatedly implies that a key purpose of the NHI is to end the disparities between public and private healthcare and ‘level up’ by providing the same high-quality treatment to all.
Generally forgotten is a telling 2004 comment by Dr Kgosi Letlape, then president of the South African Medical Association, that the government’s underlying agenda was rather to ‘get rid of the private sector in healthcare’. Behind this objective, he added, lay the health department’s philosophy that, ‘If you can’t treat everybody, you treat nobody’.
What the SACP/ANC alliance wants, in short, is to ‘level down’, rather than up. It cares little that the NHI will diminish the healthcare services now available – for all it wants to ensure is that the little that is left is shared equally among all.
NHI propaganda claims, of course, that the new system will expand health services rather than reduce them, but this is not so. Some 20% of health professionals are already taking steps to emigrate, while another 40% could leave too. The 85% of public hospitals and clinics that fail to meet basic norms will be barred from participating in the NHI. Most tellingly, the state’s monopoly over procurement will be inefficient and often corrupt, while centralised control over all health services will destroy competition and innovation.
The vaccine roll-out demonstrates the dangers
As five health experts have recently written, South Africa should have been able to make rapid progress on Covid-19 vaccines as it already had a large childhood vaccination programme and significant experience in rolling out antiretroviral treatment to millions. Instead, the country lags well behind all others on the continent because of the government’s many ‘mis-steps’.
Having insisted on being the sole vaccine purchaser, the government then dithered and delayed in developing a strategy, negotiating with suppliers, and creating a registration system to oversee the process. It then compounded its shortcomings by discarding a million AstraZeneca doses on spurious grounds, rejecting a Novavax vaccine shown to be effective against the Beta variant, and omitting to plan for unexpected contingencies.
Above all it has failed to overcome the supply constraints that are still the key obstacle to progress – and the main reason for hundreds of avoidable deaths.
The SACP/ANC alliance nevertheless seeks to move seamlessly from the state’s botched monopoly over vaccine procurement to a comprehensive state monopoly over every aspect of healthcare in the country.
This state monopoly over health will function no better than the government’s monopoly over electricity and other essential services has done. As one anaesthetist has warned, ‘the NHI will be like Eskom, SAA and the SABC combined, except that many people will die.’
- Dr Anthea Jeffery holds law degrees from Wits, Cambridge and London universities, and is the Head of Policy Research at the IRR. She has authored 11 books, including People’s War: New Light on the Struggle for South Africa and BEE: Helping or Hurting? She has also written extensively on property rights, land reform, the mining sector, the proposed National Health Insurance (NHI) system, and a growth-focused alternative to BEE.
Water, power cuts and neglect are taking their toll on South Africa’s top hospitals
A fire at one of the biggest public hospitals in Johannesburg, the Charlotte Maxeke Johannesburg Academic Hospital, and the delay in reopening the facility has brought infrastructural issues into sharp focus. The fire broke out in mid-April. Only now is a phased re-opening of the hospital being undertaken.
Reopening was delayed due to fire safety issues. A host of compliance measures weren’t in place. These included fire hydrants without a water supply, fire hydrants without correct couplings, non-functional fire doors and a lack of emergency lighting in the stairwells. These deficiencies had been longstanding.
I am extremely familiar with conditions on the ground in hospitals in the area. I interact daily with doctors and students in the different academic hospitals on the circuit of the University of the Witwatersrand. These include the Charlotte Maxeke Johannesburg Academic Hospital, Chris Hani Baragwanath Academic Hospital, Helen Joseph Hospital and Rahima Moosa Mother and Child Hospital. I also visit different institutions in the region.
I completed both my undergraduate and postgraduate training at these hospitals and worked for more than 30 years in the neonatal-paediatric intensive care unit and neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital.
During this time I’ve observed many changes in the healthcare sector in general, and in these hospitals in particular.
South Africa’s healthcare system compares favourably on a global level. Both the medical schools of the University of the Witwatersrand and the University of Cape Town are ranked in the top 100 in the world. Over the years, the region has produced many eminent healthcare workers. And the country is quite capable of delivering world-class healthcare to all its citizens.
But this is constantly being hampered by an increasingly unconducive environment.
The public sector hospitals in Gauteng, South Africa’s economic hub, are generally in bad condition. Chris Hani Baragwanath Academic Hospital is the third largest largest in the world, with almost 3200 beds and more than 6000 staff. Charlotte Maxeke Johannesburg Academic Hospital has 1088 beds and more than 4000 staff.
These large public sector hospitals provide tertiary and quaternary services to more than 250,000 inpatients and almost 1 million outpatients every year.
Most were built more than 50 years ago and have been poorly maintained. The crumbling infrastructure results in flooding, sewage leaks, lack of water, problems with the supply of medical air and oxygen, and electricity blackouts. Leaky plumbing creates a damp environment that favours pests such as cockroaches and rodents. Inadequate air conditioning results in working conditions that are unbearably hot or freezing cold. Both are harmful to patients.
Doctors and nurses are having to deal with a shortage of hospital beds on a daily basis.
Gauteng provides healthcare to many patients from other provinces, as well as surrounding countries, particularly Zimbabwe. The provinces of North West and Mpumalanaga do not have medical schools and therefore send patients for specialised tertiary and quaternary care, such as cardio-thoracic surgery and renal dialysis, to the Gauteng academic hospitals.
In addition, under-resourced regional and district hospitals result in primary and secondary patients receiving treatment in the tertiary or quaternary institutions because there is nowhere else for them to go.
Overcrowding and infrastructural issues negatively affect patient care. Hospital acquired infections with “super bugs” resistant to almost all known antibiotics are a major health challenge. Sewage leaks and inadequate plumbing increase the risk of infections.
Ongoing power cuts and water shortages compound the internal infrastructural issues at each hospital. There have been rolling electricity blackouts in the country as the government struggles to keep the power utility, Eskom, operational.
Each hospital has a diesel generator. But this emergency back-up does not always kick in during blackouts and load shedding. Patients in intensive care and the operating theatre are particularly at risk.
Water infrastructure, which has not been maintained by local authorities, is in a state of disrepair resulting in a growing number of water outages. In recent weeks, three of the largest hospitals in the province– the Helen Joseph Hospital, Rahima Moosa Mother and Child Hospital and Chris Hani Baragwanath Academic Hospital – all experienced a water outage that lasted several days.
Surgeons were scrubbing for theatre using buckets, people could not flush toilets, and patients were issued with bottled water and could not wash.
On top of all this, the COVID-19 pandemic is now raging in the province. This is proving to be the last straw for a buckling health system. Shortages of hospital beds, lack of oxygen supplies, inadequate ICU facilities are a few of the problems being faced.
Healthcare workers are exhausted and burned out.
How it got to this
There are multiple reasons for the current debacle. These include a lack of preventative maintenance, poor administration, corruption, poor forward planning, lack of financial resources, and a lack of strong governance at both municipal and provincial level.
The governance of the hospitals is complex and falls between different government departments. The Department of Infrastructure and Development, or Public Works has been tasked by the Department of Health to take care of the hospital infrastructure. This means that a hospital CEO isn’t directly responsible for maintenance of the building.
In turn this means that the system for responding to maintenance issues is not agile.
Bureaucratic processes designed to minimise corruption result in long delays. Management at all levels tends to put out fires rather than implement a long term strategy to improve the situation.
Facilities have also been affected by strikes about wage disputes. In some cases hospital facilities have been damaged during the industrial action.
Criminality is also a problem. Theft is common with wall mirrors, bathroom tiles, soft furnishings, even large potted plants disappearing. Most recently copper plumbing pipes were stolen from Charlotte Maxeke Johannesburg Academic Hospital while it stood empty.
The fallacy that South Africa has two healthcare systems
There is a perception of an “us and them” among many South Africans. People with medical aid feel relieved that they have access to private healthcare, which does not have all these problems.
This is a fallacy. The country has one healthcare system – the public academic institutions train the healthcare workers who work in both the private and public sector. If the public healthcare sector collapses, the private sector will follow.
The solution is proper management and accountability at all levels. South Africa spends enough money on healthcare (just over 10% of GDP), but there is terrible waste at many levels. The government is pursuing a National Health Insurance scheme, with the aim of pooling resources to provide “quality affordable personal health services for all South Africans, based on health needs, not socio-economic status”.
If implemented and governed properly, the new scheme is most likely the best solution to all the many problems facing country’s healthcare system. And it will allow South Africa to reach its full potential of providing excellent healthcare to all.
- Professor Daynia Ballot, Head, School of Clinical Medicine, University of the Witwatersrand
- This article is republished from The Conversation under a Creative Commons license. Read the original article.
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- SA healthcare inequity: ‘Patients shouldn’t be treated better because they can afford to pay more’
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