On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.12 Cape Town Dec. 2011
The NHI - where should the passion of our focus be?
To the Editor: Commendably, our Minister of Health is on a road show to give first-hand insight on the NHI, while the green paper is out for comments. His presentation to the North-West medical constituency at Klerksdorp in October 2011 dispelled many myths. He was eloquent, spoke with passion on wide-ranging health issues, and indicated that the NHI is only a component in the grand scheme of transforming the delivery of healthcare to all South Africans. After a 4-hour talk, there was insufficient time for questions. No sane person would gainsay the urgent need for a revolutionary culture for healthcare delivery. However, I wish to make some comments.
Firstly, focusing on the private sector is inappropriate and a waste of energy, and detracts from an excellent national plan. The private sector is doing a magnificent job, but is out of reach for many. This sector has a historic legacy in the business of selling its expertise. Like other 'commercial' enterprises, it purports to give 'value' for money. Its facilities are state-of-the-art and have understandably attracted the country's top professionals. Rather than the government's strategy sounding like a 'total onslaught', it would be preferable to focus our total energy on restructuring, re-engineering and overhauling the public health system along the lines indicated by the Minister. It should be developed to be competitive and to put the costly private sector out of business by providing a service that is efficient, effective, cheaper, accessible, and user-friendly (available at all health points 24/7, reasonable waiting periods, etc). The client will make the final choice! At worst, the two systems can be complementary, as in examples in the commercial sectors.
My other concern is the lack of recognition or admission of the enormous urban-rural disparities that must be addressed. The health service system in the affluent urban areas must be accommodated in the decentralisation of services, so that in the suburbs of Johannesburg, for example, the public facilities hierarchy applies equally.
Thirdly, the process must bring on board the consumer public at the beginning! For the optimal, appropriate, systematic, organised use of the hierarchy of facilities described by the Minister, education and orientation of the public is crucial, and is a political challenge. 'Community participation' was correctly emphasised in the Alma Ata declaration, and must happen from the beginning! Peoples' mindsets on health facility use, the meaning of primary healthcare (we must hope that unacceptable terms, such as 'minor ailment', will be avoided), and its orderly access must be part of the culture change!
There must be uniformity (enforced if possible, for rich or poor), no discrimination on any grounds (implicit or permissive, and rich and poor must access the system at identical points), and confidence in such a diversified and decentralised system must be ensured. Referral mechanisms must work, by this affordable delivery system being accessible, efficient and effective. The public must be aware of some inevitable caveats such as rationing and selection. The future system will not be 'utopian', providing 100% of services to 100% of the population for 100% of the time. Success, if it happens, will not come in the short term. Hence, I believe that our energy must focus entirely on getting our public sector overhauled, and copying and learning about the private sector's successes. The challenges to these ideals are daunting, including the influence of inequities in several non-health sectors, some causing obstacles to equitable health provision, i.e. housing, poverty, malnutriton, transport, etc.
K P Mokhobo
Part-time principal cardiologist-physician
Potchefstroom Provincial Hospital