National Health Insurance could improve health, create jobs and mitigate climate change
The advent of the National Health Insurance (NHI) scheme opens up a political space to campaign for a health service that will best address South Africa’s health crisis and reduce the extreme inequities between poor and rich, rural and urban, and public sector and private health service users.
Campaigning is necessary to raise awareness about the problems in our current health system and the best ways to address them, and to disseminate information about the most instructive examples globally of health system transformation that have resulted in impressive advances in health and substantial reductions in health inequalities.
Such a campaign must counter powerful groups with vested interests who portray public systems as inefficient and second-best, and see the NHI as an opportunity to preserve a private health system that is innately inequitable because of the need to profit from disease.
Health, health systems and a new model for health care
As we have written before (NHI key to tackling SA’s health crisis. Cape Times, October 14, 2010) South Africa’s health indicators are disturbing. Despite unprecedented economic growth over a decade, South Africa, (with a GDP/capita of $10 000 per year) compares badly with other countries of similar wealth such as Cuba, Brazil and Costa Rica. In South Africa under-5 mortality, a sensitive barometer of a country’s health and social development, has, in contrast to most countries in the world, increased over the past two decades.
South Africa’s under-five mortality rate (U5MR) of 67 deaths per 1000 live births (75 000 deaths per year) is ten times that of Cuba at 6 and six times that of Costa Rica at 11 per 1000 live births. Similarly, every year 1600 mothers die from pregnancy or childbirth complications, and 20 000 babies are stillborn.
Too many live in conditions that make them sick. Poverty and inequality are key basic determinants of child deaths: a child belonging to the poorest fifth of the population is four times more likely to die before turning 5 years old than a child in the richest fifth. Almost 20% of young children are undernourished, which predisposes them to infections, many of which spread in unhygienic and overcrowded environments.
Though there has been good progress in increasing the delivery of clean water at an aggregate national level (although not sufficiently often to individual households), large gaps and inequalities in water and sanitation exist even in Cape Town: in parts of Khayelitsha up to 400 people share a single standpipe and 9 percent of households have no toilets.
And when people become sick, they face an inaccessible, understaffed and poorly managed health service, characterised by large inequalities and gaps in distribution of financial and infrastructural resources between private and public sectors, between levels of care (hospitals vs. clinics), and in human resources. Rural areas house 43.6% of the population but only 12% of doctors and 19% of nurses work there.
A minority – approximately 16% of the population, who are also the healthiest – utilise an expensive, hospital-dominated, urban private health system accounting for approximately 60% of health spending and employing just under 50% of the country’s doctors, approximately 70% of medical specialists, 90% of dentists and dieticians and almost 40% of all nurses.
The proposed NHI scheme pools public and private health resources for health for universal coverage, increasing the funds available for health significantly, and restructuring health service delivery.
There are a number of other policy initiatives, key amongst which is the proposed ‘Re-engineering of Primary Health Care’. This stipulates that the District Health System should become the central focus of resources and activity and that the community level of health care and lower-level facilities (clinics, health centres and district hospitals) should be urgently strengthened. It also outlines a new model for human resources.
Research and experience from a growing number of countries shows rapid health improvements where community-level workers, supported by clinics and health centres and equipped with basic skills to identify, prevent and treat common - especially childhood – conditions, visit households regularly. .
Of the approximately 65 000 community caregivers (CCGs) in the country, most work in HIV/AIDS or TB programmes, employed by a myriad of NGOs. Rationalisation, standardisation and expansion of the skills of this crucial cadre is urgently needed, as is improvement of their insecure employment conditions.
This model, which is similar to Brazil’s successful Family Health Programme and in line with the revitalisation of Primary Health Care, would undoubtedly be substantially cheaper than the current private sector model, and more cost-effective than the current hospital-dominated public sector.
Human resources account for over 70% of recurrent expenditure on health care, and specialist and general doctors and professional nurses account for a disproportionate percentage of this expenditure.
Moreover, this model should, as in other countries (Brazil, Rwanda, Thailand, Bangladesh), rapidly increase access to health care by the poor and result in improved health outcomes, especially if the ratio of CCGs to population were increased to resemble that of Thailand or Rwanda where the high density of community-based workers ensures that all households are regularly visited and health problems detected early. 
In several countries such high ratios are achieved by instituting a ‘two-tier’ system where full-time CCGs (Community Care Givers) are in a ratio of 1: 300-500 households and part-time CCGs with a more limited training are supervised by the full-time community workers.
The ratio of full-time to part-time CCGs averages 1:10 to 1:20 in countries where such a system operates successfully. This would mean that South Africa would need a total of between approximately 700 000 and 1, 300, 000 community caregivers, the majority of them part-time.
This total cadre of community-based workers would, undertake a range of health care activities, spanning the full breadth of rehabilitative/palliative, treatment, and preventive and promotive interventions. They would form the base of the health pyramid.
Thus, in addition to rendering health care more accessible and equitable, such a PHC-based health system will create many more jobs, and indirectly improve health by reducing the prevalence and depth of poverty.
This is the first of a 2-part series on the NHI, based on an article written for the One Million Climate Jobs Campaign. The next article in this two-part series looks at the critical interrelationships between climate change and health, and how the NHI provides the health sector with an historic opportunity to also take a leading role in addressing climate change.
Emeritus Professor David Sanders, School of Public Health, University of the Western Cape.
Associate Professor Louis Reynolds, Health Sciences Faculty, University of Cape Town.
Both authors are paediatricians and members of the Peoples Health Movement www.phmovement.org
 Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Scaling Up: Global health workforce alliance: Health workers for all and all for health workers; 2010.
 Lehmann U and Sanders D. (2007).Community Health Workers - what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Evidence and Information for Policy, Department of Human Resources for Health. WHO: Geneva.