Podcast key moments

• LL: Letlotlo Lenake
• AS: Dr Aslam Dasoo

• 00:00: Intro

• 02:47 What are the biggest challenges facing South Africa's healthcare system?

  DR:

  “By the time we came to 1997, there was a comprehensive clear health policy that took into account the current situation in 1997 globally, economically, in South Africa and a very smart approach, which recognized that we have a private system and a public system - a small private system, but which was of a sufficient quality to be very useful. And so, what you wanted was a gradual integration to create one system, which would leave the private system profitable for those who wish to use it and a public system, which would cater for the 90 percent of the rest of the population, which the portion of the population that uses the public system. So, what happens? Naturally, there is the integration initially, which is all good. So now we've got one public health system from all the various bits and pieces.”

  “But the private system continues to grow, it's highly efficient and people want to go there. But after 2000/2003, what you got was a decline in the management of the public system. And what happens then is that despite the fact that you have constitutional access - what you're finding is reduced access despite the fact that in the Mandela administration we built one thousand primary healthcare facilities in one of the largest ever clinic building programs in the world, which brought healthcare for the first time to almost every South African within 10 kilometers of their doorstep. But then there was a decline in that.”

• 08:39 The economic impact of a weak healthcare system

  LL:

  “If you're thinking about it from a trade perspective, what does that do for investor sentiment? Do investors want to put money into potential countries that have poor healthcare services, and especially for industries that have a high reliance on employees or the potential of employees? And what happens to your employees who aren't able to be active? What happens from a productivity perspective? It doesn't send the right signals from that perspective. And it is largely negative.”

• 10:41 Opportunities for public private partnership in healthcare

  LL:

  “So, you could say there’s a clear profit motive within the private sector that everyone is trying to push this fee for service kind of environment we have, especially in the South African context. Whereas in theory, the more people that you drive into the system should be bringing costs down, but there's maybe a balance of risk and the way that people incentivize in the public and the private sector are kind of misaligned.”

• 12:30 What should be the key focus areas to improve healthcare in SA?

  AD:

  “We must separate health from healthcare, your healthcare system is at the end of a long chain - that's the healthcare delivery system, public or private. Your health comes from other factors; genetics, environment, social factors and cultural factors, which all together determine how you maintain your health. It's very clear now that the greatest healthcare costs come toward the latter parts of life. All health is determined by social and economic determinants, but mainly your social organization. So, you need good nutrition, adequate shelter, access to potable water and clean sewage, access to basic education, personal and communal safety and you need those things to work. All those factors determine your health and when there's a breakdown in any of those modalities, then your health suffers and that's when you need the health care system. So, a health care system develops in response to that.”

• 17:50 Can South Africa afford NHI?

  LL:

  “I've written past research on this, that if the NHI bill is implemented in its current form without any material changes, it presents a material risk to our fiscus. If you look at some of the financial projections on which it's based, it’s about R256 billion once it's fully implemented. And these are numbers that haven't been updated for inflation or based on the white paper or projections that are almost more than 10 years old. So, if you take into account inflation, you potentially could get a significantly bigger number than R256 billion on an annual basis. And if you're taking that as a percentage of GDP, you could run somewhere in the double digits potentially. As an emerging economy, to spend that amount of money on healthcare is quite significant.”

• 20:35 NHI, is there an alternative?

  AD:

  “No, and for a very simple reason that the NHI is a political sleight of hand. It's a distraction. It's a deflection from a government that over 20 years has brought one of the best propositions we've had for anything approaching, say, the NHS in the UK to its knees, it's done that.”

• 25:40 Lessons from other countries

  LL:

  “The challenges that we face as a country from a healthcare perspective are potentially not unique. If we look at some of our emerging market peers like Brazil, Mexico, Thailand, Kenya, for example, they still deal with the same issues of inequalities between access. But the way they're going about it, it's very clear that they're following approaches where you have a mixed healthcare system across both parts where the public and the private sector work together to deliver healthcare. A big part of that in my view, is that a lot of these relationships are built through trust. I think both parties, public and private sector, have to work together and come to the same table to build. I think that's the only way we can get to some sort of a place where we can actually have a thriving healthcare system in my view, and it all starts with leadership and governance.”

• 27:13 How do we fix the healthcare system?

  AS:

  “If 85 percent of your population use the public system, spend 85 percent of your time on that. Fix that. Fix it to the extent that those who don't want to be in private healthcare, start migrating backwards. We have such an excellent cohort of health professionals, world class. It's a resource and a national heritage, it's not for the government to do with as it pleases. So, that's what you want in the first instance. And the second instance, the private sector must be regulated, there's the recommended regulations in writing – implement. You do those two things, in five years you will have a different healthcare system, and you tax fund. You don't put an intermediary like the NHI fund in your funding of public health, you just create costs there. You tax fund as you are tax funding now, but you make sure it's not stolen. So, the money must go where it's supposed to go, and then you've got a great system.”

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