Mothers give birth in the back of bakkies, and children die because ambulances arrive late, if at all. This is the current reality for many people trying to access emergency medical services in South Africa.

Underlying this reality are deeply entrenched structural and capacity problems. Currently, most provinces simply do not have enough ambulances which often languish for months in depots awaiting repairs. In addition, there are insufficient numbers of intermediate life support and advanced life support paramedics in South Africa, so that ambulances, when they do arrive, often merely act as patient transport vehicles. All this is made worse by limited planning, co-ordination and management capacity in many provincial departments of health.

South Africa’s new National Health Insurance (NHI) Bill emphasises that everyone has the right to emergency medical treatment as stipulated in section 27 of the Constitution. By shaking up the way in which emergency medical services are organised and paid for, NHI has the potential to take us closer to realising this constitutional right, but for that potential to be realised will require ambitious reforms and careful structuring and implementation of NHI.

How will EMS work under the current NHI Bill?

The NHI Bill stipulates that the NHI Fund will purchase services from both public and private ambulance providers. The details of exactly how this will work are however still worryingly unclear. From the user side, however, the idea is that there will be a single number to call no matter where in the country you are and whether you need a public or a private ambulance. Both public and private emergency medical services would be paid, according to section 35(4)(a) of the Bill, on a “capped base-based fee basis with adjustments made for case severity, where necessary”.

Broadly speaking, it seems that private ambulance services would be contracted individually by the NHI Fund, but provinces, as “managing agents”, would provide public ambulance services.

According to section 39(3)(b) of the Bill, the NHI Fund will conclude legally binding contracts with health establishments certified by the Office of Health Standards Compliance (OHSC) and with any other prescribed healthcare service providers to provide emergency medical services. This means the fund will have the power to contract with emergency services providers directly. It is not clear however whether the compliance office will be tasked with inspecting ambulances and ambulance bases.

For public emergency medical services, another provision in the Bill (section 32(2)(a)) states that the minister may delegate to provinces as management agents, for the purposes of provision of healthcare services, and in those cases the fund must contract with sections within the province such as provincial tertiary, regional and emergency medical services. According to the Bill, these “public ambulance services must be reimbursed through the provincial equitable share”.

Either way, there isn’t much here that will change from how things are done now, given that provinces will still use money from their equitable share to run the service themselves, although equitable share allocations are likely to be significantly smaller and substantially reconfigured.

A further complexity arises in the distinction between emergency medical services and ambulance services in the proposed addition of section 31A to the National Health Act. Section 31A(3)(k) provides that one of the functions of the District Health Management Office is to “facilitate the integration of public and private healthcare services such as emergency medical services but excluding public ambulance services”. What this means, in the light of the definition of emergency medical services as “pre-hospital acute medical treatment and transport of the ill or injured”, is unclear.

Serious regression of services for asylum seekers and undocumented people

On the face of it, NHI appears to promise emergency medical treatment for all; however, the Bill says asylum seekers and “illegal foreigners” are only entitled to emergency medical services and services for notifiable conditions of public health concern.

“Emergency medical services” is defined narrowly as “services provided by any private or public entity dedicated, staffed and equipped to offer pre-hospital acute medical treatment and transport of the ill or injured.” What this really means in relation to EMS for asylum seekers and “illegal foreigners” is that this group of people will be able to call an ambulance and be assisted by paramedics but will have to pay for services if they are admitted to a hospital.

This is a serious regression of services for asylum seekers and undocumented people. Providing only ambulance services means that an undocumented pregnant woman could call for an ambulance and be assisted, but would not be able to give birth in a hospital without paying. This will potentially result in increased maternal mortality or children born with disabilities because of obstetric complications. It means a gunshot victim awaiting their refugee permit can be treated in an ambulance but will need to be dropped off at home before receiving needed hospital care if they cannot afford to pay.

The shortcomings in relation to access to comprehensive emergency medical treatment for asylum seekers and undocumented people clearly require amendments to the Bill, among other reasons to prevent legal challenge.

A lost opportunity?

Despite these various complexities, emergency medical services could nevertheless be an area where the right kind of NHI could lead to substantial improvements in the quality of service many people receive. This will, however, require that government strategises more ambitiously and puts in place appropriate funding mechanisms, contract management and implementation structures. Unfortunately, there is no indication that this kind of foresight and creative thinking is present in the current NHI plans.

In fact, since provinces will continue to manage public emergency medical services under roughly the same funding model as at present, there isn’t much reason to think things will improve.

The one aspect that seems new, the wider contracting of private ambulance services, comes with severe risks if not properly implemented. Spotlight has previously reported on dubious contracts for ground and air ambulance services in the Free State, Limpopo, Mpumalanga and North West. Apart from questions over how these contracts are awarded, Spotlight also reported on alleged overcharging and sub-standard quality of service from the contracted private providers in these cases. In these cases, private ambulance services were definitively not superior to public services.

It is essential that lessons should be learned from these cases when we start contracting more private ambulance services under NHI. If we do not address the particular ways in which ambulance services can be milked, we risk both large-scale corruption and a further decline in the quality of service.

It is also critical that regular inspection of both public and private ambulances and ambulance bases be conducted to ensure compliance with EMS regulations. Ideally, this quality control should be done by the compliance office, given the OHSC’s greater independence than, for example, provincial departments of health. The OHSC should be mandated, funded and capacitated urgently to do this work.

The optimal use of the limited emergency medical service resources available to us will also be critical if we are to turn the current situation around. Talk by some in the government of the “uberisation” of these services should be welcomed – at least in as far as it means that ambulance trips will be rationally allocated and closely tracked via GPS. Together with the uberisation, we will also require increased fraud detection mechanisms to prevent overcharging.

Maybe more fundamentally, though, what is needed is a national strategy to ensure that we train and retain enough paramedics and purchase and maintain enough ambulances to meet the needs of all who live in South Africa. NHI on its own is of course not going to be this strategy, but NHI is the one major shake-up that might provide a window of opportunity in which such a strategy can be implemented. Right now, it seems that the opportunity will be spurned. MC

Stevenson is the Head of Health at SECTION27. Low is the editor of Spotlight.