In our previous article, we said that the Covid-19 pandemic is intensifying locally and demands on the healthcare system are increasing along with pressure on scarce healthcare resources. It seems certain that the public healthcare system, which ordinarily provides care for 80% of the population, will be overwhelmed by this crisis. And clinicians will be forced to make untenable choices as to who should be prioritised. We made concrete suggestions as to how this dilemma could be made a matter of public interest.

But what is clear is that the continuation of a “business as usual” two-tiered system is clearly not tenable in the face of the current epidemic. The recent Competition Commission Health Market Inquiry found the excess capacity of high-care and intensive care unit (ICU) beds in the private healthcare sector. Recruiting these critical resources into the public arena is essential.

In this follow-up to our previous piece, we look at how the Covid 19 pandemic may nudge us in this direction and hasten the achievement of the NHI.

Global experience shows that success in containing the Covid 19 pandemic can only be achieved with a coordinated, integrated approach using the resources of public and private health systems together in the national interest. Some nations have addressed this challenge by making drastic changes to the governance, structure and partnerships in the healthcare delivery system, for the duration of the Covid-19 epidemic.

The Spanish government commandeered all hospitals and healthcare providers in the country in its latest move to combat the Covid-19 disease. Fourth-year medical students were asked to assist the country’s healthcare service. Companies capable of producing medical equipment have been asked to partner with the national government to deliver products that serve the national interest.

In Ireland, private hospitals, including 2,000 beds and thousands of healthcare workers, have been “drafted” into the public health system. Irish Health Minister Simon Harris said:

“We must, of course, have equality of treatment; patients with this virus will be treated for free, and they’ll be treated as part of a single, national hospital service.

“For the duration of this crisis, the State will take control of all private hospital facilities and manage all of the resources for the common benefit of all of our people. There can be no room for public versus private when it comes to pandemic.”

But if it works so well now, surely this a model for future health system efficacy?

The South African Response 

Given the inequities between the South African public and private health sectors, the need to take action to develop a coordinated national response which harnesses the resources of both sectors in the national interest is even more critical. Efforts to do so are underway.

The Competition Commission has published a block exemption for the health sector, to promote better coordination, sharing of information and standardisation of practice across the entire healthcare sector. The intention of the exemption is to promote agreements between the National Department of Health and the private sector. This has the sole purpose of making additional capacity at private healthcare facilities available to the public sector along with adequate medical supplies.

In the national interest, many stakeholders are making a significant effort to deal with the crisis. National departments, including the Department of Health and the Department of Trade and Industry, are engaging with national interest groups including business entities, the private health sector which includes medical aid schemes and private hospital groups, professional groups such as the South African Medical Association, and regulatory authorities such as the South African Health Products Regulatory Authority, the Health Professions Council of South Africa, the Pharmacy Council and the Council for Scientific and Industrial Research.

To coordinate these efforts, a range of “command centres” and “nerve centres” have been established from the president’s office to provincial and municipal levels. The Covid-19 crisis and its associated regulatory devices have provided these structures with the legitimacy required to prioritise, coordinate and direct all available resources needed to address this national challenge. More of this is the kind of governance is required to deliver on a national mandate with levels of efficiency and effectiveness that have previously been lacking.

The response to Covid-19 has already shown that it is essential for such structures to represent all key stakeholder groups, including healthcare workers in community settings, civil society organisations working in health, and labour. To succeed, they must make public their decisions and the reasons behind them in clear, accessible language, and provide opportunities for appeal. They must be empowered to carry out this mandate.

Lessons from Covid-19 for our proposed NHI

South Africa is committed to implementing a National Health Insurance (NHI) as a vehicle for achieving Universal Health Care (UHC). The Covid-19 pandemic is providing some valuable insights into what is required to achieve this. It also provides an opportunity to test or pilot system changes in moving towards UHC. A real-life pilot study may provide a real opportunity to test how a national, unified healthcare platform can work, as it deals with the current epidemic. We suggest that the following features of the health system could be implemented and subsequently evaluated in this “pilot” phase:

1. Establish an explicit set of national guidelines for prioritising care;
2. Mandate both public and private sector to abide by the guidelines;
3. Establish a standardised set of tariffs for all healthcare services/procedures;
4. Mandate the private sector to provide services at the agreed tariffs;
5. Create a public sector fund which reimburses private sector providers for the services rendered to patients with Covid-19;
6. Create dedicated public and private hospitals that provide highly specialised services for extremely ill patients;
7. Human Resources for Health in this crisis – create a volunteer data of retired health professionals and health workers for deployment across the designated public and private hospital system;
8. Establish a centralised reporting system; and
9. Establish a centralised monitoring and evaluation system.

The South African challenge to respond decisively during this period of uncertainty

How we respond to the Covid-19 epidemic will be important in determining how effective we are in dealing with this and the inevitable future epidemics. However, how we deal with this epidemic could also play a key role in modelling some of the essential features of our future healthcare system. As the national response to the Covid-19 crisis is showing us, only a rapid and effective removal of the separation between the public and private service delivery systems in South Africa can achieve an optimal nationwide response not only to this and the inevitable future epidemics, but also pave the way towards universal healthcare in future. DM/MC

Geetesh Solanki is Specialist Scientist at the Health Systems Research Unit, SA Medical Research Council (SAMRC); Reno Morar is Chief Operating Officer and an Honorary Research Associate at the Health Economic Unit, University of Cape Town; Louis Reynolds is with the People’s Health Movement; Neil Myburgh is Acting Dean of the Dental Faculty, University of Western Cape; and Leonard Gentle is a former trade unionist and former research translation consultant to the SAMRC.