Healthcare stakeholders have raised concerns around the future of healthcare in South Africa under the proposed National Health Insurance (NHI) scheme – including issues of governance, management and accountability.

These concerns are highlighted in a new report published by Section 27 and the Concentric Alliance on Monday (20 June), which considered the opinions of 33 major stakeholders in the health sector.

13 respondents, including officials from the department of health, stated that governance, accountability, and management systems of the public health sector are an area of great concern, and in need of urgent reform.

There is also great concern that the public health sector has fallen prey to political patronage and corruption, illustrated most recently by the investigation into the irregular tendering of services from Digital Vibes by the Special Investigations Unit (SIU), the subsequent resignation of the health minister Dr Zweli Mkhize and suspension of the director-general Dr Sandile Buthelezi.

“For many respondents, the history of corruption and state capture, and the fact that, notwithstanding the post-Zuma leadership’s expressed commitment to good governance, state corruption continues unabated in the department of health, creates significant governance risks for a National Health Insurance model and the delivery of health services in the future.”

All respondents also raised concern about the systems of governance within the public sector, which they believe undermines both accountability and effective service provision to the public.

“One academic went as far as to argue that this was an intentional design flaw that creates space for systems of patronage to flourish and would act as a blockage to reform within the public sector.

“Nine respondents, including government officials, have stated that one of the most severe outcomes of poor accountability in the public sector, is corruption and escalating costs resulting in significant misallocation of resources out of the public sector.”

Covid shows health sector is not clean 

One of the biggest clouds hanging over the proposed NHI is the recent Covid-19 pandemic and the response by the government.

While the government was originally praised for its quick response to the pandemic and its move to free up funding for the healthcare sector, public sentiment quickly turned when it emerged that billions of rands were misappropriated by government officials or those connected to them.

Four participants, all of whom have worked at various levels of the public sector and government, identified weak procurement systems being the cause of the PPE procurement scandals that have taken place during Covid-19, where middlemen and close associates of politicians have sold PPE to government at significantly inflated prices

A respondent from the government also added that weak accountability and the existence of embedded patronage networks is a system that benefits regional offices of the governing party.

Weak accounting and oversight structures, such as hospital boards, clinic committees and untransparent systems are also present in hospitals and clinics, if they exist at all. Concern has been raised about how existing governance systems will interplay with the proposed governance systems in the NHI Bill.

Seven participants, representing civil society and regulators, argued that the current Bill concentrates too much power in the hands of the minister of health without providing the necessary oversight over the planned massive resources of the NHI.

One participant from a regulator stated categorically that ‘the fund will be plundered‘.

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