The global spread of SARS-CoV-2, which causes the disease COVID-19, has caused an international standstill as nations face the true test of their health care systems. South Africa’s National Health Insurance (NHI) system is only set to come into effect in 2026 but, in the interim, the country needs a strong and collaborative national response by the private and public health care sectors to contain this pandemic. By Prof Narnia Bohler-Muller and Nokuthula Olorunju
The COVID-19 pandemic has brought South Africa face-to-face with the harsh realities of a two-tier system of health care that protects the wealthy and leaves the majority of South Africans at risk. In 2008 and 2009, there were 3,533 ICU beds in private hospitals serving 20% of the population and 1,186 in public sector hospitals serving 80% of the population. This is according to an article by Dr Tom Boyles, an infectious diseases consultant at Helen Joseph Hospital in Johannesburg. The same figures were reported in a 2013 article in the South African Medical Journal and a 2019 article in the Southern African Journal of Critical Care. In the latter, researchers warned that South Africa faced significant resource shortages in terms of ICU bed numbers compared with high-middle-income countries, especially in state hospitals. There was also a shortage of trained nurses and intensivists and insufficient data evaluating resource provision.
With public sector ICUs already at full capacity, a large COVID-19 outbreak would put an immense strain on services and many poor patients would be left behind in the struggle to survive, Boyles warned, adding that COVID-19 would bring inequality into sharp focus.
As of 2 April, two COVID-19 cases were confirmed in Khayelitsha and one in Alexandra – large townships where the poor have no medical cover to protect them – and South Africa had 1462 confirmed infections. It is clear that the virus does not discriminate, but due to the current state of poverty and inequality, the poor will suffer the most if the spread is not contained:
“If the worst happens, and there is a large outbreak affecting rich and poor communities alike, we will see an enormous strain on health services which will bring inequalities between the haves and the have nots into sharp focus. Although tragic, at the same time it would illustrate why South Africa desperately needs the National Health Insurance bill,” wrote Boyles.
In developed countries, the strongest predictors of death from COVID-19 are advanced age and comprised immune systems. If there is a major outbreak affecting all communities in South Africa, the strongest predictor of survival will be “access to medical insurance and therefore an ICU bed”, according to Boyles.
An increased NHI focus
While media coverage has centred predominantly on COVID-19 causing more strain on the public healthcare system in South Africa, there is increased consideration of how the cooperation and coordination of the public and private health sectors and the proper allocation of funds would be of benefit to the poor and most vulnerable. South Africa’s NHI system is only set to come into effect in 2026, if the legislation is passed after further consultations take place once Parliament reconvenes. While the NHI is not explicitly mentioned, there is a more pointed focus in media coverage on the principles and provisions contained in the Bill (11 of 2019), especially related to a nationally coordinated response to health care needs.
Lessons from abroad
The biggest global lesson of this pandemic is the need to establish an effective public health care system that does not discriminate on the basis of race, class, beliefs, origin, or gender. For South Africa to implement an effective NHI system, the state must learn from the triumphs and challenges faced by other nations.
A frightening lesson has arisen from a country that has been virtually decimated by the virus. The northern part of Italy, which has seen the highest number of cases, is facing the collapse of their health care system. According to an article by Italian researchers in The Lancet in March, the country’s health care system, which is based regionally and run by local governments, has over the past decade suffered severe financial losses. This was due to inadequate strategic leadership, fragmentation, increasing privatisation of national health care services and the lack of resources.
Similar results are evident in many other European countries, leading to Ireland and Spain nationalising private hospitals and various governments struggling to meet the needs of an increasingly vulnerable populous. In the US, where deaths are predicted to exceed 200 000, individual states are competing for ventilators and other medical equipment in the absence of strong leadership and a centralised response to the virus.
A need for strategic leadership
Following the declaration of a national disaster according to section 27 of the Disaster Management Act, 2002, EFF opposition leader, Julius Malema stated that:
“We also call upon the private hospitals, that the only way to avoidnationalisation of those private hospitals is by fully co-operating with the ministerof health when he needs beds for our sick people. It’s not a time to make a profit.”
It has become increasingly clear that health care requires a strong national response, not only when faced by pandemics, but to ensure the health of all and access to health care by all. The crucial integration of public and private entities in all sectors, and particularly the health care sector, is apparent. Media coverage has focused on the numbers and the graphs, but commentary is also trending towards a focus on the importance of the rights to health care, equality and dignity.
South Africa urgently needs an effective universal health care system. Such a system, and by extension the NHI, must avoid fragmentation and promote social solidarity. The institutionalisation and coordination of the public and private health care sector is central to an effective system. Consistent, strategic, accountable, transparent and decisive leadership is vital.
Coming to the table?
On 30 March, the Netcare Group said in a media release that its private hospitals have suspended non-essential elective surgery, closed its hospital pharmacies to the public, and have proposed to the national and provincial Departments of Health that they will treat public patients in Netcare facilities. “Given the exceptional circumstances and to ensure sustainability, Netcare will provide these services to COVID-19 related patients on a not-for-profit basis, seeking only to recover costs,” said the group’s CEO, Dr Richard Friedland. Netcare clarified that, given its hospitals’ limited capacity, referrals from the public sector “will need to be assessed and pre-authorised by Netcare on a case-by-case basis”.
South Africa has not seen the worst effects of this pandemic, and it remains to be seen how cooperative the private health care sector will remain when faced with the ‘masses’ who cannot pay and have no private medical aid protection.
Social solidarity will become even more crucial, with all sectors willing to collaborate and give, and perhaps also to sacrifice the privileges enjoyed on the fortunate side of the country’s two-tiered health system.
Prof Narnia Bohler-Muller