1ts Edition FrankTalk Journal

FrankTalk
Issue #1 | July 2011
In this issue
1
Introducing FrankTalk
2
Why Health-Care?
3
A Case for Information and Engagement
5
Balancing the Scales – Justice and the National Health Insurance Plan in South Africa
7
The National Health Insurance Debate
9
The Proposed National Health Insurance
Scheme and its Potential Impact on All
Sectors of Society
11
The NHI will Struggle without Private
Health-Care Sector Reform
13
A Revolution in Health-Care
15
Contributors
Issue #1 | July 2011
INTRODUCING
Frank Talk
Nkosinathi Biko
W
elcome to the inaugural issue of the
FrankTalk Journal, an initiative of the
Steve Biko Foundation. Named after the
pseudonym under which Steve Biko wrote,
FrankTalk is a non-partisan platform designed
to bring together South Africans from all walks
of life to reflect collectively on the state of
our democracy.
Going beyond the customary
dialogue platform, FrankTalk
challenges its participants to use
their citizenship as agency.
In this regard, the sessions
speak to the challenge of
advancing democracy by being
active citizens, and finding
harmony between our personal,
political and professional identities.
In addition to contributions from recognised thought
leaders, the Steve Biko Foundation (SBF) will
also publish pieces from the public, creating an
opportunity for individuals who would like to share their
perspectives in greater length and depth.
PHOTOGRAPH: SUPPLIED
The Steve Biko Foundation
“FrankTalk
challenges its
participants
to use their
citizenship as
agency.”
Structurally, FrankTalk consists of three
elements: a monthly dialogue session; an
online platform and this journal. The FrankTalk
Journal will be distributed monthly. It intends to be an
intellectually engaging and interesting publication that
is accessible to a wide range of readers.
Please visit the FrankTalk website in the coming
weeks for a full publication schedule and for other
opportunities to get involved. We welcome and await
your feedback on any elements of this programme and
your thoughts on its evolution. Until then, enjoy and
share the legacy.
Nkosinathi Biko
Pg 1 | Issue #1 | July 2011
ABOUT
The Steve Biko Foundation is
a community development
organisation inspired by the
legacy of Bantu Stephen Biko.
An examination of the leading
South African institutions that
have contributed to shaping
national discourse highlights the
void that exists in promoting the
intangible aspects of development:
identity, culture and values, the issues
that speak to the soul of a nation. The
Foundation has sought to fill this gap since
its inception. It will intensify its efforts to
strengthen democracy by championing
dialogue, scholarship and programmes on
the relationship between identity, agency,
citizenship and social action.
Its vision, mission and values find
expression in a variety of areas. Broadly,
each intervention is designed to advance
policy, dialogue and advocacy; knowledge
production and dissemination; and
leadership development.
Why
Health-Care?
By Obenewa Amponsah
E
veryone in the country will be affected by the
proposed National Health Insurance scheme.
Our first issue of FrankTalk explores the proposed
NHI and highlights some of the related issues that
ought to be considered as the nation dialogues.
PHOTOGRAPH: SUPPLIED & ISTOCKPHOTOS
In 1966, Steve Biko enrolled to pursue
a medical degree at the University
of Natal’s Black Section. These
years as a medical student were
to form a pivotal chapter in
Biko’s life, with his time at the
university serving as a backdrop
to the creation of the South
African Students Organisation
and the formation of the Black
Consciousness Movement.
But his student activism was not
without cost, as Biko was expelled
from the university in 1972
– ostensibly because of a poor
academic performance.
However, his friend Pityana observes, “While Biko did
not qualify as a medical doctor, he became a doctor
of the soul.” In his 30 years of life, Biko spoke to the
challenges of communities and, with his colleagues,
sought to develop concrete, innovative solutions to
what ailed society. This is a tradition which we, at the
Steve Biko Foundation, aim to uphold through our work
at large and FrankTalk in particular.
As we considered what the focus of the inaugural issue
ought to be, health-care seemed in many ways to be an
obvious choice. While South Africa has made significant
strides toward actualising the promises enshrined in its
constitution, the challenges that continue to confront the
nation are strikingly evident in the area of health-care.
From the deaths of newborns in our hospitals and the
inaccessibility of health-care facilities in many rural areas,
to the high burden of disease experienced by much
of our population and recent strikes in the sector, it is
clear that measures need to be taken to create a more
equitable and efficient health-care system.
Pg 2 | Issue #1 | July 2011
The latest proposal put forward by the government is to
develop a National Health Insurance scheme; and as
Minister Dr Aaron Motsoaledi has intimated, everyone
in the country will be affected by it. So this first issue
explores the proposed NHI and highlights some of the
related issues that ought to be considered as
the nation dialogues.
With that said, the contents
of this journal by no means offer
a definitive “solution” to the
challenges facing our health-care
system; rather, they are meant to
inspire constructive debate.
So we invite you to continue
the dialogue in the days and
months to come through
FrankTalk online.
A Case for
Information
& Engagement
By Ghairunisa Galeta
L
ast year, my father, Hotep Idris Galeta, a chronic
There are no metrics that speak to the impact of civil
asthmatic, started having difficulty breathing at home
society on government accountability or its role in
around 6.30am. It had been a rough allergy
policy-making processes. Furthermore, there is no
season but he had managed. Paramedics
indication of how voices of the constituency speak –
were called. They knew him, and he even
and are heard – outside of the ballot box.
had private mobile numbers for the
The Health Ministry’s 2007 Policy
local fire department. The attack got
on Health-Care Quality proposes
"One does not
progressively worse. Ninety minutes
uniform quality assurance
and over 30 phone calls later, there
mechanisms guided by district
have to look far, or
were no paramedics and no more
officials at the facility
wide, to paint a picture health
airtime. By 8.20am he was no
level. Of five main principles
longer conscious. Ten minutes
to be applied in ensuring
of the disparate and
later the paramedics arrived.
quality, improving quality and
disjointed scenarios
He could not be revived. When
resolving quality problems,
I arrived, two or three cars
and situations that
“a focus on user needs” is
worth of first responders were
the
first – listed as “central in
characterise our healthpacking up. He died waiting.
care system – public
the planning and performance
PHOTOGRAPH: SUPPLIED
of any activity.”[3] The report
Over the past eight years, our
proposes varied mechanisms
and private ."
Health Department has released
to gather what these needs are,
four publications addressing healthincluding regular Patient Satisfaction
care access, quality or visions for the
Surveys and a National Complaints
future – the most recent is three years old.[1]
Procedure.
This is meagre at best, considering whispers of
forthcoming movement towards national systemic reform.
Where are these opportunities for input?
With government-commissioned research and policy
frameworks already in place, availability of more recent data
A collaborative, government-driven and multilateral
is not a tall order. It is about time.
Our minister in the presidency’s recently released
Development Indicators Report highlights health as one
of 10 “measures that assist in understanding the impact
of various government policies and programmes on the
country and its citizens.” [2] Of health indicators presented,
data on health-care access and quality are absent. The
availability of self-generated information for self-determined
future policy, programming, strategic planning and directives
for National Health is paramount.
Where is this information?
Social cohesion is also one of these 10 development
indicators. The section lists promoting citizen
participation in both civil society and democratic
processes as goals to strengthen “voice and
accountability” – the indicator’s opening subcategory.
Pg 3 | Issue #1 | July 2011
engagement process is as important as countryspecific indicators and analyses of Europe’s National
Health Systems in our planning and policy-making journey.
Developing and implementing these platforms for
stakeholder and community engagement are crucial
first steps for creating a culture of trust in current
practices and future reforms.
It took a while to reflect on my personal experience and
to collect the following anecdotes from friends. While
nowhere close to a comprehensive survey of healthcare access experiences in this country – nor intended
to be – they are real. These anecdotes are included
here to reinforce at least two things.
First: One does not have to look far, or wide, to paint
PHOTOGRAPH: ISTOCKPHOTOS
a picture of the disparate and disjointed scenarios and
situations that characterise our health-care system –
public and private – nor does one have to fight folk to
share their stories. Second: Engagement was a starting
point for me, and should be for any movement towards
any sustainable and appropriate health-care reforms in
this country.
“After the accident … I passed out. The next thing I saw
was one of the guys walking outside of the car. I crossed
the road and lay down. The paramedics came. I heard
them say ‘No one in this car survived. I’ve worked these
things before.’ I tried to speak but I couldn’t. A woman
found me and told the paramedics. They put us all in a van
and they assumed we all belonged in a public hospital. No
offence, but he didn’t ask us. Someone thought to ask us
… they could’ve taken us to Union. I couldn’t speak and
had to pull the guy’s pants [to get his attention]. I whispered
and said I had medical aid, and that we all did – even
though we didn’t. But I said we all had private and we could
all go to Union. So we went there, they took care of us,
our families came, we survived, and everything was cool.”
20-something male. 2003. Union Hospital.
“... I … was having a fling with this guy and he flew here and
had malaria. I just took him to a doctor in Melville, paid cash
[about R200] then had to take care of him for five days.”
30-something female. Year unknown. Private doctor.
“I had back surgery in 2009. A replacement disc, made
of titanium and plastic, was inserted into my lower
spine. A complex procedure, delicate. I was recovering
in the Donald Gordon Medical Centre and was always
surprised by the number of trainee nurses in attendance
without supervision. It was late at night when two of these
trainee nurses flipped me incorrectly. It almost undid my
surgery and left me in serious pain. It wasn’t their fault, or
mine, or the senior staff, or the surgeon. Blame remains
unallocated. All I know is that I was afraid in that hospital,
because medical negligence kills and I felt the weight of
uncertainty in the people caring for me.” 20-something
male. 2009. Donald Gordon Medical Centre.
“Although people have all sorts of tales to tell and woes
about Jhb Gen – which is now Charlotte Maxeke – I know
their neurosurgery is top notch. Need emergency brain
surgery? That’s where you want to go. They have amazing
care and the level of expertise [is] among the world’s
finest. My husband had brain surgery there to clip a brain
aneurysm.” 40-something female. 2007. Charlotte Maxeke.
“A friend’s grandma was lying in a ward where feral cats
were walking about amongst the beds. Hospital officials’
response was that they did not know how to get rid of
them.” 30-something male. Year unknown. Public hospital
in Pietermaritzburg.
References
1.)
(2008) Policy on Quality in Health Care for South Africa
(2007) Policy on Health Care Quality
(2004) Strategic Priorities for the National Health System
(2003) Primary Health Care Facilities Survey
Last accessed Jan 2011 via http://www.doh.gov.za/docs/policy/index.html
Pg 4 | Issue #1 | July 2011
2.)
(2010) Development Indicators Report. p.1.
Last accessed Jan 2011 via http://www.thepresidency.gov.za/pebble.
asp?relid=2876
3.)
(2008). Department of Health. Policy on Quality in Health Care for South Africa. p.20.
By Harriet Etheredge and Tejal Mistri
Acknowledgement: Professor Ames Dhai
T
Balancing the Scales –
Justice and the National
Health Insurance plan
in South Africa
he end of apartheid in 1994 heralded a new era
for South Africa. South Africans had high hopes
for a state where citizens were treated fairly and
equally – based on a human rights ideology as opposed
to the racially separatist ideology which dominated at
the time of apartheid. Concepts such as justice, fairness
and equality came to epitomise the optimism of the early
post-apartheid era. The adoption of the South African
Constitution in 1996 was viewed as a formative moment,
entrenching these notions as cornerstone
values of the New South Africa [1] (at least
in theory).
Definitions
For the purposes of this paper, justice shall mean: “Fair
and equitable distribution of resources amongst a
population.” [2]
The National Health Insurance
PHOTOGRAPH: SUPPLIED
Historically, comment on issues of health policy in
South Africa has been prolific. Many organised groups
have developed and proposed strategies to
address inequalities in access to healthcare, resource allocation and health
status. The NHI is said to be an
"Historically,
all-encompassing framework which
comment
aims to integrate these proposals.[3]
Now, 17 years after democracy,
questions continue as to the
progress made. Do we really
on issues of health
live in a country characterised
This new policy is scheduled to
by just, fair and equal
be implemented over a roll-out
policy in South
treatment of (and opportunities
period of 14 years, commencing
extended to) all citizens?
in 2012.[4] It will be funded
Africa has been
Or are these notions more
through an NHI tax payable by
entrenched in the platitudes of
those
who earn a taxable income
prolific."
political oratory than the day-to(registration with SARS an obvious
day lives of the populace? Have
pre-requisite, thus overlooking the
inequalities really been addressed
large, informal sector) as well as a
and if so, in what tangible way? General
hike in VAT. Furthermore, tax rebates
consensus on the answers to the questions
for medical contributions (currently valued at
posed above is: “Yes, we have made some progress,
between R10bn and R15bn per annum) will be phased
but not nearly enough, and not nearly as significant as
out. Those who have the inclination – and the financial
was originally anticipated.”
means – to do so may remain a member of a medical
aid scheme. Payment for this, however, will be over and
The proposed National Health Insurance (hereafter
above the NHI tax.[4]
referred to as NHI) is a policy which is set to
Positivities
revolutionise health-care in South Africa. It has great
potential to further the ends of justice, fairness and
Envisaged outcomes like universal access and healthequality. When it comes to such policy measures,
care which is good value for money are laudable.
the NHI also seems by far the most ambitious,
Universal coverage entails “access to key, affordable,
complicated and controversial undertaking to date.
preventative, curative and rehabilitative health interventions
for all”.[5] If all goes according to plan, the NHI will operate
as a mechanism for redressing disparities and promoting
This article briefly examines the NHI from the
justice, thus the initiative should be commended. From
perspective of its potential to render South Africa a
a public-health perspective the NHI promises a move
more just, equal and fair country. It also considers the
towards preventative primary care as opposed to an
pros and cons of the NHI from a justice perspective.
Pg 5 | Issue #1 | July 2011
emphasis on curative care. This will ultimately go some
way towards the further realisation of justice as it could
lead to a healthier overall population and redirection of
resources from curative care.
• Those who are wealthiest will likely be the only ones who are able to remain on medical aid. This does
not seem just as it means that once again the very
wealthy are in a position of privilege and enjoying
superior services.
There are, however, many opponents of the scheme and
numerous objections regarding the very fundamentals of
its structure – like financing and implementation.
Conclusion
Objections to, and criticisms of, the NHI
Internationally, many countries, both developed and
developing, have experience with implementing a
programme for universal health insurance. Germany
introduced such a policy in 1883. Today, this country is
considered to exemplify a functioning, just NHI system –
although it took 120 years to get to this point.[6]
In England, the National Health Service (hereafter referred
to as NHS) was put into operation on 5 July 1948. To this
day, the NHS is still facing functioning and process issues,
with long waiting lists and limited access to some drugs.[7]
South Africa has demonstrated a strong commitment to the
NHI on paper. It is important, however, that this commitment
does not remain “on paper” only. As was the case with
the South African Revenue Service, the administrative
structure of the NHI will need to be built from the ground
up. The administration of the scheme will be responsible for
overseeing all aspects of its implementation. This will take
some time and staff will need extensive training.[8]
Unfortunately, South Africa’s administration also has a
widely acknowledged tendency towards corruption.
Should those who are employed to administer the NHI
exhibit this worrying trait – and many believe that this will be
the case[9] – the ends of justice will not be served, as the
coffers will remain relatively empty, in spite of a substantial
cash inflow.[10]
In theory, numerous positive outcomes are foreseen as
the NHI is phased in, and these have been considered in
this paper. However, there does not seem to be adequate
public buy-in to the scheme or into the generosity of spirit
which dictates it. This is evidenced by the numerous
strong objections which have been raised. It is arguable
that the South African government has not instilled within
the general population the confidence to believe that
this proposal can be implemented without corruption,
mismanagement of funds and political meddling.
In order for justice to accompany the NHI, public buy-in is
vital, as is an unambiguous and sincere reassurance that
the most obvious pitfalls will be strongly guarded against.
References
1. Democracy: The Constitution of South Africa. nd. South Africa Info (online).
Available from: http://www.southafrica.info/about/democracy/constitution.
htm [Accessed 10 January 2011].
2. Wallace, R. B. and Kohatsu, N. 2008. Public Health and Preventative
Medicine (15e). MacGraw-Hill Professional (online). Available from: http://
books.google.co.za/books?id=5ACWr8YcB2AC&pg=PA35&lpg=PA35&dq
=Justice:+Fair+and+equitable+distribution+of+health+care+resources+am
ongst+a+population&source=bl&ots=GBo0cf0Fhn&sig=v6o3GpIxQVMmG
GYJ-ipsRHHqkxg&hl=en&ei=IwbuTMHLCoaPswaRnvj6Cg&sa=X&oi=bo
ok_result&ct=result&resnum=1&ved=0CBUQ6AEwAA#v=onepage&q&f=tr
ue [Accessed: 21 October 2010].
3.
Blaauw, D. and Gilson, L. 2001. Health and Poverty Reduction policies in
South Africa. Centre for Health Policy, South Africa (online). Available from:
http://web.wits.ac.za/NR/rdonlyres/77C69FE0-40FB-448B-AED7C53FSDA3035C/0/b41.pdf. [Accessed: 9 November 2010].
Secondly, it could be argued that the implementation of
the NHI will further increase disparities in health-care if the
system does not function with the efficiency anticipated
of it. The formal sector in South Africa (those who are
registered to pay tax) is comprised of approximately 7
million people.[11] These are the people who will be further
taxed to fund the NHI. This funding – as well as other cash
inflows mentioned previously – will then be used to pay for
the health-care of the other 41 million in the country who
are not taxed.[12]
4. Wasserman, H. 2010. How NHI will affect you. In Fin 24 [Online]. Available
from: http://www.fin24.com/PersonalFinance/Money-Clinic/How-NHI-will
affect-you-20101011 [Accessed: 21 October 2010].
The limitations of such a plan are immediately obvious, and
most notable amongst these is the fact that a much larger
pool of resources will likely be required to provide good
quality health services. This dependence on the wealthier
sector of the population could have some other negative
consequences for the entire country:
8. Abel-Smith, B. 1992. Health Insurance in developing countries: lessons from
experience. In Health Policy and Planning 7 (3) 215 – 226.
•
•
The hike in taxes may prompt those who can afford it
to emigrate to another country where the service is deemed superior, thus income for the NHI will be lost.
Doctors may accept jobs overseas which pay better and are not as administratively fraught as they would be under the NHI.
Pg 6 | Issue #1 | July 2011
5.
Shisana, O., Rehle, T., Louw, J., Zungo-Dirwayi, N., Dana, P. and Rispel, L.
2006. Public perceptions on National Health Insurance: Moving towards
universal health coverage in South Africa. In The South African Medical
Journal 96 (9) 814 – 818.
6. Altenstetter, C. 2002. Insights from Health Care in Germany.
In The American Journal of Public Health 93 (1) 38 – 44.
7.
9.
National Health Service in the United Kingdom of Great Britain. 2010.
The NHS is Born on July 5th (online). Available from:
http://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/NHShistory1948.
aspx. [Accessed: 17 November 2010].
Bateman, C. 2010. Izindaba: NHI Fund to be Vetted Along SARS Lines.
In The South African Medical Journal 100 (12) 796 – 797 (online).
Available from: http://www.samj.org.za/index.php/samj/article/
viewFile/4632/3022 [Accessed: 21 January 2011].
10. Bega, S. 2010. Experts attack NHI plan. In The Cape Argus October 02
2010 (online). Available from: http://uct-heu.s3.amazonaws.com/wp
content/uploads/2010/10/CapeArgus_021010.pdf [Accessed:
17 November 2010].
11. Futuse, B. 2007. SARS ready for SA Taxpayers. in Fin 24 (Online). Available
from: http://www.fin24.com/Business/SARS-ready-for-SA
taxpayers-20070805 [Accessed: 19 November 2010].
12. The World Bank. 2008. Population Statistics (Online). Available from:
http://www.google.com/publicdata?ds=wb-wdi&met=sp_pop_totl&idim=co
The National Health Insurance
Debate
By Dr Jonathan Broomberg,
Chief Executive Officer, Discovery Health
I
PHOTOGRAPH: SUPPLIED
believe it is important that as a society we debate
the National Health Insurance scheme. To this end
I would like to make two general points about the
debate as a whole and then three specific points about
the NHI itself.
serve as a magic bullet and solve all our problems
overnight. It is long, hard work and there are tough
problems that we are facing.
These problems are partly inherited from the
apartheid era – we have had to create a
The first general point to make is that,
health-care system out of the apartheid
to date, the debate around the NHI
provinces and the bantustans and
has broadly been characterised by
try and put them together. We have
“There is no one
the media as a fairly oppositional
a legacy of terrible illness and
NHI and there
one, creating a sense that there
disease and we have inherited
are people who are against
problems in the post-apartheid
is no one piece of
the NHI – whatever the NHI is
period to do with the structure,
legislation that
– and those who are for. In my
bureaucracy, corruption, a
view, this is an unhelpful and
whole lot of other issues as
will serve as a magic
polarised way to conceptualise
well.
In the private sector I think
bullet and solve all
the NHI. I think all stakeholders in
we are facing our own problems.
our problems
our society, be they in the health
sector or not, would acknowledge
They are not the same as in the
overnight . ”
that the health-care system in this
public sector but they are equally
country is broken – and quite badly.
serious. They are to do with a shortage
of doctors and quite powerful providers
The public sector is badly broken and so is the
– like hospital groups and others – which push
private sector and there are many problems. I think we
up costs and so health-care in the private sector gets
all need to acknowledge that we are not in good shape
more expensive every year. In my opinion, saying that
from the point of view of the health-care system, and
there are some who are for the NHI and some who are
that as citizens and stakeholders we have a lot of work
against is not helpful.
to do. I think it is true that all stakeholders including the
private sector, in which my organisation is an important
We need to get around the table and look at the detail
player, are very strongly in support of reforming the
of what particular solutions will address the particular
health-care system, including various NHI models.
problems of this country in an effective way and in an
affordable way. In encountering this debate, I think it is
At this point it is important to note there is no such
quite helpful to try and break the issues down in a way
thing as “The NHI”. There are dozens of health-care
that leads to constructive dialogue.
systems around the world that are called National
Health Insurance and not one of them is the same
One set of issues is around the money, so we need
as any other one. They differ on how the government
to ask: how much money do we currently spend on
collects money, how people pay, how they organise the health-care and how much should we be spending?
health-care system, and whether the delivery is public
And if we do need more, where should it come from?
or private. I can talk to you for hours about different
Then, when we have got our money together, we need
models and they are all called NHI. So there is no one
to address another question: what is the best structure
NHI and there is no one piece of legislation that will
for a health-care system to deliver care to the people?
Pg 7 | Issue #1 | July 2011
Is it an insurance system which is somewhat implied
in the ANC paper, a sort of giant medical aid for the
whole country? Or is it a public system like you have
in Britain where the government collects the money
and the government owns the hospitals and employs
the doctors and nurses? The UK has a brilliant publichealth system but it is not an insurance system and so
the question does arise around the structure: is a public
system or an insurance system the right model for this
country?
PHOTOGRAPH: OPEN SOURCE
In regard to the financial aspect, South Africa already
spends significantly more per capita in the public-health
system – I am ignoring private now – than any other
African country and most other developing countries
at our stage of development. So we spend more than
most of our peers but we have terrible results. We get
terrible value for money – our mothers die much more
frequently, and so do our babies.
I think to assume that we need to put in a lot more
cash is a superficial analysis of the problem and
throwing money at our health-care system won’t solve
the problem. It’s as if you have a car whose engine is
broken: taking it to the garage and pouring in petrol
won’t make the car go, no matter how much petrol
you give it – we have to fix the engine and the engine
is about management of the hospitals in the public
system – it is about getting enough doctors and nurses
and it’s about motivating people and the culture of work
so that there is compassion and care in the system.
Pg 8 | Issue #1 | July 2011
There is a lot of talk about the attitude of nurses to
patients in the public sector and yet the same nurse
will go to a shift in the private hospital the same night
and treat patients completely differently. What is the
difference? I think it’s about the work environment, how
people are managed, and how they are motivated.
We mustn’t assume we are short of money. If we do
need to raise more money – and we may well need
to – then it becomes a question about how much
we can afford as a society. Remember that there is
a small number of people paying tax in this country
so to collect more money from them is to put a big
tax burden on them. And what are we going to give
up if we spend more on health? Are we taking it from
education? From housing? From defence? I think
these are all important aspects of the debate.
And then finally, on the structure side, is what I think is
an important technical debate: I haven’t seen, in the
published documents, a good argument for why an
insurance mechanism is better than a public-sector
mechanism. You could achieve quite a lot of the same
through reforming the existing public sector.
Equally, you could achieve it through an insurance
system – but we have to then set up a new insurance
system as we don’t have an existing one. We do
have a public sector today and so I think what we
need, in the debate, is for those who are proposing
an insurance model to explain to us why, in technical
terms, that model would be better.
The Proposed National
Health Insurance Scheme
and its Potential Impact
on All Sectors of Society
By Roseanne Da Silva, Convener,
NHI Task Team of the Actuarial Society of South Africa
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profession
in South in South Africa.
professional
of the
actuarial profession
Africa.
It is a meeting
point of actuaries,
It is a meeting
point of actuaries,
where we can do work together
where
we can
do work
together
on industry
specific
issues
and assist with matters in the
on
industry
specifi
c issues
and
broader
public
interest.
That is
where the focus on
assist with matters in the broader
the NHI comes in, as part of the mission of the
public interest. That is where
Actuarial
to harness
the
focusSociety
on theisNHI
comes the
in, expertise
of the
profession
as
partactuarial
of the mission
of to
theassist in
public debate.
Actuarial
Society is to harness
the expertise of the actuarial
At the moment,
one ofinthe
profession
to assist
public
challenges in discussing the
debate.
NHI is that it is very difficult to
At
thewhat
moment,
of the
know
to talkone
about.
We
challenges
the NHI is
do not haveina discussing
formal document
from Government to be able to
talk
about.onWe
doso
not
have
a formal
comment
and
while
there
document
has been afrom
lot ofGovernment
debate and to be able
to
commentit on
and sospeculation
while there has
discussion,
is largely
been
a
lot
of
debate
and
it is
on what this framework is discussion,
going to
largely
speculation on what this framework is
look like.
going to look like.
So while we are eagerly awaiting a more concrete formal
asproposal
possible costing
assessing
implications
fromhas
a resource
around and
the NHI,
the Actuarial
Society
been
point of viewdeveloping
of the different
scenarios
that are
discussed.
a model
for costing
thebeing
scheme.
That way, the debate
can focus
on the
issues
in terms
The society
is even
going
beyond
theof
ramifications, in terms
of eligibility and
somodel
forth, rather
than the
on
development
of the
to assess
implications of NHI in terms of
debating the numbers wider
themselves.
things like access to health services
andeagerly
other pertinent
Our
So while we are
awaiting aissues.
more concrete
view isaround
that we
as much
formal proposal
thecan
NHI,throw
the Actuarial
asdeveloping
we like at the
problem
Society money
has been
a model
for
inequitable
care, is
but
costingofthe
scheme. health
The society
even
we do not
the facilities
goingifbeyond
the have
development
of the
and
human
resources
to deliver
model to assess the wider implications
quality
services
to South
Africans
of NHI
in terms
of things
like access
then
all
the
money
in
the
is
to health services and other world
pertinent
issues. Our view is that we can
our present work at the moment
throw as much money as we
is focusing on developing a model
like at the problem of inequitable
or a framework that can be used to
but if we do not have
testhealth-care,
various scenarios.
the facilities and human resources
deliver
services
South
I thinktothat
it is quality
important
whentowe
look
Africans
then
all
the
money
in
the
at an NHI framework to look at the different
world
not People
going totalk
fix that
problem.
components
asiswell.
about
NHI
ourdoes
workthat
at the
moment
is focusing
or SHI – but So
what
mean?
It really
boils
onaspects
developing
a model orsome
a framework
down to the different
of structuring
kind of
canpopulation.
be used to test various scenarios
health-care provisionthat
for the
around benefits, eligibility, funding and
resource
allocation.
The aspects that
we need
to look at are things like eligibility:
"We can throw as
much money as we
like at the problem
of inequitable
health-care, but ...
all the money in the
world is not going to
fix that problem."
From the point of view of the Actuarial
From
theit point
view
of the
Actuarial
Society it makes
Society
makesofus
quite
cautious
about
us quite cautious about addressing public forums like this
addressing public forums like this because we
because we certainly do not want to promote speculation and
certainly do not want to promote speculation and
misconception; but at the same time, a topic as potentially
misconception;
but at theHealth
sameInsurance
time, a topic
as potentially
far
reaching as National
in South
Africa is
far to
reaching
as National
Health
in South
important
the nation
as a whole
andInsurance
worth discussing.
Africa is important to the nation as a whole and so is
worth
Iobviously
must stress
thatdiscussing.
the
Actuarial Society does
mustitsstress
that
the a
notI see
role as
being
Actuarial in
Society
does
stakeholder
the debate
its role
as Ibeing
eithernot
forsee
against
NHI.
a stakeholder
in the
am not
sure that there
is
for against
anyonedebate
who iseither
against
NHI
the NHI.
I ambetter
not sure
or is against
getting
access to that
quality
health
care
there
is anyone
to all South who
Africans
– it is the
is against
simply a question
NHI orofis doing
againstit in
getting better access
the AS viewstoits
role as
acting asto
quality
health-care
a technical resource
all stakeholders
allto
South
Africans – it is
in this discussion in terms
of providing
as of
simply
a question
accurate as possible costing
and
assessing
doing it in a financially
implications
from away.
resource
of view
responsible
So thepoint
Actuarial
of
the
different
scenarios
that
are
being
discussed.
That
way,
Society views its role as acting as a technical resource to all
stakeholders in this discussion in terms of providing as accurate
in terms of eligibility and so forth, rather than on debating the
numbers themselves.
Pg
| Issue #1 | July 2011
By 9Ms Roseanne Da Silva, Convener, NHI Task Team of the Actuarial Society of South Africa.
it going
the whole
population?
it going
to be
IIsthink
that to
it isbe
important
when
we look atIsan
NHI framework
differentiated
for people
who are employed
and contributing,
to
look at the different
components
as well. People
talk about
as opposed
who that
are perhaps
either
below
NHI
or SHI – to
butpeople
what does
mean? It earning
really boils
down
to
the different
level to contribute
such an entity
is there
going to be
aspects ofto
structuring
some or
kind
of health-care
any kind of
in The
thataspects
kind of eligibility?
These
are at
provision
fordifferentiation
the population.
that we need
to look
really
the factors
that distinguish
National
Health for
Insurance
are
things
like eligibility:
who is going
to be eligible
this cover
and is
Social
Health
these terms are
that
defined?
Is itInsurance,
going to beI suppose,
the whole but
population?
often used interchangeably.
Is it going to be differentiated for people who are employed and
The other issue
is the pooling
mechanism
terms ofearning
how
contributing,
as opposed
to people
who areinperhaps
are
the
funds
put
together
and
held.
So
either
you
have
a
either below the level to contribute to such an entity or is there
separate
entity
which
is what seems
to be
what
is on the
going
to be
any –kind
of differentiation
in that
kind
of eligibility?
These are really the factors that distinguish National Health
create a separate funding pool as we have with the Road
Insurance and Social Health Insurance, but these terms are often
Accident Fund or the Unemployment Insurance Fund. So
used interchangeably.
are sitting as a separate fund. If you look at something like
The
other issue
is theService
poolinginmechanism
terms of you
howwill
the
the National
Health
the United in
Kingdom,
funds
are
put
together
and
held.
So
either
you
have
a
separate
see there is not a separate entity funding that; it is funded by
entity
– whichfunding.
is what seems to be what is on the table,
government
although, again, this has not been clarified – where you create a
separate
pool
as we
have
withof
thethe
Road
Accident Fund
And thenfunding
of course
there
is the
issue
services
or
the Unemployment
Insurance
Fund.
themselves
and how those
are purchased.
Those funds are not sitting as part of the central fiscus,
but are sitting as a separate fund. If you look at something like
the National Health Service in the United Kingdom, you will
see there is not a separate entity funding that; it is funded by
government funding.
And then of course there is the issue of the services themselves
and how those are purchased. Are they purchased through
contracting with private sector service providers or are they
purchased by actually employing or owning the resources
and providing the services that way? Again, you can see the
parallels in terms of different systems we see around the world.
In the case of the National Health in the UK those doctors
and resources are generally owned by the government and
employed by the government but certainly in Asia you see
models where there is actually contracting with the private
sector. This then raises the question as to whether there is a role
for the existing private sector in this whole structure or will NHI
replace the existing private sector structure?
PHOTOGRAPH: ISTOCK PHOTOS
I think then just a final point for me to make is in terms of the
funding itself – as to where the money comes from. It is the
perennial issue with health-care: we tend to be dealing with a
situation of unlimited demand – it is very rare that people will
say that they are healthy enough. So people will always have a
demand for health-care, yet there is a perception that people
will be able to consume enough health-care services to meet
that demand. It suggests that we are always going to be in the
situation where we are trying to ration – that we have to make
distribution decisions – about the allocation of finite resources
to fund infinite demand. This structure is just one mechanism in
which that can be done and it is important that we think broadly.
Certainly I believe FrankTalk constituents can think innovatively
around different structures that can be utilised to fund something
from finite resources, bearing in mind the tax burden carried by a
relatively small portion of the population.
Pg 10 | Issue #1 | July 2011
NHI will
will Struggle
NHI
without the
Private
struggle
without
the
private
health-care
Health-Care
sector
Sectorreform
Reform
I
t is imperative that we ask ourselves what our health-care
t is imperative
what
ourdiscussing
system
should that
look we
like ask
in 15ourselves
years’ time
when
health-care
system
should
look likeplans.
in 15How
years’
time
the
NHI (National
Health
Insurance)
should
the with
National
Healthsector
Insurance
(NHI)
the when
privatediscussing
sector coexist
the public
and should
the
private
bethe
composed
of three
large groups
plans.
Howsector
should
private sector
coexist
with theowning
about
84%
of
the
private
hospitals
and
only
serving
public sector and should the private sector be 16% of
the South African population?
By Mamosa Motjope and Dr Howard Manyonga
The second approach, of designing mechanisms to share
We
want all
South the
Africans
have
access
to does
qualityrequire
and
resources
between
privatetoand
public
sector,
timely
health-care
that are
within
a reasonable
thorough
analysis ofservices
the challenges
that
can be
posed by the
distance
from theirofhomes
– hence
the first
approach, of
current landscape
the private
health-care
sector.
strengthening the public sector, is a non-negotiable and
The government
could
faced
with
needs to occur
at allbe
levels
of the
public health
challenges
such
as:
system. The second approach, of designing
composed of three large groups owning
mechanisms to share resources between
about
84 percentcriticism
of the private
The common
of the private health
• having to bargain with an oligopoly that is resistant to
private and public
does
hospitals
and
only
serving
16
percent
change andthe
is understandably
moresector,
concerned
sector is that it:
"We want all South about therequire
analysis
of the
of the South African population?
impactthorough
on their profi
ts
challenges that can be posed
• caters for the wealthier minority and
Africans to have access
• the
companies
not of
availing
excludes
the majority
of South
The
common
criticism
of
bydominant
the current
landscape
the
theirprivate
resources
from
accessing
health care
theAfricans
private
health
sector
health-care sector.
is that:
• is not easily accessible to
people who reside in townships
• and
it caters
for the wealthier rural areas
minority and excludes the
cost of
• the
majority
ofprivate-sector
South Africans
care is increasing
and
health
from accessing
health-care
becoming unaffordable.
•
it ischallenges,
not easily along
accessible
These
with to
public
people
in are
sectorwho
ineffireside
ciencies,
core of the
current
at the
townships
and
rural NHI
areas
to quality and timely
health-carwe services
that are within a
reasonable distance from
their homes."
discussions. These discussions
aspire to give all South Africans their
•
the cost of private sector
basic human right to quality health
carehealth-care
increasing
and and are alsoisfocused
on designing
mechanisms
becoming
unaffordable.
around
the existing setup of the
private and the public health systems, as per the
ANC NHI
discussionalong
paper.with public sector inefficiencies,
These
challenges,
are at the core of the current NHI discussions. These
“The implementation of the national health insurance plan
discussions
aspire toofgive
Southmodel
Africans
their basic
means transformation
the all
funding
for health
as well
human
right to quality
health-care
and Universal
are also focused
as reorganisation
of health-care
delivery.
access toon
health services
can only be
achieved
simultaneous
designing
mechanisms
around
the through
existingasetup
of the
and two-pronged
approach.
First,
significantly
strengthen
private
and the public
health
systems,
as per
the ANCthe
NHI
public sector so that it becomes the provider of first choice.
discussion
paper.
Second, design mechanisms for ensuring that scarce and
critical health service resources in both public and private
“The
the national
health
sectorimplementation
are shared and of
optimally
used by
all toinsurance
maximise social
value.”
[IS THIS
A DIRECT QUOTE
THE
PAPER?
plan
means
transformation
of theFROM
funding
model
for WE
NEED TO
THIS PROPERLY,
I THINKdelivery.
– WHERE
health
as REFERENCE
well as reorganisation
of health-care
IT COMESaccess
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THE PAPER
– AND
WHAT
Universal
health services
can only
be achieved
PAGE.
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CAN’T
FIND
A
COPY
OF
THE
PAPER
ONLINE,
through a simultaneous and two-pronged approach.SO
PERHAPS SOMEONE COULD CONTACT THE WRITER TO
First,
significantly strengthen the public sector so that it
CHECK THIS?]
becomes the provider of first choice. Second, design
mechanisms
for ensuring
that
scarce
and
We want all South
Africans to
have
access
to critical
quality health
and
timely health-care
are and
within
a reasonable
service
resourcesservices
in boththat
public
private
sector are
distanceand
fromoptimally
their homes
– hence
themaximise
first approach,
shared
used
by all to
socialofvalue.”
strengthening the public sector, is a non-negotiable and needs
to occur at all levels of the public health system.
Pg
| Issue #1Motjope
| July 2011
By 11
Mamosa
• the government not being
Thetogovernment
could
able
implement the optimal
be
faced
with
challenges
solutions since it has limited
choices
of potential partners in
such
as:
the private sector
• bargaining with an oligopoly
• the resources not being
thatshared
is resistant
to change
and is
optimally
if the dominant
understandably
more
concerned
players do not buy into the
about NHI
the vision
impact on their profits
• companies
designing mechanisms
that suit
• dominant
not availing resources
the oligopoly to an extent
that the government indirectly
• the government not
being able
implement
strengthens
the to
dominance
of the optimal
oligopoly
the private
sector. partners
solutions since itthe
has
limited inchoices
of potential
in the private sector
These challenges could lead to delays in the
implementation of the NHI, unexpected cost implications,
• disgruntled
the resources
not left
being
shared
if the dominant
a
society
feeling
that optimally
the government
is not
players
do
not
buy
into
the
NHI
vision
delivering on their promises, and achieving minimal social
value.
• designing mechanisms that suit the oligopoly to an
The
private
is an important
playerstrengthens
but it is the the
extent
that sector
the government
indirectly
configuration of the players in the private sector that poses
dominance
of the
the private
sector.
risks
that should
beoligopoly
addressedinduring
the NHI
discussions.
These
challenges
couldmore
lead tocompanies
delays in thein the
Why can’t
we have
implementation
of
the
NHI,
unexpected
cost implications,
private sector?
a disgruntled society left feeling that the government is
The delivering
governmentonneeds
participation
the private
sector
not
their the
promises,
and of
achieving
minimal
in ordervalue.
to implement the NHI successfully. The private sector
social
is instrumental in addressing the capacity challenges faced in
terms of facilities, beds and human resources. If, in the next
The
private
an important
player
butthat
it isis the
15 years,
wesector
want a is
private
health-care
sector
more
competitive, has
players in
of the
varying
sizes,
reaches
configuration
of more
the players
private
sector
thatout to
the broader
insteadbeofaddressed
16% of the population,
poses
riskssociety
that should
during the offers
the public
a variety of services at a broader price range, then
NHI
discussions.
we must recognise the existing key barriers to entry
and sustainability.
Why can’t we have more companies in the
private sector?
The government needs the participation of the private
sector in order to implement the NHI successfully. The
private sector is instrumental in addressing the capacity
challenges faced in terms of facilities, beds and human
resources. If, in the next 15 years, we want a private
health-care sector that is more competitive, has more
players of varying sizes, reaches out to the broader
society instead of 16 percent of the population, and offers
the public a variety of services at a broader price range,
then we must recognise the existing key barriers to entry
and sustainability.
These barriers are primarily access to funding
and government regulations and processes,
but also include:
• the red tape involved in obtaining hospital licences in
some provinces
• the lack of clarity and transparency around the
Department of Health’s processes when it comes to
issuing licences
• the lengthy turnaround time in issuing hospital licenses
• the fact that both private and government financial
institutions are more inclined to provide funding if the
entrepreneur is embarking on a large scale project
• how innovative concepts are viewed with scepticism
and as too risky for financial institutions
• the fact that public-private-partnerships that are
government initiated tend to favour well established
businesses instead of smaller businesses that are not that well capitalised. This actually strengthens the
dominance of the few players in the private sector.
The inflexibility of financing institutions to see beyond
check boxes and “known successful models” limits
innovation not just in health-care but across all industries
and consequently suppresses entrepreneurship in
South Africa. We can only grow what the government’s
development financial institutions are willing to invest
money in.
What role can the Government play in
changing the private sector landscape?
The government has significant influence on how
financial resources are allocated to new and existing
players in the health-care sector through development
financial institutions such as the DBSA, IDC, PIC, and
so on. The government also decides on who gets
the licences and for which geographical areas. The
government can significantly alter the landscape of the
private health-care sector if it so desired.
Pg 12 | Issue #1 | July 2011
This is not implying that the government should attempt
to control the private sector but rather highlights the
opportunity the government has to open up the private
sector to a number of smaller players through making
licences and funding available to new players.
If more licences are issued for rural areas and
townships, then South Africa will have more medical
facilities in these previously under-developed areas. If
funding is made available to new entrepreneurs, then
in 15 years time we will have an industry that has a
radically different landscape.
Redirecting funding and hospital licenses to new players
could have the following benefits:
• an increase in the number of medical facilities, beds
and human resources
• attracting the health-care workers who are currently
working overseas – providing the new players can provide better working conditions
• job creation, which will increase the tax pool
• penetration of the under-developed areas, thus enabling
the majority of South Africans to have easy access to
health-care, a short distance away
• development of innovative and affordable health-care
solutions since new players will most likely seek market
niches and not compete directly with the existing few
industry leaders
• a cheaper health-care alternative for people who
currently cannot afford the existing private health-care
services. This will reduce the number of people
dependent on free health-care
• the government will have a wider variety of choices for
private partners when implementing future initiatives.
Do we need a lot more money to change the private
health-care industry landscape? No, we just need to
repackage and allocate resources differently. We need
the Department of Health to streamline its process
of issuing licences and the development financial
institutions to be willing to take risks with smaller
entrepreneurs with viable projects.
The precise nature of the proposed NHI is still the
subject of discussion, and these discussions should
involve a wider audience. The government must be fully
aware of the important role it plays in shaping the private
sector through financial resources and hospital licencing.
The government cannot afford to shy away from using
these levers to shape the private health-care industry
landscape – not if it wants to implement the NHI
successfully.
A
Revolution in
HEALTH-CARE
I
n seventeen years of democracy, significant progress
has been achieved in improving access to health.
However, more remains to be done to ensure that
all South Africans enjoy quality health services without
catastrophic medical costs and consequences.
The South African health system has multiple challenges
that need to be addressed to improve the delivery of
services. At the 52nd ANC National Conference in
Polokwane the meeting provided the policy
impetus by calling for the “implementation
of a National Health Insurance (NHI) to
further strengthen the public healthcare system and ensure adequate
provision of funding”.
The implementation of the NHI
plan means transformation of the
funding model for health as well as
reorganisation of health-care delivery.
Universal access to health services can only
be achieved through a simultaneous and twopronged approach. First, significantly strengthen the public
sector so that it becomes the provider of choice. Second,
design mechanisms for ensuring that scarce and critical
health service resources in both public and private sector
are shared and optimally used by all to maximise social value.
PHOTOGRAPH: ISTOCK PHOTOS
SOURCE: HTTP://WWW.ANC.ORG.ZA/DOCS/ANCTODAY/2009/AT03.HTM
This resolution acknowledges
that the South African health
system has challenges that can
only be addressed through a
comprehensive transformation of
the system.
The transformation process intends to fundamentally
address structural and systemic aspects of the health
system that are sustaining current inequities, and engender
solidarity through redistributive and social justice in the
delivery of health services.
The establishment of a National Health
Insurance is predicated on two core principles:
• First, the right to health: the state must take reasonable
legislative and other measures, within its resources, to
achieve the progressive realisation of the right to access
health-care services. A key aspect of ensuring access to
Pg 13 | Issue #1 | July 2011
health-care is that services must be free of any charges at
the point of use.
• Second, social solidarity and universal coverage:
the commitment to social solidarity in the South African
health system means a mandatory contribution by South
Africans to funding health-care according to their ability to
pay. Given the massive income inequalities, progressive
funding mechanisms must be used (that is, the rich
should contribute a higher percentage of their
income to funding health services than the
poor) and the government contributes
for the indigent. There should be
universal access to health services
that meets established quality
standards so that everyone is
able to use health services
according to the need for
health-care and not on the
basis of ability to pay.
The main sources of funding
for the NHI will be allocations
from general tax revenue with
a progressive increase of the
public-health sector budget over five
years and a small mandatory health
insurance contribution. All of these funds
will be combined into a single NHI fund, from
which all services covered by the NHI will be funded. The
resources pooled in the NHI Fund will be managed by
a public authority that will allocate them according to an
agreed annual national health plan and be responsible for
central purchasing of health services for the NHI through
sub-national levels.
Central allocation of funds and purchasing is critical in
ensuring that national public health policy objectives are
achieved and unnecessary disparities are avoided. The
allocations will be based on relative health-care needs,
such as the size of population, age and sex composition of
the population, HIV/AIDS/tuberculosis and levels of ill health.
There will be a separate mechanism for allocating capital
funds under the NHI. Underlying this separate allocation
mechanism is the need to redress historical inequities in
the availability of health infrastructure and improve physical
access for all.
Purchasing refers to the transfer of financial resources to
both private and public health service. The NHI, through
its sub-national levels, will assess the specific health-care
needs of the community served, decide on what type
and quantity and quality of health services are required to
meet these needs, and which health-care providers should
provide these services to ensure that appropriate services
are available to the population.
PHOTOGRAPH: ISTOCK PHOTOS
This process of assessment applies to services directly
provided by the purchasing organisation itself and
to services provided by independent contractors. A
single purchaser will fundamentally address the current
fragmentation, spiralling costs and allow the government to
implement public health policy effectively.
There will be a comprehensive package of services that
includes primary health-care services as well as hospital
inpatient and outpatient care. People will be expected to
follow the appropriate referral route to ensure effective gatekeeping as at the primary health-care level before referrals
to specialists and hospital-based care when necessary.
This will ensure that resources are used efficiently and
appropriately. People will have choices as to where to
obtain care.
The main provider mechanism will be capitation payments
(that is, a set amount per person per year) in its various
forms. The payment arrangements will be structured to
ensure that both providers and users of services are less
inclined to overuse or over service patients and hence
control spiralling of costs. Health-care will be purchased
from either public or private health-care providers which
have been accredited by the NHI. Providers will be
accredited on the basis of their ability to provide services
of acceptable quality, willingness to accept payment levels
affordable to the NHI, and the need for such providers
within a particular area.
Pg 14 | Issue #1 | July 2011
At the primary care level, existing private general
practitioners (GPs) can be accredited if they work in group
practices, which include primary health-care nurses and
a range of allied health professionals. Similarly, public and
private hospitals at various levels will be accredited to
provide NHI services. People can then choose between
accredited providers in their area.
However, it is important that other health system challenges
are addressed and this includes: interventions to improve
human resources for health, infrastructure revitalisation,
maintenance and new developments, reforming
management of hospitals and general quality improvement
plans. To ensure effective stewardship of the health system,
there must be an appropriate and integrated framework for
regulating the quantity, distribution and quality of care of
both public and private health-care providers.
Although in the past recommendations for substantial health
systems transformation in South Africa have not been taken
forward, the Polokwane resolution to proceed with an NHI
combined with the prioritisation of health and education
sectors, suggests that the pace of change is likely to be
faster than seen hitherto.
The challenges for such substantial transformation of all
aspects of funding and providing health services in South
Africa are well appreciated and understood; that is why it
is critical that the process be phased over a period of up
to five years.
However, each year will be characterised by significant
changes towards the full implementation of NHI. To facilitate
the transformation process appropriate legislative reforms
will be implemented soon to provide the legal framework for
introducing change and formation of appropriate institutions
for NHI. It is only through such bold changes that universal
access to quality services can be guaranteed.
Contributors
Nkosinathi Biko
Nkosinathi Biko is the Chief Executive Officer of the Steve Biko Foundation. He is a
founder member of the Board of Trustees and chaired the Steve Biko Foundation
for the first five years. Biko graduated from the University of Cape Town where he
pursued a Bachelor of Social Science (Economics) and a Postgraduate Diploma in
Marketing Management. He studied Property Development and Finance through the
University of the Witwatersrand. He is also a published writer and speaker and has
given lectures on the international circuit.
Obenewa Amponsah
Obenewa Amponsah is the Steve Biko Foundation’s Director of Fundraising
and International Partnerships. With a background in African affairs, Amponsah
is particularly interested in the creation of Pan African solutions to foster African
development. She holds an undergraduate degree in International Relations from
Boston University and is currently pursuing a Masters in International Relations at
the University of the Witswatersrand.
Ghairunisa Galeta
Ghairunisa Galeta is a black South African-American and lives in Johannesburg.
She holds a BA in Sociology/Anthropology from Spelman College in Atlanta,
Georgia in America and an MPH in Socio-medical Sciences and Health Policy
from Columbia University, New York. As a freelance consultant, she has a cross
sectoral interest and focuses on social justice, community engagement and
cultural activism.
Pg 15 | Issue #1 | July 2011
Contributors
Harriet Etheredge
Harriet Etheredge holds an MScMed degree in Bioethics and Health Law
from the University of the Witwatersrand, Johannesburg. Currently working at
the Steve Biko Centre for Bioethics, Etheredge is involved in lecturing and
research. She has presented at conferences both locally and in the United
States. Etheredge has authored and contributed to numerous articles and book
chapters. She is also the author of a book entitled: Looking at the Living Will: Your
Death, Your Dignity and Your Doctor and she sits on the Wits Human Research
Ethics Committee (Medical).
Tejal Mistri
Tejal Mistri has a BA Degree majoring in Psychology and Media Studies from the
University of the Witwatersrand. She joined the Steve Biko Centre for Bioethics
as a research assistant in January 2010. Mistri is actively involved in compiling
and coordinating research projects at the centre. She is also involved in planning
Ethics Alive, an annual Ethics Week hosted by the Faculty of Health Sciences and
the Steve Biko Centre for Bioethics.
Dr Jonathan Broomberg
Dr Jonathan Broomberg is the Chief Executive Officer of Discovery Health. A
medical doctor and health economist, he studied Medicine at the University of
Witwatersrand, and obtained an MA (Politics and Economics) from Oxford University. He later completed an MSC and a PHD in Health Economics at the University
of London. He has spent over 20 years working in the fields of health-care management, health economics and policy in both the public and private sectors, in
South Africa and abroad. He also plays a role in international public health affairs,
and served on the Technical Review Panel of the Global Fund to Fight Aids, TB
and Malaria for five years.
Pg 16 | Issue #1 | July 2011
Contributors
Mamosa Motjope
Mamosa Motjope holds a BSc degree in Electrical Engineering from the University
of the Witwatersrand as well as an MBA degree from the Heriot-Watt Business
School in Edinburgh in the United Kingdom. She has worked as an information
engineer and strategy consultant. Her main interests are in the field of strategy,
politics and entrepreneurship. Her opinions on the health-care system have been
inspired by the projects she’s involved in with a start-up company called PeoKura.
Dr Howard Manyonga
Dr Howard Manyonga has a Bachelor of Medicine and Bachelor of Surgery from
the University of Zimbabwe he also holds an executive MBA from UCT. Dr Manyonga has been an obstetrician and gynaecologist for the past 10 years, and is
an honorary lecturer and external examiner at the UCT Medical School. His main
interest is strategic communication and the facilitation of strategic discourse in
multi-stakeholder environments. He has a keen interest in the application of ICT as
an enabler of communications in health-care and is currently the Executive
Director of PeoKura, which focuses on health-care solutions.
Roseanne Da Silva
Roseanne Da Silva is a consulting actuary with over 17 years of experience in the
South African health-care and employee benefits fields. She graduated from Wits
in 1993 and qualified as an actuary in 1995. She has presented the following papers to the Actuarial Society of South Africa: “Managed Care and South Africa” in
1996 and “The impact of HIV/AIDS on Medical Schemes in South Africa” in 2006.
She has served on the health-care and research committees of the Actuarial Society and is convenor of the Actuarial Society’s NHI Task Team. Her current areas
of practice are health-care, employee benefits and AIDS consulting.
Pg 17 | Issue #1 | July 2011