Does the discrimination and exclusion of traditional health practitioners in South African national health insurance foster inequality of access to health care?

Abstract

In order to close the gap between public and private health care services in South Africa and ensure the realisation of the constitutional right to access to health care services (under section 27), National Health Insurance (NHI) has been introduced by the government to ensure equity and parity of access to health care services. This article provides a general overview of the NHI Bill, highlighting the advantages and disadvantages of NHI and its future implementation in South Africa, and interrogates universal healthcare coverage and National Health Insurance through the lens of traditional health practitioners. Traditional health practitioners treat the majority of people in rural and urban parts of South Africa and often face discrimination when it comes to the provision of health care services.

Introduction

South Africa has been grappling with access to and provision of health care services for the majority of its population, most of whom rely on a public health care that is often over-populated and under-resourced. ¹ Only 25% of its population makes use of private health care services, which in contrast to the public health care, is more efficient with state of the art medical equipment and adequate staff. ² In order to close the gap between the provision of public and private health care services, and ensure the realisation of the constitutional right to access to health care services in terms of section 27 of the Constitution, the government has introduced National Health Insurance (NHI) to ensure equality and parity in the access of health care services in South Africa. ³ The economic and social status of an individual is no longer to be a factor when it comes to accessing health care services as currently is the case. The President signed the NHI Bill into law on 15 May 2024.

This article provides a general overview of the NHI, and highlights its advantages and disadvantages and future implementation in South Africa, particularly from the perspective of equality with respect to the access to and provision of health care services. Due to the history of inequality in terms of access to health care in South Africa, it is important to touch upon broad critiques of shortfalls in the NHI. Furthermore, the public perspective, awareness and understanding of the NHI is important to highlight because much has been said about it and how it is to be effective once rolled out. A comparative analysis of countries who have implemented similar legislation or policies geared towards universal health coverage is also important in order to draw some lessons and map a way forward, particularly with respect to the issues of equality as to the access to and provision of health care services. Most importantly here is the interrogation of universal healthcare coverage and National Health Insurance through the lens of traditional health practitioners, due both to their relevance and that they often face discrimination when it comes to providing health care services. Traditional health practitioners fall neither under public nor private health care. They are often treated as stepchildren when it comes to the provision of health care in the country, despite the reality that they treat the majority of people in rural and urban parts of South Africa. ⁴ At this point is important to pause and ask who is a traditional health practitioner. In terms of the Traditional Health Practitioners Act 22 of 2007, the following categories of people qualify to be called traditional healers. This includes herbalists, traditional birth attendants and traditional surgeons. ⁵ All of these categories of traditional health provision must be registered under the above-mentioned Act to offer their services and are regulated by the Traditional Health Practitioners Council of South Africa. ⁶ The Traditional Health Practitioners Council of South Africa aims to ensure the efficacy, safety and quality of traditional health care services in the country. ⁷

General overview of the National Health Insurance Act (NHI)

The NHI sets the framework for a health financing system designed to pool funds together to provide access to quality and affordable personal health services to all South African citizens; permanent residents; refugees; inmates detained in correctional centers; certain categories of foreigners; all children, including children of illegal migrants or asylum seekers. Illegal foreigners and asylum seekers will only be entitled to emergency medical services and services for notifiable conditions of public health concern. ⁸ The main objective of the NHI is to ensure that both public and private health care providers and systems work hand-in-hand and close the current gap in health provision which is centered around competition. This is to be through the merger of the health systems excluding traditional healers, and the establishment of the NHI fund with the government as the main stakeholder. ⁹ This system is to function similarly to medical aid schemes in that it will provide healthcare coverage and eliminate the payment of any fees at health facilities as the fund will cover the costs in the same way that medical aid schemes do for their members. ¹⁰ There will be one pool of healthcare funding for private and public healthcare providers alike, the NHI fund as funded by general and payroll taxes (monthly contributions made by employees to the fund in a similar manner to Unemployment Insurance Fund (UIF) contributions) ¹¹ through a surcharge on personal income tax, and a reallocation of funding for a medical scheme tax credit paid to various medical schemes towards the funding of NHI. ¹² When the NHI is fully implemented, medical schemes may only offer complementary cover to services not reimbursable by the NHI fund. ¹³ Based on the above, it becomes very clear that traditional healers as medical practitioners are excluded from the main objective of NHI as they do not fall under either of the categories of public or private health care providers in the country.

The advantages and disadvantages of the national health insurance (NHI) act

The introduction of NHI in the provision of health care services comes with advantages and disadvantages. The advantages include:

• South Africans will no longer be required to contribute directly to a medical health scheme to get quality health care;

• Lower overall health-care costs by having the government determine and control the price of healthcare and by decreasing administrative costs;

• Finite determination of costs related to health-care procedures with no unexpected costs or depletion of medical aid benefits;

• Potential improvements in healthcare due to higher standards being set for hospitals and clinics;

• Possible improvement in available services, hygiene and safety in public hospitals;

• The removal of health-related barriers to education for children with undiagnosed or untreated health issues;

• Stimulation of the economy by allowing for a healthier workforce where the NHI provides for preventive care;

• Better salaries for medical practitioners in the public sector;

• Improvement of social security by for example, preventing future social issues such as crime and welfare dependency;

• The promotion of equality by removing barriers to health care based on the ability to pay; and

• A real attempt being made at the progressive realization of socio-economic rights and addressing of the inequities and scarcity of health-care resources in South Africa. ¹⁴

In contrast, the disadvantages of the NHI are the following in point form:

• A blow to autonomy as all South Africans will be forced to make use of NHI, regardless of whether they want to or not;

• Unemployment could rise as those previously employed by medical aid schemes may be retrenched due to whole departments of these enterprises becoming redundant;

• Medical practitioners will seek greener pastures and more financially lucrative employment overseas leaving South Africa with a human resource deficit in the context of healthcare;

• Long waiting times for elective procedures as the primary focus of the NHI will be directed towards basic and emergency healthcare;

• There may be fewer health-care facilities and providers due to an uncertain system of accreditation;

• A decrease in the quality of care provided;

• Uncertainty regarding what will in fact be covered by the NHI and what will not;

• Uncertainty and vagueness surrounding the financial aspects of the NHI;

• The healthy paying for the sick and increased burdens on taxpayers;

• A decrease in financial incentives to be and to remain healthy;

• The NHI may be seen to be political pandering rather than a real-life workable and practical system; and

• NHI necessitates confidence by the people in a system under governmental control; and

• The (very real) potential for corruption and misappropriation of funds. ¹⁵

Furthermore, Michel et al. ¹⁶ argues that the disadvantages of having NHI in South Africa now will exacerbate the lack of trust by the public due to the corruption at play, it will open the floodgates for rampant unemployment and also the regressive aspects of value added tax. Budgets; fickle political will; corruption; drivers of private health costs; provincialization as opposed to district health authorities; and incompetent leadership are all factors that must be addressed before the NHI is implemented in order to achieve its objectives.

Despite the disadvantages posed by NHI in the current health system, the South African Health Professions Council’s (HPCSA) President has warned against private medical schemes barring the way of the government to adopting and implementing the NHI in order to protect their patronage and position. ¹⁷ He has reminded all role players about the main objective of the NHI, which is to address inequality of access to healthcare, the poor state of many state healthcare services, the shortage of trained medical staff in the country, high personal taxes, and an undue burden on an already overloaded and understaffed public health service. ¹⁸ This resonates more with the view that it no longer is business as usual when the majority in the constitutional dispensation who are largely poor and marginalized are unable to access quality health care as envisaged and promised by the Constitution. Thus, a call is made that a challenge to the NHI in South Africa must be made reasonably and sensible in the interests of the broader populace.

It is clear from the above analysis that there are pros and cons when it comes to NHI and it is important that a balanced view be maintained in ensuring universal health coverage for the greater good of all people is realized. However, it is also important to mention that in the advantages and disadvantages of NHI, no reference is made on how its implementation is going to affect traditional health practitioners and yet South Africa prides itself as an inclusive country that is diverse. The question remains, why are traditional health practitioners excluded from the NHI provisions post the democratic and constitutional dispensation? This is a question worthy of being interrogated.

Broad critiques of the shortfalls in the national health insurance (NHI) act

Despite the positive aspects of attaining equality in terms of health coverage, the NHI has several shortfalls: First is the creation of many and seemingly superfluous administrative units and public agencies. While these structures are aimed at enhancing accountability and improving health administration, the NHI has the potential to create bureaucratic problems, especially considering the nation’s poor institutional performance and the government’s less than pristine corruption record. ¹⁹

Second, the policy (NHI) implicitly assumes that its proposed public health sector reforms will somehow cause many health care users to move voluntarily from the private to the public healthcare system. This is unlikely to happen. Poor professional conduct and negligence within public healthcare has caused an ingrained mistrust of the public health system to the extent that even if ultra-modern facilities are provided, individuals using the private healthcare, especially urban dwellers, will unlikely transition to the public system. ²⁰ The policy (NHI) also has a limited mechanism to facilitate private and public sector interface. It appears that the private healthcare system will be pivotal in ensuring coverage under the NHI, and it is essential to engage private healthcare professionals and facilities for the system-wide improvement desired. ²¹

Furthermore, Pauw argues that the constitutional right of public participation in health policy decision-making and its vital role in understanding the user perspectives to ensure successful implementation of the NHI is very important. ²² He recommends that to achieve this objective, approachable and communicative leaders are required to facilitate public participation and to engage with the public and health workers. Such leaders will need to be innovative and creative to overcome current public health shortfalls. ²³ This point will be highlighted in detail below. Brauns and Stanton take the critiques of the NHI to another level and argue the poor service delivery and ineffective policy implementation regarding healthcare and that implementation failure is one of the main reasons why policies do not yield the results expected. ²⁴ They argue that NHI is only a funding mechanism and not a general panacea for South African healthcare system and that we will need a careful examination of service delivery in the existing South African context of poor public health systems. ²⁵ They conclude by holding the view that many failings in our health system are based on design faults that continue to entrench inequities, disparities in health outcomes and unfairness in access to quality healthcare arise. ²⁶ From the above is clear that NHI is not the problem but before its implementation the current system in terms of provision of health care needs work and attention in order to reach the desired outcome. NHI can thus not be used as a scapegoat from dealing with the rot in health provision, but its main objective is to attain universal health coverage for all.

Public awareness, understanding and perspectives on national health insurance (NHI)

Murphy and Moosa conducted research on the views of public service managers on the implementation of NHI in primary care in the Johannesburg District. ²⁷ The managers viewed NHI as a social and moral imperative but that they lacked clarity and insight into the NHI as well as the associated implementation strategies. The managers felt that national and provincial governments continued to function in a detached and rigid top-down hierarchy. Managers highlighted the need for their inclusion in NHI policy formulation and training and development for them to oversee the implementation strategies. ²⁸

The Open Public Health Journal conducted research on the perception of professional nurses about the introduction of the NHI in a private hospital in Gauteng, the capital hub of South Africa. ²⁹ Findings indicated that they acknowledge the principles of the NHI such as a right to access healthcare, equity, affordability, efficiency, effectiveness, and appropriateness. ³⁰ However, there were concerns on the Department of Health’s ability to ensure adequate human resources, sufficient equipment, safe infrastructure, meeting the national core standards, which are still hampered by challenges experienced in public hospitals. ³¹ Participants indicated that the government is not ready for the implementation of the NHI, based on the perceived non-transparency on outcomes from NHI pilot sites.

The Health and Human Rights Journal published a paper by Drs Douwes, Stuttaford and London on the insights into civil society’s experiences in the pursuit of universal health coverage via the implementation of the NHI. ³² They explore the interplay of trust, reciprocity, and altruism and how these individual actions can advance toward solidarity and collective action. Participants said that different communities cannot rely on one another because nowadays, everyone looks out only for themselves. One of the participants referred to the fact that strong ties in society used to come from the action of Ubuntu, which means I am because you are, and it champions for co-existence and solidarity. ³³ However, this feeling has been eroded by modern urban culture, which encourages individuals to act for themselves. Although participants shared a positive view on altruism, they agreed that this was not the norm and that most people just look out for themselves. The study showed that the public’s trust in the South African government is low, and that a first step in the implementation of the NHI should focus on rebuilding trust. ³⁴ Part of this effort could include the establishment of platforms for collective action and citizen participation. There should be a shared recognition and acceptance of the importance of civil society action and collective action between the government and communities. However, there are concerns about the exclusion of civil society in the establishment of the NHI.

Weimann and Stuttaford conducted a survey using the Mxit social network to encourage public comments on the proposed NHI and to raise awareness about the rights to free and quality health services. ³⁵ The respondents addressed the lack of trust in the health care system and proposed a code of ethical values for health care professionals to address corruption in the health care system. Major themes are the improvement of service delivery and patient-centered health care, enhanced accessibility of health care providers, and better health service surveillance. Furthermore, health care users demand stronger outcome-based rather than rule-based indicators of the health system’s governance. Intersectoral solidarity and collaboration between private and public health care providers are suggested. ³⁶ There must be collaboration and a clear position when it comes to the existence, operation and implementation of traditional health system in general. This is because the silo approach to health care provision in South Africa is one of the main reasons for poor and dangerous health care practitioners in the sector and resulting in loss of life and abuse in some instances. ³⁷

From the above is very much clear that the government needs the buy in and support of communities and all stakeholders in health to attain the full implementation of NHI. Furthermore, as already highlighted above, there is an erosion in terms of co-existence in communities and it is no longer about the group but more about an individual. A call is made for society and government to go back to the Ubuntu philosophy of co-existence and inclusivity. This requires the inclusion of traditional healers as medical practitioners who live nearby, speak the same language and work with people on the ground for better awareness and understanding of the NHI and its objective. However, how can traditional healers help in this regard if they are excluded completely from the architectural framework of the NHI?

A comparative analysis of countries who have implemented similar legislation or policies geared towards universal health coverage

Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is currently being implemented through the National Hospital Insurance Fund (NHIF). ³⁸ Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. ³⁹ Rwanda operates a community-based health insurance system called the ‘Mutuelle de santé’ scheme. ⁴⁰ These approaches demonstrate the growth and independence of African countries in attaining equality and universal health care provisions as a basic human rights for all without taking into account the socio-economic status of patients.

Furthermore, reference is made to countries like Brazil, The United Kingdom (UK), Canada, Chile, Colombia, and Thailand, who have implemented the NHI successfully despite encountering challenges, making great strides. ⁴¹ These countries have features and health systems that make their experiences relevant to South Africa’s plan to establish an NHI fund. These countries have addressed some of the thorniest governance issues as also facing South Africa, such as: the future role of provinces and medical schemes; ways of engaging private providers; the implications of poor quality in public sector provision; and the need to manage expectations and costs. In this way, they provide a window of experiences in other countries that can serve as sources for ideas and inspiration. ⁴² A collaborative approach and understanding of each other’s health provisions is imperative, and taking into account the context of each country is important in order to achieve the stated objective of universal health coverage.

Universal healthcare coverage and national health insurance (NHI) through the lens of traditional health practitioners

As many South Africans use the services of traditional health practitioners, they can make significant contributions to the attainment of universal health coverage as envisaged by the NHI. ⁴³ This form of care surprisingly is not factored into the NHI objectives as it previously has been factored into policies aimed at combating some priority diseases such as TB, STIs and HIV/AIDS. ⁴⁴ No national integration policy has come into play yet to incorporate traditional medicine and traditional health practitioners into the NHI system despite the recognition of traditional health practitioners as health care personnel in terms of the Traditional Health Practitioners Act of 2007 as already mentioned. ⁴⁵ This means that traditional health care is a third tier of health provision in the country despite being excluded from the NHI and this point will be outlined in depth below. ⁴⁶

In the NHI, the dominant view is that South Africa has a two-tier healthcare system – one private and the other public. Vawda challenges this view and argues that South Africans use traditional healing methods for treatment for a range of conditions. She argues that the exclusion of the third-tier traditional healing in NHI should be reconsidered. ⁴⁷ This means that South Africa does not have simply public and private health care providers, but rather there is a third tier of traditional healing that forms part of the culture and belief of the people.

Is there any justification for its exclusion in the entire NHI? Xego et al., answers this question in the negative on the basis that the exclusion of traditional health is based on the premise that traditional medicines need to be scientifically tested first, before the traditional healer can be allowed to work with the biomedical personnel. ⁴⁸ In many instances, the relationship between traditional and western health practitioners is one of co-existence rather than collaboration. ⁴⁹ A collaborative approach is thus necessary due to relevance and locality which traditional healers operate and are most importantly part of communities and not seen as service providers but members of a community. ⁵⁰ This makes them have a lot of influence and leverage over people in a number of communities they live in and the government can take this opportunity in order to make them partners and to be ambassadors for the attainment of NHI.

Another dimension that can be argued as the reason why the NHI excluded traditional healers in the provision of health care is the stigma and ignorance associated with the use of traditional medicine. ⁵¹ Better awareness and understanding as already mentioned is very important to achieving universal health care. Section 57 (1) of NHI speaks about a gradual implementation of the Act and traditional health only features as one of the Acts which needs reform for the full implementation of the NHI. ⁵² In the entire NHI Act, this is the only reference made to traditional healing, and begs the question of whether this is enough in the South African context where inequality is a dominating factor and reality and often dividing society.

A deliberate attempt was and is necessary to ensure that traditional healing is explicitly mentioned and discussed in NHI and how it is to be part of the universal coverage of health provision in the country, not only as an afterthought. This would be in line with a transformative agenda of the government as part of eradicating inequality in general and for this purpose in the provision of health care services to all people.

A case in point for South Africa is the Taiwanese NHI system, which was introduced in the 1990s and covers specified traditional therapies. In the Taiwan NHI, reference is made to the distinctive Taiwanese setting and presents a way to learn about their experiences with traditional therapies. ⁵³ Furthermore, the perceptions of health care professionals and insured individuals in Taiwan about their satisfaction with the Taiwanese NHI system regarding the coverage of traditional Chinese medicine are examined. ⁵⁴ The results, combined with previous literature, suggest that the universal health system designed with consent of the populace in mind may lead to better satisfaction with the health system post-development. ⁵⁵

Practical suggestions based on the experiences in Taiwan could be useful to stakeholders in other countries like South Africa and economies that are considering the integration of traditional medicines into their universal health insurance system. ⁵⁶ The use of traditional medicines and methods must not be used only when there are pandemics and crisis like we have seen in the past with TB, and HIV\AIDS, but must form part of the whole ecosystem of health provision in the country. ⁵⁷ Kasilo et al., emphasizes this point and argues for further investment in African traditional medicine as a component to conventional medicine in order to promote the attainment of the World Health Organisation’s (WHO) objectives of Universal Healthcare Coverage. ⁵⁸ It highlights the technical tools provided by WHO to assist African countries in developing traditional medicine as a significant component of healthcare.

Many African countries adopted these WHO tools after appropriate modifications to advance research and development of their traditional medical schemes. ⁵⁹ An analysis of the extent of this development was undertaken through a survey of 47 countries in the WHO African region. Results show impressive advances in research and development of African traditional medicine, the collaboration between traditional health practitioners and conventional health practitioners, quality assurance as well as regulation, registration and the integration of traditional health practitioners into the national health systems. ⁶⁰ This highlights the various ways investment in the research and development of African traditional medicine can affect policy and practice. It also underscores the need for frameworks for fair and equitable sharing of all benefits arising from the research into African traditional medical products involving all the stakeholders. ⁶¹

The NHI in its universal health coverage objective must be intentional and clear to close the gap and not only ensure that both public and private health care work together but to affirm the position and role of traditional health practitioners. Traditional healers are the first port of call for patients before accessing the “mainstream” health care services that are either a public or private health care provision. This proximity needs to be fully exploited by the government in order to attain universal health coverage. The introduction of NHI in South Africa is a welcome relief due to the history of the country, despite the challenges it will bring in its implementation as already mentioned.

However, a missed opportunity has been identified in this article by including traditional healing in the NHI provisions and most importantly to address a historical injustice of giving and affirming the role of African way of life through healing and living. Importantly, it is not too late to address this mistake or oversight as highlighted here. There is an opportunity for the government to engage the sector of traditional healers, be deliberate with the help of all stakeholders, and ensure that that their position and role in universal health coverage in the NHI is clearly articulated in line with the objectives set out by the constitution of inclusivity and a non-racialized South Africa. Based on the above, there is no justification for the exclusion of traditional healing in the NHI, and it is irrational and discriminatory with respect to both traditional healers and those people who make use of this method of healing and access to health care, as guaranteed by the Constitution.

Conclusion

In conclusion, a compelling case has been shown here that the exclusion of traditional healers in the construction of the NHI is unjustified due to the significant role they already play in the provision of health care in South Africa. In addition, it exacerbates inequality of the access to and provision of health care services particularly for the more vulnerable groups in society. Traditional healers form part of the ecosystem of health provision in South Africa and it is pertinent for the government to heed the call to include them and ensure that their voices and perspectives are taken into account. Such a move lies within the broader strategy of the government in its nation building and ensures the realization of the constitutional right to access to health care services in terms of section 27 of the South African Constitution.