Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine
ß The Author 2014; all rights reserved. Advance Access publication 25 June 2014
Health Policy and Planning 2015;30:759–767
doi:10.1093/heapol/czu053
The drive for universal healthcare in South
Africa: views from private general practitioners
Rebecca Surender,1* Robert Van Niekerk,2 Bridget Hannah,3 Lucie Allan4 and Maylene Shung-King5
1
Department of Social Policy and Intervention, University of Oxford, Oxford OX1 2ER, UK, 2Institute for Social and Economic Research,
Grahamstown, Eastern Cape, 6139, 3Institute of Social and Economic Research, 4Department of Pharmacy, Rhodes University and
5
University of Cape Town, Private Bag, Rondebosch 770, South Africa
*Corresponding author. Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford
OX1 2ER, UK. E-mail: [email protected]
Accepted
13 May 2014
To address problems of inadequate public health services, escalating private
healthcare costs and widening health inequalities, the South Africa (SA)
Government has launched a bold new proposal to introduce a universal,
comprehensive and integrated system for all SAs; National Health Insurance.
Though attention has been devoted to the economics of universal coverage less
attention has been paid to other potential challenges, in particular the important
role played by the clinicians tasked with implementing the reforms. However,
historical and comparative analysis reveals that whenever health systems undergo
radical reform, the medical profession is instrumental in determining its nature
and outcomes. Moreover, early indications suggest many SA private general
practitioners (GPs) are opposed to the measures—and it is not yet known whether
they will comply with the proposals. This study therefore analyses the dynamics
and potential success of the reforms by directly examining the perceptions of the
SA medical profession, in particular private-sector GPs. It draws on a conceptual
framework which argues that understanding human motivation and behaviour is
essential for the successful design of social policy. Seventy-six interviews were
conducted with clinicians in the Eastern Cape Province in 2012. The findings
suggest that the SA government will face significant challenges in garnering the
support of private GPs. Concerns revolved around remuneration, state control,
increased workload, clinical autonomy and diminished quality of care and
working conditions. Although there were as yet few signs of mobilization or
agency by private clinicians in the policy process, the findings suggests that it will
be important for the government to directly address their concerns in order to
ensure a stable transition and successful implementation of the reforms.
Keywords
Medical profession, South Africa, universal healthcare reform
KEY MESSAGES
Examines doctors’ attitudes towards universal healthcare (UHC) in South Africa (SA) in the context of imminent White
Paper release.
Analyses the role of key actors and implementers in the health policy process and the factors that influence successful
implementation of UHC in developing country context.
Findings suggest large sections of private doctors will not support the proposals that may undermine reform efforts.
759
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HEALTH POLICY AND PLANNING
Introduction
Despite concerted attempts in South Africa (SA) since 1994
to improve the health status of historically disadvantaged
populations, the healthcare system continues to be fragmented
and unequal, with the majority of the population relying on a
public sector which has significantly less resources than its
private equivalent. In order to address these inequalities, the SA
government has launched the most radical and ambitious
reform strategy to date—the introduction of a National Health
Insurance (NHI) (RSA and DoH 2011, ‘Green Paper’).
Notwithstanding the term ‘insurance’ the reforms aim to
achieve a universal tax funded system: comprehensive, integrated and available to all South Africans. The proposal seeks to
make healthcare a social right rather than a market product
and is in keeping with the current international drive for
universal healthcare in developing countries (WHO 2005; UN
2012).
Regardless of the government’s determination to enact the
proposals, it is yet unknown whether they will be implemented
as envisaged or whether clinicians will comply with them.
Although much attention has been devoted to the proposal’s
infrastructure requirements and fiscal affordability, relatively
little attention has been paid to the important role played by
key stakeholders tasked with implementing the reforms.
However, policy analysis underscores the need to understand
actors’ beliefs, motivations and behaviour when analysing the
likely robustness and outcomes of policies (Lipsky 1980; Walt
and Gilson 1994; Le Grand 2003). In particular, historical and
comparative analysis shows that whenever health systems
undergo radical reform, the role of the medical profession is
without exception crucial in determining its eventual success
and character. The inception of the UK National Health Service
(NHS) in 1948 and US Medicaid in 1968 demonstrates the
power of the medical profession in extracting concessions from
the State at times of major system change (Klein 2001; Rodwin
2011). Recent battles between the profession and governments
across Africa, Asia and Latin America about values, means and
interests (Chatterjee 2006; Carasso et al. 2012; World Bank
2013), have resulted in negotiated settlements in which the
eventual arrangements reflect not the original preferences of
policymakers, but the political bargains and compromises they
were able to achieve (Reich 1995; Paim et al. 2011; Lagomarsino
et al. 2012). Evidence from other developing country attempts
to introduce universal healthcare demonstrates that despite
radical reform efforts, many systems stubbornly remain two-tier
without a motivated medical workforce (Watts 2000; Homedes
and Ugalde 2005; World Bank 2013). Assumptions concerning
human motivation and behaviour are thus central to the
successful design of health policy.
This study analyses the dynamics and feasibility of the NHI
reforms by examining the views of doctors, chiefly privatesector general practitioners (GPs), on them. The study focuses
on private GPs because the reorganization prioritizes primary
healthcare and proposes (at least initially) to draw upon
human resources in the private sector to help serve the needs
of the wider population. Private GPs are thus strategically and
organizationally significant for the success of the reforms.
Furthermore, recent surveys and media reports indicate that
the sector is opposed to the proposals (Wild 2012; Kahn 2013;
Loggerenberg 2013). This article assesses GPs expectations of,
and their likely response to, the proposals. It seeks to
contribute to a better understanding of the substantive issues
facing SA healthcare as well as the challenges encountered in
translating health policy intentions into successful outcomes in
low- and middle-income countries generally.
Background and proposed reforms
Few in SA (especially the medical profession) doubt that
current health arrangements are in need of reform. The health
system confronts a significant ‘quadruple burden of disease’
(Coovadia et al. 2009) and on key morbidity and mortality
indicators its performance is poor for a middle-income economy. Moreover, the current healthcare system remains highly
inequitable. Though at 8.5% of Gross Domestic Product (GDP),
SA exceeds the WHO (2011) recommendation that countries
devote at least 5% of GDP to health, the expenditure is
unevenly distributed among its population of 50 million.
Although only 16% of the population belong to private
insurance (medical) schemes they consume more than 50% of
total healthcare funds; the remaining 84% relying on an
underfunded public sector. Approximately (Rand) R11 150 per
capita is presently spent on private patients compared with
R2 776 spent on public patients. The distribution of human
resources is also dominated by private practitioners, with 59%
of doctors, 93% of dentists and 89% of pharmacists in private
practice (McIntyre 2010; Ruiters and Van Niekerk 2012).
Although in theory, public-sector primary-care services are
free and charges in public hospitals are means tested, many
barriers to access exist including availability of and distance to
facilities and cost of transport. Moreover, differences in the
quality of service provision in each sector regarding medicines,
equipment, waiting times and infection control are conspicuous
(Bateman 2012; Mkokeli 2012; Kahn 2013b).
The private sector however also faces a crisis of affordability
and sustainability. Though patients enrolled in medical-aid
schemes are subsidized by both employers and the state
(tax exemptions to medical-aid schemes currently constitute
R10 billion per year) private healthcare costs have increased by
120% over the past 10 years and there is a growing mismatch
between services and costs. The remaining 95 medicalaid-schemes have experienced spiralling contributions;
increased from 7% of average wages in 1980 to 14% by
2008, with increasing substantial out of pocket co-payments.
Consequently, SA has the highest share of healthcare expenditure funded from voluntary health insurance in the world
(McIntyre 2012; Doherty and McIntyre 2013).
It is these combined problems of inadequate public health
services, escalating costs of private care and excessive health
inequalities that the recent proposals attempt to address. A
central plank of the reform is ‘primary healthcare re-engineering’, which seeks to balance the existing emphasis on
hospital-centred curative care by focusing on prevention and
health promotion at the community level. Although GPs will
form part of the first line of service in districts, it is important
to note they will be just one component of a wider Primary
Health Care (PHC) platform which will include a range of
frontline health providers in District Clinical Specialist Teams,
THE DRIVE FOR UNIVERSAL HEALTHCARE IN SOUTH AFRICA
761
municipal ward-based home and community services and
school based services.
According to the Green Paper, the NHI will be funded
through general tax sources, new dedicated taxes and the
removal of tax subsidies for private insurance. These reforms
are quite different to past incremental reorganizations and will
have far-reaching implications for the private health sector. Key
features involve the creation of an NHI Fund to collect, pool
and distribute funds, a purchaser–provider split and delegated
service delivery management to District Health Authorities. The
gate-keeping role of primary-care clinicians and the referral
system will be strengthened and there will be greater managerial autonomy for hospitals. Private health insurance will be
allowed to continue but is envisaged to eventually play only a
complementary role after tax subsidies for premiums are
removed. Details about the role of private providers are still
unfolding though current staff shortages and capacity means
that private GPs will be included in the reformed system with
government acknowledging that private doctors (initially at
least) are an essential factor in implementing a successful NHI.
There is a cautious timetable for the rollout of the new system,
to be implemented over 15 years, with 11 pilot sites currently in
place (Minister of Health 2012)
Association (SAMA) and local Independent Practitioners’
Association (IPA)].
Interviews examined respondents’ understanding and
knowledge of the proposals, the anticipated impact on them
personally (volume and nature of work, clinical autonomy,
remuneration) and the wider health system (equity, quality,
efficiency), and the response of the profession to the proposals.
Interviewees were identified via publically available databases
of GPs in the EC and Independent general practitioner (IGP)
lists and some ‘snowballing’. Interview guides were developed
and administered by the study researchers. Interviews ranged
between 30 and 90 min, were taped and transcribed and
transcripts coded and analysed using the software package
NVivo 10. The process conformed to standard rules for
qualitative analysis (Auerbach and Silverstein 2003; Grbich
2007). A thematic approach to analysis was adopted with major
themes ranked according to frequency and intensity of responses. To ensure confidentiality, individual responses are
anonymized and identified only by organizational type. For
convenience private GP practices have been grouped according
to size: solo/small private practice (S/SPP) 1–3 partners,
medium private practice (MPP) 4–6 partners and large private
practice (LPP) 7þ partners.
Methods
Results
A case study (Yin 1984; Stark and Torrance 2005) of the
Eastern Cape (EC) Province was undertaken in 2012 after the
release of the Green Paper. Given that a key objective of NHI
is to improve the health outcomes of the most disadvantaged,
EC was chosen as one of the most impoverished and socioeconomically unequal Provinces in the country; with a poverty
rate of 71%, poor population health outcomes and the lowest
public-sector health spending. The Province incorporates the
previous Transkei and Ciskei Bantustans which endured
extremely weak administration during the apartheid era.
Four of the province’s nine districts were selected for
fieldwork: Cacadu, Nelson Mandela Metropolis, Amathole and
Oliver Reginald (OR) Tambo, which is also one of the 11
national pilot sites. Criteria for site selection included demographic factors, rural/urban composition and location, and
number and mix of clinicians and facilities including hospitals.
As with most qualitative studies, the sampling criteria were
purposive rather than random with no attempt to achieve a
statistically representative sample. However, efforts were made
to achieve a balanced mix of respondents in terms of race,
gender, varied practice types, geographical location and socioeconomic status of the populations served, in order to give voice
to as wide a range of experiences and views as possible (see
Figure 1 for descriptors).
Seventy-six interviews were conducted. Because the focus of
the study was to explore primarily the views of private-sector
GPs, they formed the majority of interviewees (N ¼ 54/71%),
though several were currently working (in sessions) or had
previously worked for the public sector and therefore were
familiar with both sectors. Interviews were also held with other
key stakeholders for contextual purposes and to triangulate
findings: 8 hospital doctors, 10 public-sector GPs and 6
representatives of professional associations [SA Medical
In general, most respondents had a fairly accurate understanding of the objectives and mechanisms of the proposals, largely
via medical associations, discussions with colleagues and the
media. Overall, few interviewees disagreed with the need to
improve the current system and as might be expected, all
clinicians held the view that in principle healthcare should be
available to the whole population. However, many argued that
existing arrangements already constituted a ‘universal’ system
because theoretically public healthcare was available to all
citizens and means testing ensured that those lacking financial
means were not refused treatment. These respondents argued
that more efficient management of existing resources rather
than additional resources or radical reform was needed.
Relatively few supported the idea of a UK-style single-payer
system—with most private-sector GPs ideologically opposed to
such a ‘nationalized’ system.
Scepticism about feasibility of NHI
Generally, the majority of respondents were very critical
towards the NHI proposals. Views ranged from scepticism
about the feasibility of the initiative to outright hostility. A
main argument against NHI viability was that it was fiscally
unaffordable:
It looks like just a pie in the sky, I mean how are you going
to finance this thing? . . . We’ve got about 5 million people
who are paying tax. They are going to subsidise the other 45
million? That’s just not practical. (MPP)
. . . first world medicine costs a pretty penny. That’s the
problem . . . but where is the money going to come from?
Who is going to pay for it? . . . it’s going to be totally
unaffordable. (LPP)
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HEALTH POLICY AND PLANNING
Figure 1 Description of study respondents
Lack of human resource and institutional capacity were also felt
to undermine the feasibility of the proposals. Respondents
across all sectors argued that the system could not be easily
expanded due to insufficient clinicians and allied staff,
infrastructure and, especially, administrative and management
capacity:
Do we have enough personnel . . . skilled people? Do
we have a radiologist in Bizana? Do we have lab technicians
there? . . . There are facilities there, but [no] personnel.
(Public-Sector GP)
Impact of NHI on remuneration
Despite initial scepticism, when asked to consider the potential
impact of NHI on them individually and the wider system,
private GPs voiced several concerns. Chief among these was
the impact on remuneration. The universal assumption was
that the state would not be able to pay practitioners at current
private-sector rates and so doctors would suffer reduced
income. The language of commerce and business was
pervasive and indicative of the strong market ethos of the
private sector:
I don’t think there is the management capacity
to micro manage all these facilities, all these
processes . . . to make sure that all the procurement processes and things are done properly—they haven’t got the
capacity. (IPA Rep)
We are not making huge profits. We really aren’t. We’re just
getting through . . . removing one sale from this practice or
to work at a cheaper remuneration would make the practice
nonviable . . . it’s a private company, if the company goes
bankrupt, what happens? The guys will leave. Certainly a
large number of the doctors will leave the country. (MPP)
Even among the minority of clinicians who in principle
supported the proposals, there were major reservations. Many
argued that changing the finance would do little to address
fundamental system weaknesses such as low numbers and quality of staff in rural areas:
[NHI] can’t make me work harder than what I’m working
now, for less money. Let’s face it, it’s a business, I’m
running a private practice, I’ve got fourteen families
dependent on me and my partners. (MPP)
The rural areas are highly understaffed and you will never
get regular doctors working there . . . to go to a village
and send your children to a bush school . . . where there is
no proper shopping centre . . . no employment for
spouses . . . they [government] live in a dream world. No
qualified doctors will go there . . . except for idealists and
missionaries. (Hospital Specialist)
The notion that doctors were rational actors who would seek to
maximize their economic well-being was prominent. Although
all stated that they wanted to provide patients with good care,
several indicated that they were ‘not charity workers’. There
was extensive discussion that the likely tariffs and prices would
not reflect ‘true’ costs and would not compensate fully
for medical training, overheads, transport and insurance:
The common opinion among private-sector respondents
was therefore that the implementation of the NHI proposals
was politically driven, non-viable and unlikely to materialize.
A typical view was that ‘it won’t happen in my lifetime’.
My concern is that as a private practitioner I have
overheads and expenses and I don’t want to subsidize the
state . . . many of us are highly qualified . . . they can’t just
get us on the cheap. (LPP)
THE DRIVE FOR UNIVERSAL HEALTHCARE IN SOUTH AFRICA
Don’t expect me to leave my practice and go into a rural
area because then . . . I’m travelling at my expense, my
maintenance of the vehicles. (S/SPP)
Our insurance costs are already sky high . . . and with
more feet through the door the mistakes are only
going to get more . . . is government going to underwrite
us . . . pick up the tab when the malpractice suits roll
in . . . (MPP)
Many took the view that it was nonsensical for one flat price
regardless of the quality of the service. Because doctors varied
in terms of their education, training, expertise and facilities, the
idea that there should be flat rate pay scales flew in the face of
market principles and competition. Many argued that the skill
and reputation of a doctor should determine the price they
charged and the custom they attracted, not a bureaucratic
mechanism:
. . . they’ll have to pay me for my experience . . . the time I’ve
trained and spent already . . . and my feeling is they must do
it according to your qualifications. It’s not x doctors, x
amount of money, no! (LPP)
Doctors appeared to have quite a sophisticated understanding
of the different (at times, perverse) incentives flowing from
different potential finance systems. Many predicted that
whatever the eventual payment mechanisms it would be
possible to ‘game the system’ through adverse selection or
diluted care.
At the end of the day the bottom line is going to be the
money . . . if the NHI wants to not pay you per patient [but]
pay you for amount of hours that you work . . . I can say oh
well I’ll see a patient an hour, as slow as I possibly can
work and take my time and it doesn’t matter. (MPP)
Is it a flat rate? Whether you are coming in with a broken
leg, or coming in to have a Caesarean section, or coming in
with the flu? If it is a flat rate, why should we take the
expensive cases? (S/SPP)
Finally, several private-sector GPs aired concerns that the
reforms would create new winners and losers. Existing
tensions between providers in the current entrepreneurial
system would intensify and become potentially distorting.
Some worried that ‘weaker’ practices would become bolstered
by government contracts and be made more viable despite
poor quality services. Most were concerned that pressure to
accept NHI patients would dramatically change their ability to
provide the current quality of care to private patients—who
would migrate to rival private providers. There was a sense
that there would be heightened competition and a culture of
‘everyone looking over their shoulder’:
Some will contract . . . some will be reluctant to contract . . . and some will cream it . . . Your elite practices in
affluent areas will actually benefit from only private
patients . . . I will lose patients . . . I will lose patients to
somebody who says ok, I will set up an elite
763
practice . . . though it’s going to be smaller because of the
tax. (MPP)
Private patients feel they are paying you . . . therefore they
want your services now . . . they don’t want to wait . . . so if
you now are doing NHI clinics, you are going to alienate
your private patients . . . if they are now going to sit in a
waiting room that is overcrowded and they are going to be
seen only for 5 minutes . . . they are not coming back to me,
I’ll lose my existing patients . . . they will go and see
someone else. (LPP)
Impact of NHI on workload, professional life and
clinical autonomy
Doctors expressed concerns about how the new system
would impact their working conditions and clinical autonomy
and anticipated a dramatic rise in workload due to
the increased population access. Many anticipated that if they
were to receive a lower tariff per patient and had to trade
‘quantity for price’, this would lead to ‘factory line medicine’.
They predicted that increased pressures on providers and
rationed care for patients were inevitable. There were repeated
references to the current public system’s ‘conveyer belt medicine’, sub-optimal consultation times for patients and overwork for providers.
. . . you need to examine the patient and to do it properly . . . it takes about 15 minutes . . . that’s 4 patients
an hour . . . some practices see 120 a day! ok, that depends
on them . . . but their patients aren’t getting satisfactory
care . . . never physically examined in meetings with
a doctor! That’s not healthcare. (LPP)
I’d like guarantees that we won’t be overworked . . . a set
amount of patients a day, with limitations on after-hours
work . . . At the moment [we] are three doctors and we do
every third weekend and every third night but you get
to sleep and you get to survive, whereas . . . for the government you wouldn’t sleep in a whole night. (S/SPP)
Anxiety about the physical working environment, inferior
medical equipment and infrastructure that was likely to
exist in public clinics also featured extensively:
What kind of facilities are we going to work in? . . . not even
a chair to sit down in or proper telephones or water, never
mind X-ray and diagnostic equipment . . . it will be going
back into the dark ages. (MPP)
For most respondents autonomy was paramount and synonymous with private medicine and private practitioners
deeply valued the fact they could determine their own ‘tradeoffs’, work balances and method of practice:
The thing I like about private practice is that I can control
the number of people I see in a day, which is about 30.
And the whole environment is quite controlled . . . it suits
me and my time and my stress levels - the way I work now,
where I can control it. (LPP)
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HEALTH POLICY AND PLANNING
There were frequent protests that clinical autonomy was
already being eroded by the existing system of managed
care being ‘forced’ on doctors by medical schemes.
Complaints about prescribed drug lists, patient protocols,
guidelines and pre-authorization before admitting or referring
were widespread. Nevertheless, the assumption was
that coming under ‘state control’ would only exacerbate
these trends. In this context, the issue that elicited the
strongest negative reaction was the suggestion that doctors
would come under provincial government control. There was
universal condemnation of current public-sector governance
and complete lack of confidence in government’s ability to
manage or regulate. The idea of losing autonomy to the state
elicited a more emotive reaction from clinicians across all
sectors than a potential cut in pay:
At the moment . . . the [Provincial] guys in charge can’t even
make state hospitals work—they just don’t have the
expertise, you know they don’t have the knowledge. I
don’t know if it’s the will lacking or whatever it is but they
just can’t do the job. (SAMA Rep)
It’s a joke to think they have the ability to manage
something as big as NHI . . . if it’s not corruption, it’s
mismanagement and incompetence . . . they can’t even
manage the pay roll for the public doctors they have now.
(Public-Sector GP)
Despite strong concerns from the majority of private
practitioners, it is important to highlight that opinions were
not unanimous. Because not all practitioners faced the same
sets of conditions, unsurprisingly, experiences and opinions
varied. Most public-sector GPs in hospital settings largely
welcomed the reforms, anticipating that increasing capacity
in the private sector would lessen their workload. Additionally,
some private practitioners, particularly smaller practices in
less affluent areas also welcomed the potential increased work
prospects and better security of remuneration that the new
arrangements afforded:
As a small independent practitioner I’d like to be honest
with you: if it means more money in my pocket at the end
of the day I don’t have a problem with it – I’ll go with it.
If at the end of the month it means more money in my
pocket I think it’s OK. (S/SPP)
I think it’s gonna depend on the doctor. I mean, some
of them will embrace it . . . We’re not a high turnover
practice . . . we
have
a
relationship
with
our
patients . . . [We’re] not just a sausage factory. Whereas
some practices are geared to that, they have a fast throughput . . . one could question the quality of medicine that they
practice. (MPP)
Ability of private practitioners to influence the
policy process
Given the strong negative reactions of private practitioners
towards the NHI proposals, interviews explored the extent
to which they were preparing to defend their interests. It was
striking that on the whole there was little evidence
of organized opposition from the profession or willingness
to try to influence the policy process. Some predicted that
doctors would vote with their feet and take early retirement or
emigrate. However, more common was a feeling of resignation with little motivation to challenge the reforms. Relatively
few interviewees had been active in attending meetings
or voicing concerns via their professional associations or
directly via the media. Despite general discontent
that they had not been sufficiently included in the consultation
process and resentment about reforms being ‘forced
down throats’ and government ‘riding roughshod’ over
them, doctors appeared pessimistic about their ability to
change or influence things:
At the end of the day the doctors are not in the driving
seat—government will do what it wants to do . . . we don’t
have any power . . . (Hospital Specialist)
We are not the ones who will call the shots. We have
been abused by all sides—government on one side and
the medical-aids and hospitals on the other . . . no one is
entering the profession any more. (MPP)
Explanations
for
this
‘passivity’
ranged
(as
in
other countries) from simple lack of time to the individualistic
culture of general practice. However, several respondents
were cynical about the motives of the government and for
these clinicians, the perceived anti private-sector sentiments
of the Ministry of Health generated mistrust and hostility and
contributed
to
their
unwillingness
to
engage
with the policy process:
Motsoaledi [Health Minister] has already said the privatesector is a monster . . . so we are sitting with a major
problem; we already dislike each other ok, so how are you
going to appease us, because we know what their intention
and their agenda is. They want to basically take the privatesector and wring its neck, to see if they can force us all
to work for the state sector. (LPP)
Another considerable factor undermining an organized response
from the medical profession was the fractured nature of the profession itself, apparent in the manner in which clinicians spoke
and identified themselves. Fragmentation appeared along geographical and organizational lines; regional, rural, urban,
private, public, tertiary and primary divides. Another factor
adding to the complexity of relationships was the continuation
of racial divisions and in particular that doctors in private
practice interacted very strongly along racial divides.
It was striking how racially divided the larger practices in this
study were, and that the majority of small/solo practices
comprised mostly Black and Indian doctors. The legacy
of racial and structural rifts meant clinicians faced fundamentally different pressures and had very different demands:
SAMA can’t represent doctors’ views as a whole,
because . . . they all have different needs. Private-sector
doctors feel very differently about this than those of us
working in rural health . . . if my priority is access
to healthcare, that’s a very different issue than if you’ve
THE DRIVE FOR UNIVERSAL HEALTHCARE IN SOUTH AFRICA
got a thriving private practice in the centre of town. (SAMA
Rep)
. . . doctors have very different perspectives, different priorities and speak different languages . . . So it’s a complex
relationship . . . At the moment the medical fraternity in SA
doesn’t have a feeling as a whole community . . . there’s no
such thing as a uniform medical community . . . It’s very
splintered. (IPA Rep)
Discussion
To the extent that the SA government intends to create an
integrated and universal system of healthcare provision, it will
face according to the results of this study significant challenges
in garnering the support of sections of the medical profession.
Although several public and some private GPs regarded a state
led NHI beneficial for both patients and themselves, most
private GPs were opposed to the measures which they viewed
as impractical and threatening to their commercial and professional interests. Respondents feared lower remuneration but
increased workload and despite public statements about
strengthening primary-care and the referral system no one
expected greater empowerment for primary-care providers.
Other concerns revolved around clinical autonomy and the
quality of services and conditions of work, though the most
fervent focused on government control, with little confidence in
government’s ability to implement or manage the new system.
It is important to contextualize the strong response of
clinicians in this study within the historic weaknesses of the
Eastern Cape provincial administration (Van Niekerk 2012) and
to recognize that wide institutional differences between
Provinces will mean that the reforms will be implemented
more successfully in some than others. Nevertheless, it seems
that the dynamics identified here are not unique or fundamentally divergent from the national situation. Recent acrimonious debates between the Minister of Health and medical
associations underscore that concerns about remuneration,
autonomy, state capacity and lack of consultation are deeply
felt (Archer 2014a,b; Malan 2014). Perhaps more direct
confirmation of the study findings is the DoH’s struggle to
recruit GPs to participate in the 11 pilot sites currently
underway. Only 96 private-sector doctors signed contracts to
work in NHI pilot clinics between March 2013 and 2014, well
short of the target of 600 set for the year (Kahn 2014).
Moreover, the majority of those participating were in Gauteng
Province (one of the richest and best capacitated provinces)
with the lowest participation rate in the EC site where this
study was conducted (Cook 2013).
Because this research was undertaken a number of developments have occurred which suggest that policy makers are
responding to some of the concerns. Following a national
consultation exercise by the Minister of Health during 2012, a
new national GP contract model is being shaped which
addresses some of the concerns articulated here. Although the
current remuneration for doctors contracting with pilot sites
has been derided as too low and rigid (a flat hourly rate of
R355), the proposed national contract will permit additional
allowances for clinical experience, travel and for working in
rural or very deprived areas. Additional performance incentives
765
(some financial, others to do with enhanced continuing
professional development) will also be instituted. The government has also focused on strengthening public-sector administrative and managerial capacity to ensure the system is ‘fit for
purpose’ and a National Academy for Leadership and
Management in Healthcare is in the process of being established under the auspices of the National Department of health
(DOH).
Whether these plans are enough to command the trust and
co-operation of private GPs, is yet to be seen, though this must
remain the goal for policy makers—not least because their
support and motivation is essential for the stable transition and
sustained implementation of the reforms. One strategy for
achieving greater buy-in from GPs will be to avoid a ‘one size
fits all’ model. This study found substantial material difference
between practices, the pressures they face and consequently the
demands they have regarding NHI. Although some did not
begrudge increased patient loads or were willing to trade
autonomy for securer remuneration, other practices prized
autonomy above all else. Flexibility in arrangements and
models, with choice of contracts, conditions of service and
career advancement pathways, will be both pragmatic and
tactical. Variation in remuneration packages, with transparency
in the criteria being used to determine prices will be essential.
Upgrading the conditions and infrastructure in public-sector
clinics and enabling those who wish to, to provide services from
their own premises will also encourage more engagement.
Finally, allowing larger practices (or groups of practices
working in consortium) greater autonomy from close government management (as proposed for some hospitals) may also
be strategic.
It is interesting to observe that in terms of influencing the
policy process, the SA profession appears mostly to be ‘reactive’
rather than proactive, to the extent it is mostly trying to block
reform rather than initiate it. One explanation for the relatively
muted response is that is it just too early in the process
(especially given the scepticism about the feasibility of the
initiative). Equally, the findings may signify that due to
historical legacies, the exceptionally fragmented nature of the
profession undermines its power as an actor in the policy arena.
However, in either scenario, government would be foolish to
ignore the professions’ discontent. There are certainly recent
examples of the SA medical profession using its power to block
reform and assert its own interests, including stalling government attempts to issue a ‘Licence or Certificate of Need’ (2004)
and the recent victory for the profession in the courts in the
2001 ‘dispensing row’ (Pretorius et al. 2012). Given the
necessary reliance on the private sector to contribute to
healthcare services in the immediate term, policy makers will
need to identify strategies to incentivise them to achieve desired
outcomes.
To this extent, current policy makers may do well to consider
previous efforts to engage with the SA private health sector, in
particular the system of ‘part-time district surgeons’ (PDS)
initiated during apartheid but continued out of necessity by the
1994 democratic government. In order to address the acute
shortage of public-sector primary-care services during the
transition, provincial Departments of Health contracted with
private GPs to work part time for the public-sector. Research on
766
HEALTH POLICY AND PLANNING
the PDS system undertaken at the time revealed the same sets
of conflicts and tensions between government and private GPs
as in the present situation. Particularly salient for NHI are
findings from case studies which show that the most successful
PDS schemes were those that used a more ‘relational’ rather
than formal contractual approach (PRICON Study 2000). That
is, ‘influencing providers via an emphasis on co-operation,
mutual shared interest and their role as independent professionals’ rather than a contractual sanctions based approach’
were most effective (Palmer and Mills 2003). An explicit
acknowledgement of ‘mutual dependence’ between government
and clinician together with activities which built greater
communication and trust between parties were the key.
Similarly, in the long term, the challenge for the current
government will be to achieve a shift in ethos and norms if NHI
is to succeed. Encouraging providers to explore shared notions
of professional standards and social responsibility instead of the
entrenched and deep-rooted market culture which presently
encourages self-interested and profit maximizing behaviour will
be essential for a new NHI system with patient centred values.
Key to all of this will be the need to counteract historical
mistrust and acrimony by bringing the profession into the
process more and facilitating more consultation, transparency
and information flows.
Finally, it is important to recognize that despite their significance both numerically and strategically, GPs are but one strand
of the medical workforce and GP contracting just one element
of the policy change—which focuses on primary healthcare
re-engineering more broadly. This includes the deployment of
integrated clinical specialists at district level including obstetricians, gynaecologists, midwives, paediatricians, paediatric nurses,
anaesthetists, as well as family physicians and primary healthcare nurses. School based PHC services will in most instances be
lead by professional nurses. It is therefore essential that further
research is undertaken concerning the perceptions and interests
of these other groups of medical personnel—arguably the
majority of implementers—to ensure that policy design is
informed by the experiences of all ‘front line’ implementers
and that practical solutions are found to challenges.
Conclusion
Health policy analysis shows that although in most contexts the
state, market and profession exist in a delicate balance, the
power of the medical profession has traditionally been a key
determinant in shaping how that balance is either maintained
or changed. Judging from these research results, the government has not yet been able to convince private medical doctors
(in particular GPs) that the NHI scheme is viable, or indeed,
desirable. Because doctors working in private practice constitute
nearly 70% of the total number of GPs working in SA, they will
need to be convinced of the new proposals if the NHI scheme is
to be implemented effectively.
Acknowledgements
The work was supported by the Sandisa Imbewu Grant from
Rhodes University, SA and a John Fell Grant (Grant Number
CV0035) from the University of Oxford, UK. Both funding
agreements ensured the authors’ independence in designing the
study, interpreting the data and, writing and publishing the
report.
Conflict of interest statement. None declared.
References
Archer C. 2014a. NHI: Let’s Talk about this Revolution. http://mg.co.za/
article/2014-02-06-lets-talk-about-this-revolution,
accessed
7
February 2014.
Archer C. 2014b. Right of Reply: Motsoaledi Makes Fools of Us. http://mg.co.
za/article/2014-02-13-right-of-reply-motsoaledi-makes-fools-of-us,
accessed 14 February 2014.
Auerbach C, Silverstein L. 2003. Qualitative Data: An Introduction to Coding
and Analysis. New York: NYU Press.
Bateman C. 2012. ‘Will our public healthcare sector fail the NHI?’ SAMJ,
Vol. 102. No. 11.
Carasso BS, Lagarde M, Cheelo C, Chansa C, Palmer N. 2012. Health
worker perspectives on user fee removal in Zambia. Human
Resources for Health 10: 40.
Chatterjee P. 2006. India’s doctors protest over caste quota plans. The
Lancet 367: 1892.
Cook R. 2013. GPs contracting with the NDoH: the practice and the promise.
Presentation to the Child Health Priorities Conference, Johannesburg.
Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. 2009. The
health and health system of South Africa: historical roots of
current public health challenges. The Lancet 374: 817–34.
Doherty J, McIntyre D. 2013. Addressing the failings of public health
systems: should the private-sector be an instrument of choice?. In:
Surender R, Walker R (eds) Social Policy in a Developing World.
cheltenham: Elgar.
Grbich C. 2007. Qualitative Data analysis: An Introduction. London: Sage.
Homedes N, Ugalde A. 2005. Human resources: the Cinderella of health
sector reform in Latin America. Human Resources for Health 3: 1.
Kahn T. 2013a. ‘Province Health Vacancies for Doctors, Nurses,
Shocking’. www.bdlive.co.za/national /health/2013/01/17, accessed
25 January 2013.
Kahn T. 2013b. ‘Doubts in Soweto over NHI’. www.bdlive.co.za/national/
health/2013/03/06, accessed 18 October 2013.
Kahn T. 2014. ‘Doctors-Too-Greedy-for-Nhi-Says-Motsoaledi’. http://
www.bdlive.co.za/national/health/2014/03/06/, accessed 06 March
2014.
Klein R. 2001. The New Politics of the NHS. Harlow: Longman.
Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. 2012. Moving
towards universal health coverage: health insurance reforms in nine
developing countries in Africa and Asia. The Lancet 380: 933–43.
Le Grand J. 2003. Motivation, Agency and Public Policy: Of Knights and
Knaves, Pawns and Queens. Oxford: Oxford University Press.
Lipsky M. 1980. Street-Level Bureaucracy: Dilemmas of the Individual in
Public Services. New York: Russel Sage Foundation.
Loggerenberg D. 2013. ‘NHI: Economic Suicide for Doctors?’ News 24. http://
www.health24.com, accessed 05 July 2013.
Malan M. 2014. Motsoaledi Frenzy Over NHI. http://mg.co.za/article/201402-21-00-motsoaledi-frenzy-over-nhi, accessed 21 February 2014.
McIntyre D. 2010. National Health Insurance: Providing a vocabulary for
public engagement. South African Health Review, Durban, Health
Systems Trust.
McIntyre D. 2012. The political economy of the health industry and the
private health funding crisis. In: Reuters G, Van Niekerk R (eds).
THE DRIVE FOR UNIVERSAL HEALTHCARE IN SOUTH AFRICA
767
Universal Healthcare in Southern Africa. Scottsville: University of KwaZulu Natal Press.
Ruiters G, Van Niekerk R. 2012. Universal Healthcare in Southern Africa.
Scottsville: University of Kwa-Zulu Natal Press.
Minister of Health. 2012. ‘National Health Insurance: Presentation on
NHI Pilot Districts Selection’. www.doh.gov.za/docs/presentations/
2012/nhipilot.pdf.
Stark S, Torrance H. 2005. ‘Case study’. In: Somekh B, Lewin C (eds). Research
Methods in the Social Sciences. London: Sage Publications, pp. 33–40.
Mkokeli S. 2012. ‘ANC Plan to Grab Control of Top State Hospitals’.
bdlive.co.za/national/health/2012/12/28, accessed 25 January 2013.
Paim J, Travassos C, Almeida C, Bahia L, Macinko J. 2011. The Brazilian
health system: history, advances, and challenges. The Lancet 377:
1778–97.
Palmer N, Mills A. 2003. Classical versus relational approaches to
understanding controls on a contract with independent GPs in
South Africa. Health Economics 12: 1005–20.
Pretorius JC, South MS, Care NR. 2012. BHF ‘upset but undeterred
by Appeal Court ruling’. South African Medical Journal 102: 819–20.
PRICON Study. 2000. ‘New Purchaser/Provider Relationships in Primary Health
Care: The Desirability of Contracts Between Health Providers and Private
Providers. Cape Town: Centre for Health Policy, Univ. of
Witwatersrand and Health Economics Unit.
Reich MR. 1995. The politics of health sector reform in developing
countries: three cases of pharmaceutical policy. Health Policy 32: 47–77.
Rodwin. 2011. Conflicts of Interests and the Future of Medicine. Oxford:
OUPM.
Republic of South Africa (RSA), Department of Health (DoH). 2011.
National Health Insurance: Healthcare for all South Africans (Green
Paper), www.doh.gov.za, accessed 13 March 2013.
United Nations (UN). 2012. The Future We Want. http://un.org/doc/
N1243688.pdf.
Van Niekerk R. 2012. Revisiting History: the Creation of Provinces and
the Politics of Social Policy in a Democratic South Africa. Social
Policy and Administration, Vol. 46. No. 6.
Walt G, Gilson L. 1994. ‘Reforming the health sector in developing
countries: the central role of policy analysis’. Health Policy and
Planning 9: 353–70.
Watts J. 2000. Strikes continue in South Korea as doctors fight drug
reform. The Lancet 356: 1583.
Wild S. 2012. www.bdlive.co.za/articles/2012/07/06/doctors-will-get-nhipay.
World Bank. 2013. The Impact of Universal Coverage Schemes in the
Developing World: A Review of the Existing Evidence (UNICO
Studies Series 25). Washington DC: The World Bank.
World Health Organization (WHO). 2005. ‘Sustainable Health
Financing, Universal Coverage and Social Health Insurance’.
World Health Assembly Resolution 58.33. Geneva.
World Health Organization (WHO). 2011. National Health Account
Database. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS.
Yin RK. 1984. Case Study Research: Design and Methods. Beverley Hills: Sage
Publications.