MALAIKA MAHLATSI: How surgery in a private hospital deepened my support for NHI
As I sat in my comfortable hospital room post-surgery, having a delicious lunch of ham and cheese sandwiches with rooibos tea and a slice of cheesecake, I couldn’t help but reflect on how such a privilege is accorded to only a few, writes Malaika Mahlatsi.
While the quality of healthcare in the private sector is exceptional, it is unaffordable for most people, including medical aid members. Picture: Pexels
On 20 October, I flew to South Africa from Germany, where I emigrated a few months ago, to seek medical treatment.
While Germany provides universal primary healthcare to all residents, it is faced with challenges not too dissimilar to those faced by the United Kingdom’s National Health Service (NHS) - the service in the UK paid for by the government that provides free medical treatment for all residents.
The most salient of these problems include a shortage of healthcare professionals and a huge backlog for specialised services.
According to a BMA analysis of NHS England Consultant-led Referral to Treatment Waiting Times statistics, which was last updated in October 2023, there are 7.7 million people awaiting treatment, with nearly 3.25 million of these patients waiting for over four months.
Over 400,000 of these people have been awaiting treatment for over a year.
For serious illnesses such as cancer, the waiting times have increased post-pandemic.
The healthcare system in Germany too is not without its problems. For one thing, the workload per nursing staff is significantly higher than in other comparable countries.
By international comparison, a disproportionally high number of treatments take place in the inpatient instead of the outpatient sector, leading to a high workload for hospital staff. Additionally, the German healthcare system is known for its low level of digitisation by international standards, as well as inadequate technical equipment for the local health authorities.
A 2021 study by Christine Arentz and Ines Läufer argues that in the area of local health authorities, the financially responsible federal states have neglected the staffing and material equipment for years.
For this and other reasons, securing an appointment with a specialist in Germany is a Herculean task.
Over the last three months, I have been slowly losing my sight in the right eye – a disaster I couldn’t afford as I have just started my doctoral studies.
But upon my arrival in South Africa, I was able to secure an appointment with an ophthalmologist at the Pretoria Eye Institute, Dr Hamza Tayob, within three days.
Following a very severe diagnosis of retinal detachment, Dr Tayob determined that I needed to go into surgery within a week. Having cancelled my medical aid when I left South Africa, I had to come up with over R120,000 within 48 hours in order to secure my hospital booking and the two specialists who were to treat me – an ophthalmologist and an anesthesiologist.
With the support of loved ones, I was able to secure the money.
On 1 November, I was admitted to the Pretoria Eye Institute, where I received exceptional medical treatment. (My one eye is still bandaged as I write this article).
One might wonder why I did not go to a public hospital. The answer is simple – I would have gone completely blind by the time a specialist was able to attend to me.
Just over a year ago, the Gauteng Province recorded an official backlog of just under 14,000 people for cataract surgery.
Cataract surgery was one of two surgeries that had to be simultaneously performed on me – the other being posterior vitrectomy, including anterior vitrectomy.
According to the Gauteng Department of Health, the waiting times for eye surgeries are variable, with the longest being two years at Mamelodi Hospital, 22 months at Sebokeng Hospital, and 18 months at the Chris Hani and George Mukhari hospitals.
But this is not just a Gauteng problem.
The Western Cape Province has some of South Africa’s best performing hospitals dealing with eye conditions. At Eerste River Hospital, approximately 2,500 cataract surgeries are conducted annually – far higher than at any hospital in the country. And yet, sometimes patients must wait for up to two years or longer for the operation.
As of July 2022, the two biggest hospitals in the Western Cape, Tygerberg and Groote Schuur, had a collective cataract surgery backlog of nearly 4,000 people. I mention the Western Cape and Gauteng specifically because the two provinces not only have the highest eye surgery backlogs in the country, but they also have the highest number of ophthalmologists.
And so, if provinces that have high numbers of ophthalmologists have waiting times of two years, there’s no question that the situation is dire in other provinces, and that I was not going to receive the help I desperately needed in time to save my vision.
As I sat in my comfortable hospital room post-surgery, having a delicious lunch of ham and cheese sandwiches with rooibos tea and a slice of cheesecake, I couldn’t help but reflect on how such a privilege is accorded to only a few.
There are not many people in our country who can pay hundreds of thousands of rands to access healthcare in private facilities such as the Pretoria Eye Institute. It is simply inaccessible for the majority.
The number of South Africans who are covered by medical aid has been declining over the years and currently sits at just under 16%.
As incomes decline and inflation rises, many people have opted out of comprehensive medical cover and are using basic cover that has many exclusions. Such cover also requires high co-payments from people who often do not have disposable income.
It is also important to note that only 9.9% of Black people are covered by a medical health scheme. This means that most people in our country rely on the public healthcare system which is in a state of deterioration.
Despite the government’s increasing spending in public healthcare, the sector has been in a state of crisis for many years. A copious amount of research has been done on the subject, and while many factors have been identified as causes for the poor state of South Africa’s health system, the three that stand out are: population growth that has outstripped investment into new hospitals; poor infrastructure maintenance and planning; and corruption.
Another issue that has been raised in some research is the lack of synchronicity between departments. For example, the budget for the maintenance and development of new healthcare facilities sits with the Department of Public Works, which is responsible for the maintenance and construction of public facilities and infrastructure.
The implication is that when hospitals and clinics have maintenance challenges, the Department of Health must first engage with the Department of Public Works before any repairs can be undertaken. This not only delays the time it takes to facilitate repairs and maintenance, but it is also costly.
In response to the challenges of healthcare access, the government has proposed the National Health Insurance (NHI), an instrument to achieve universal health coverage.
The NHI aims to ensure that all residents of South Africa have access to quality healthcare services. Additionally, the bill also aims to provide for the establishment of a fund that will be used to pay for almost all medical treatments from accredited providers.
The NHI will establish a single pool of healthcare funding for private and public providers. Although the NHI bill was recently passed in Parliament, there have been a lot of legal challenges to it, and not everyone agrees with its implementation.
The position of medical aid providers is clear – they would be losing clients, and will not be able to offer any services that are offered by the NHI.
But for individuals, particularly the middle class and the wealthy, the concerns are more complex. For one thing, South Africans within a certain income bracket will have to make mandatory monthly payments towards healthcare in addition to carrying a higher tax burden.
The NHI Bill also has a number of grey areas on very important aspects, including the establishment and financing of the fund, and the structure of the contracting unit for primary healthcare needs.
But none of these challenges supersede the necessity of having universal healthcare access to all South Africans, regardless of their socio-economic background.
Most people do not realise that private healthcare receives a similar amount of funding as public healthcare, despite the fact that it caters to only the 16% of the population.
And while the quality of healthcare in the private sector is exceptional, as I experienced at the Pretoria Eye Institute and had experienced even prior to my emigration, it is unaffordable for most people, including medical aid members who, as explained, cannot afford comprehensive coverage.
The implication is that while public hospitals are over-burdened, private hospitals are under-utilised, which is why I could get an appointment for eye surgery within days of my first consultation, while thousands of South Africans using public healthcare must wait for 18 months to over two years.
The NHI will improve the resourcing of public hospitals and healthcare services, as the burden of care will be more evenly distributed. In so doing, the NHI will guarantee South African residents’ access to affordable quality healthcare.
Access to healthcare is not only about health, but also about the economy. Those who argue that the NHI will cost taxpayers a lot of money do not seem to appreciate that low-quality healthcare is not only increasing the burden of illness and health costs but is also impeding our country’s prospects for economic growth and development.
The causes of poor health for millions of South Africans are rooted in political, social, economic, and spatial injustices. Thus, poverty is both a cause and a consequence of poor health, as poverty increases the chances of poor health, and poor health, in turn, traps communities in poverty.
While Germany and the UK are evidence that a national health system or instance will not be without challenges, we must not give up on the idea of implementing the NHI in South Africa.
It’s the only way we will equalise healthcare access and provision for all – and this is a noble pursuit that gives practical demonstration to our commitment to equality and dignity for all.
Malaika is a geographer and researcher at the Institute for Pan African Thought and Conversation. She is a Ph.D. candidate at the University of Bayreuth, Germany.