Dr Nicholas Crisp was interviewed by MedBriefAfrica
“I am blessed to be an eternal optimist and a utilitarian. I would not have climbed into the bullring if I were not committed to NHI. Do we have all the answers? No. Do we have a clear and unequivocal blueprint? No. But we do have a plan, a clear vision and a lot of powerful global players praising us for embarking on this journey.”Nicholas Crisp
These are the words of Dr Nicholas Crisp, the man who has been appointed to one of the most challenging positions in the country’s healthcare system – that of developing and implementing the organisational capacity for the administration and operations of National Health Insurance (NHI). He took time out of his gruelling schedule to answer questions from MedBrief Africa co-editor, Marietjie van den Berg on why he believes that the NHI could be instrumental in changing South Africa’s healthcare system for the better.
Q: In short, what makes you believe that NHI will work in South Africa?
Nicholas Crisp: Why not? We are sitting on a time-bomb and I believe that if we leave the present arrangements unchanged the entire system will implode. Our problem is that we live in two worlds; one world of those that believe that we must compete with the most developed and expensive services in the world and those that aspire to share in that world created by those who own the privilege. The truth lies somewhere between the two and if we fail to improve the health (and education) outcomes of the nation the economy will never grow. NHI is not a magic bullet. It is also not the health system. It is a financing mechanism that seeks to redress imbalance, achieve social solidarity and ensure that nobody endures financial hardship because they become ill. In its published form, the NHI will indeed force essential systemic changes in the health system.
Q: You have worked in the state sector for many years before joining the private sector and are semi-retired. What made you decide to go back to the state sector to take up a position that is set to become one of the most challenging in the health sector?
Nicholas Crisp: Although I ran a private company, it was a public sector health specific consulting business. Through that business I worked exclusively in the public sector in Africa. So, my experiences are deeply seated in the public sector, although I do have an interest and the desire to see the public and the private sectors working more closely together to utilise the capacities of both to the full. I am more than willing to return to the public service to help establish the NHI because I believe that health is not a commodity to be traded but is a public good and that equitable access to healthcare is within our grasp if we manage the resources efficiently.
Q:You are in an environment where you have on one hand political spin on the NHI that is sounding more and more hollow because of the mistrust of people in both the public and private sector, and on the other hand, blazing criticism on the plan because of fears that it will further impact on the right to access rather than improving it? How do you deal with these two opposing sides and is there a middle way?
Nicholas Crisp: We need to recognise that there is mistrust between the public and private sectors but there is also huge expectation amongst the majority of the population that the government will indeed improve their access to healthcare and other basic human rights. Most of the criticism comes from parties who perceive that they stand to lose something through the implementation of NHI.
NHI may be seen by some to be a political intervention. However, it is the financing mechanism that has been chosen to achieve universal health coverage in South Africa. We have the dubious honour of being the most inequitable society in the world and it is extremely unlikely that fiddling with the edges of the current inequitable parallel systems will achieve the desired equity in access to healthcare.
I believe that there is a role for everyone, public and private, to improve efficiency and the effectiveness of our healthcare system and to achieve better outcomes for the investment that we make in delivering healthcare. I know that this will require ongoing and concerted effort to find common ground between all the many divergent interest groups. We have been known to overcome huge differences in the past and I need to believe that we can do it again.
Q: Can one be optimistic that the NHI will be implementable in seven years’ time, given the fact that since the plan was announced ten years ago, the public sector has deteriorated immensely instead of improving?
Nicholas Crisp: Frankly, I will be surprised if the NHI can be fully implemented in 7 years. Most countries take decades to implement reforms of this magnitude. I have no doubt that we will still be developing our health system in decades’ time. However, I am also convinced that in 5 to 7 years we can put the building blocks in place and develop the structure and operational requirements to deliver a more coordinated and integrated health system where services are purchased by a single common fund.
A significant contribution to the deterioration of the public sector commenced in the late 1980s, and I witnessed it while I was a regional director in that government. As the private sector was established and deregulated, and private hospitals mushroomed, the only place to secure staff was from the public sector, which was systematically eroded and has not been able to recover. This is not to say that there’s no room for dramatic improvement in the management in the public sector but I remain convinced that without better integration of the public and private sectors, and better utilisation of the total resources of the country, we will not achieve a sustainable health system for everyone.
The report on the NHI Pilots was not very conducive in convincing people that we are in fact on the right track. Do you think that the massive problems identified in the pilot districts could be rectified in the next few years?
The evaluation concluded that there were both successes and challenges during phase 1 of NHI implementation, and lessons learned must strengthen interventions in phase 2.
The main successes were increased coverage to new intervention services such as 4 339 875 learners screened through School Health Programme, and 504 803 of these referred for treatment; 330 GPs had been contracted; 3519 Ward-Based PHC Outreach teams WBPHCOTs established covering 12 816 152 households; 2 182 422 patients were enrolled for CCMDD and collecting medicines in over 855 Pick Up Points, 3167 clinics and community health centres; and 20 700 149 people were registered on the HPRS in 2968 PHC facilities.
The overall challenges experienced during NHI phase 1 included inadequate planning, lack of resources, inconsistent communication, silo implementation and lack of coordination where necessary and insufficient mechanisms to monitor progress to ensure course correction. The allocated budgets did not always follow priorities and at times led to the interventions going underfunded. The organisational culture was also perceived to be overly bureaucratic and often not supportive of problem solving and leaves little room for creativity or innovation.
Once the NHI Fund Office takes shape, and the functions of the Fund vs the Office are more clearly separated, it will be easier for each affected party to focus on building the proof-of-concept and roll-out of operations required to manage the system better.
Q: The Presidential Health Summit highlighted the massive problems in the public sector. Government is adamant that this will be fixed while the NHI is being rolled out. Surely, one can’t expect a system to work if it is not built yet, particularly when people’s health and lives are at stake?
Many of the problems in the public sector are structural and will require fundamentally different approaches to address them. The Health Compact lists key interventions in nine ‘pillars’. Given the serious budget constraints and poor performance of the economy, we may need to temper time-line expectations, but all the interventions are doable, and the relevant stakeholders have committed themselves to addressing them. Some of the targets have already been met and a monitoring and evaluation mechanism has also been convened to track progress.
The fundamentally different approach of NHI (purchaser/provider split) will steadily move the country away from the two-tier system that we have, and away from the present public sector budgeted system where health departments are both purchaser and provider. Strategic purchasing aims to create incentives to motivate providers to be more efficient and to deliver high-quality care, while also directing the population through the health system to use services in the most cost-effective way. It also increases purchasing power, owing to the huge volumes involved, thus driving unit costs down and freeing resources to provide more healthcare.
Effectively, public and private providers will compete for (and complement one another in) NHI funded work and the whole system will benefit from lower commodity prices. So, waiting to ‘fix’ the public system when there are no additional funds will not be smart. We need to free up funds to fix the system.
Q:The private sector’s buy in is key to making it happen. What is, and can be done (apart from promises), to ensure that they become involved?
Nicholas Crisp: Change is always difficult, especially if it affects us personally. And there is no getting away from the fact that the reforms on the table will result in big changes. With or without NHI as a financing mechanism the private sector is going to be regulated far more tightly from now on. The HMI report should be seen as an embarrassment by all role-players in healthcare.
The question should not be ‘what will I lose’ but ‘what will the country gain’ from a reformed health system? There is global evidence that “Better health is central to human happiness and well-being. It also makes an important contribution to economic progress, as healthy populations live longer, are more productive, and save more.” (WHO) We cannot justify spending 8,4% of our GDP on healthcare and achieving the poor outcomes that we do relative to our economic peers.
My personal hope is that colleagues recognise the need to work together to build better health services with better outcomes and a healthier population. There are several forums for engagement and all professional associations are welcome to engage will the reforms at every level, not in the hope of protecting the status quo, but in the spirit of finding optimal home-grown solutions that will benefit everyone.
The HMI report came out after the NHI Bill. Can the recommendations still be accommodated in the Bill, and according to you, what are the most important recommendations that will ensure that the private sector becomes part of this envisaged single health system?
The Department of Health is in a process of aligning the recommendations of the HMI with the NHI Bill but will reserve comment until the Bill has been adopted as law by Parliament. Parties that wish to submit comments from the HMI recommendations to Parliament for consideration in the development of the Bill are encouraged to do so.
In the coming phase of building the NHI Fund, operational capacity to manage its functions, including accrediting providers, developing the benefits framework and prices, registering users and registering referral pathways (to name a few), the private sector will continue to play its current role. The more the deficits of the private sector are addressed in this period, the more it may influence the role the sector will play in the reformed health system.
Although we are seeing promising steps (such as the establishment of the Health Anti-corruption Forum) to prevent the fund from being subjected to the massive looting and corruption in state departments and SOEs, the damage has been done to the reputation of the fund even before it has been set up. What do you say to people to convince them that it is going to be different?
As a citizen and taxpayer, I can only share the outrage that we experience as we watch the unfolding exposure of the State Capture and other processes. I am also encouraged by recent reports of action and of court rulings that show that things are being done to address the past plunder. I returned to the health system from planned early retirement because it’s easy to sit on the sidelines and complain, but it’s important to get in the bullring and play if you want your complaints to be taken seriously.
The NHI Fund (as an entity) needs every mechanism to prevent, manage and deal with corruption and fraud. This starts with systems design, including smart digital technology, thorough and ongoing risk assessment, built in warning flags, protected whistle-blower mechanisms, immediate response and investigation, dedicated legal support, limited exposure, clear checks and balances in every operating procedure, transparent reporting, not only by the Auditor General but by the Fund, and the support of all of the agencies in the Health Anti-corruption Forum to investigate and secure conviction when necessary.
The Fund will start small, with dedicated and limited payments being made initially. Only once benefits are designed, costed and published with their prices can shifts in functions and funding happen. This is a complex process and will be managed together with the provincial health departments, National Treasury, and with inputs from the FFC and other players.
Q: Government keeps on skirting around the funding issues and what services will be paid for. In the light of the country’s economic crisis and the endemic underfunding of healthcare services. How will this fund just miraculously find the funding and can private money from the funding industry be diverted to this fund?
Nicholas Crisp: This is a lengthy discussion with many ifs and buts. The starting point is that the country spends about 8,5% of GDP on health. Just under half is paid directly from taxes through budget allocations to organs of state (mostly provincial departments of health but also Correctional Services, military, municipalities and the national department). Citizens and others in the country spend a similar amount to purchase services privately (mostly pre-financing through medical schemes, but also significantly out of pocket cash). Both sectors are failing. The public sector can’t cope with the sheer volume of work and the private sector has begun to price itself into extinction. Together the systems have failed to achieve a situation where the public are protected from catastrophic disaster due to ill-health, and access to services is as inequitable as it was pre 1994. The NHI is predicated on the principles of social solidarity and equity (large single pooled fund to spread risk through formulae-based allocation and strategic purchasing). How to do this is complex and will evolve over time.
The challenge is how to effect the redistribution without eroding services. And this is where additional funds arise. If new money is added to the pool, then there is less need to ‘shift’ resources in the existing pool. However, there is a lot of room to shift resources! There is waste in both public and private sectors and it is the elimination of waste that will reduce the need for new funds. At the same time there are some service deficiencies where new funds are needed.
In times of economic abundance new funds are more available and many changes can be effected simultaneously in a short timeframe. The corollary is true, and that is where we find ourselves. So, the simple truth is that less change is possible now than was hoped for. This means that the NHI Fund will be able to procure a more constrained set of benefits initially. It does not change any of the imperatives to improve the public sector services and to regulate the private sector appropriately in the coming five or six years. The R30m that is mentioned is to introduce a set of additional services that are designed to reduce inequitable access for the poor.
As far as the source of funds is concerned, S48 of the NHI Bill describes a range of sources but the bulk of NHI funds will come from tax via the fiscus (national revenue account) in an annual allocation approved by Parliament. (Cash is usually drawn down weekly.) Money matters are the function of national Treasury and the Minister of Finance. Although the Bill raises the possibility of a payroll tax (remembering that voluntary contributions to medical aids that the employed public have become used to will largely disappear), the decision as to how to raise the money for health services rests with the Minister of Finance using the laws that s/he administers.
Theoretically, the NHI Fund can be implemented with no additional funds but that will severely curtail the ability to use the money lever to reshape health care delivery.
Private medical schemes will be impacted as benefits are designated and they are disallowed from providing cover for that growing list. Medical scheme contributions are not anticipated to decrease. On the contrary, by their very nature, the cost of belonging to a medical scheme will continue to rise.
Private money from the funding industry will not be “diverted to this fund”. What is likely to happen is that members of medical schemes will reach a point in each of their budgets where belonging to a scheme is no more beneficial than being cared for by the NHI Fund and they will migrate to the NHI Fund’s accredited providers, and their care be paid for from the Fund. As investment decreases on private voluntary contributions, some increased investment will be needed from tax. How and when that happens, and what mechanisms the Treasury chooses to use to raise the deficit, will be moot until the tipping point is reached. If medical schemes and private providers implement the HMI recommendations, schemes become more transparent, members have real (understandable) choice, etc. then this will be a far smoother transition.
Q: According to the NHI Bill, medical schemes will basically become redundant when the NHI is fully operational. Your opinion about this and what do you think schemes should do in the meantime to ensure that they remain relevant?
Nicholas Crisp: In the coming five to seven years, the entire private sector needs to heed the HMI report and clean up.. The intention is that medical schemes will provide ‘top-up cover’ (or insure the costs of services not covered by the NHI Fund benefits). Schemes belong to members and are not-for-profit entities, so they need to re-examine how they pay for the healthcare of their members more efficiently and effectively. This could mean amalgamating, reducing package options and creating bigger risk pools, etc. I think that there will always be demand for services that the NHI Fund would either not regard as contributing to improved health outcome (like aesthetics and cosmetic surgery), or cannot afford to cover, so sets limits in the standard treatment guidelines (such as age cut-offs for certain procedures and treatments, as is the case already in the public sector). There will also be health technology that is adjudicated to add no benefit, but which some patients may ‘demand’ despite there being no ‘need’.
Medical schemes will no doubt change shape, probably radically over the next ten years, but I doubt that they will disappear.
Q: One of your tasks will be to establish the NHI Fund office. How big will this office be, what will you require of the staff you bring into this office and do you think you will be able to recruit the necessary expertise?
Nicholas Crisp: The design of the office to support all the statutory functions (NHI Bill, PFMA and other relevant laws), including support to all the many committees envisaged, is close to 400 positions. This does not include any regional, district or other peripheral capacity since that is still too distant to anticipate and will be dovetailed with existing provincial functions and capacity wherever possible.
Almost half of these positions will be filled from staff employed in the National Department of Health, either as public servants or on contract positions, where they have been developing NHI systems for some time. There are also some staff of other agencies that may be seconded to the putative office. Finally, there are key skills and competencies that do not exist amongst current employees and those posts will be filled through open advertisement as and when budget allows.
The final office can only be established when the Bill is enacted, and the provisions of the law are clear.
The people who are recruited to this office will need to be able to think very differently from the usual public service rules-based approach. So much will be new that each person will need to think on the spot, be creative and work in a team to find appropriate solutions. Above all, absolute honesty and integrity are required. Public scrutiny will be acute and relentless, and the public will be anxious to see that their tax is spent and accounted for absolutely transparently.
So far, I have been approached at many events and talks by professionals who have come forward and asked to be given an opportunity to join the NHI Fund team. The CVs of these people give me great hope for NHI.
The NHI Fund is not the health service. We need every healthcare provider, public and private to adopt the same commitment to service, and to demonstrate caring, before we can expect the health outcomes that we should be achieving in the country.
I am absolutely convinced that maintaining the status quo will be a disaster and that major reform is essential. There is no doubt in my mind that universal health coverage is not negotiable. And universal means relating to or done by all people in an equitable manner. How will we reduce the ‘massive burden of disease’ if we do not reform the healthcare system? And how will we reduce the ‘huge shortages of healthcare providers’ if we do not utilise what we have efficiently and effectively instead of the current wasteful system?
Mark Banfield is an independent consulting providing services to the Health Technology Sector.