This article was written by Mark Hayward and published in the Daily Maverick
Nicholas Crisp has been hanging around the health system in South Africa for a long time. After qualifying as a doctor in the 1980s, between 1994 and 1999 he worked as the head of the Limpopo health department. Later he was acting CEO of the National Health Laboratory Services (NHLS). But, like so many other health activists with ethics, he was blown out of the public health system during the disastrous reign of former health minister Dr Manto Tshabalala-Msimang between 1999 and 2008.
That was when the rot in SA’s health system really set in.
Since then, Crisp has worked a lucrative business as a private consultant, ironically often ministering to an ailing public sector. In the capacity of Mr Fix-It, his work has led him to poke his nose into almost every corner of the health system, most recently into the SA Health Products Regulatory Authority (SAHPRA).
“For me, there’s a solution to every problem. The joy of my life is trying to find them. And, in my experience, the people who work in the system often already have the solutions, they are just denied the opportunity to present them.”
So, one thing we can say about Crisp is that he has an intimate knowledge of the health system’s recesses, history and potential.
But today Crisp is a man on a new mission. He has been appointed by Health Minister Dr Zweli Mkhize as the head of the National Health Insurance (NHI) office. Now, even before the NHI Bill has passed Parliament, he has embarked on a plan to build the behemoth.
In the early hours of Thursday 15 August, just before Crisp was due to make a presentation to the National Health Council (NHC), Anso Thom and I, a duo of sceptical former health activists, lobbed questions at him during the winter of discontent.
To our surprise, his answers – and he has answers for everything – brought with them the feeling of spring.
Corruption: One of the main arguments of the NHI naysayers is that setting up a R500-billion fund in the aftermath of State Capture and the ongoing maths of Eskom, the SABC and every other state-owned honeypot, defies logic. In fact, it’s beyond absurd.
Paradoxically, Crisp thinks:
“Now is the best time to do it.”
He says while society is “still raw” and trying to staunch the open wounds of State Capture, “civil society is going to be super observant and never allow grand theft again”. This, combined with the “IT systems we can now set up using new technologies, give us much better systems to fraud-proof NHI”.
He announces that “right from the beginning we are setting up a fraud and anti-corruption unit” and that there will be zero-tolerance of theft.
He echoes his boss:
“There have to be consequences and we will fire people.”
But he is also “baffled” by the notion that corruption is a public sector problem. Referring first to the preliminary findings of the Health Market Inquiry (HMI), he talks about “massive, institutionalised, organised” fraud.
Here we agree. We may not call it theft but, over-servicing and what the HMI euphemistically calls “supply induced demand” is jimmying the system for private gain. To illustrate, he gives us an example his personal experience, recounting how a recent shoulder operation was going to be billed at R35,000 – “for three screws!” he exclaims. He challenged it and was offered an 80% discount by the medical technology company that provides the shoulder screws.
I couldn’t stop myself silently nodding. Every user of the private health system knows these practices are endemic. We pay profitable non-profit medical schemes to insure ourselves against catastrophic costs – not catastrophic disease. Unlike Crisp, few of us can challenge our exploitation because of what experts call the “asymmetry” of knowledge between provider and users in the health system.
And so, the costs add up.
Then the discussion on corruption segued conveniently into a discussion about private sector regulation and reform. I challenged Crisp on my fears that after the NHI Bill the recommendations of the Health Market Inquiry are likely to be overlooked. This, I said, would not only be a waste of R200-million, a huge amount of evidence and the best efforts of a group of experts. It would also be a missed opportunity for practical, tangible, immediate reforms.
Again, Crisp had a different take:
“The HMI has got to happen anyway,” and, he says, he identified “47 very tangible and manageable steps that will improve efficiency in the private sector. We will find each other,” he predicts confidently.
I asked him if he agrees that the HMI recommendations and the NHI Bill reflect different ideological approaches to the private sector and medical insurance in particular. The HMI leaves room for medical schemes but seeks to improve their governance, transparency, accountability and to end uncompetitive and collusive practices. The NHI, by contrast, reduces their role to nothing more than providing care over and above that funded by the NHI Fund, Big Brother.
Not so, says the pragmatist. The NHI Fund is only envisaged to come into operation from 2026. Between now and then the HMI reforms will be vital to improving quality, efficiency and cost-saving.
Let’s see, I thought.
And from here we turned into another corner of Can’t Do Street. It is a common refrain that despite the mantra of a “capable state”, the state we have is becoming increasingly incapable. This is as evident in the health sector as it is in basic education or at Eskom.
“None of the regulatory bodies works, so how can you build an uber-regulator?” I asked him, pointing to the Health Professions Council of SA (HPCSA), the Council for Medical Schemes (CMS), SAHPRA, and the NHLS, all of which have been corrupted and function sub-sub optimally.
Again, a riposte, although this time a little concession.
As mentioned, Crisp was recently tasked with fixing SAHPRA. This institution is vital for medicines regulation, safety, and investment in clinical trials. It has been in a deep, costly quagmire of incompetence for at least a decade.
Crisp says when he was sent to assist SAHPRA it had 200 people: 97 were clerical staff and only 100 had professional qualifications.
“So, my first job was to draw an organogram. We advertised 109 posts and got 7,100 applications. Many of the CVs were incredibly positive, including many coming from the private health sector, many of the people pissed off with the medical schemes environment.”
He tells us SAHPRA is now on an “irreversible positive trajectory.” (We can only hope he’s right).
The plan is that by January 2020 there will be 50 to 60 people in the NHI office and that people currently spread across disparate offices will converge and operate from one planning and coordinating centre. After the SAHPRA experience, he’s “not worried that we will find competent, capable people”.
“The challenge going forward is to insist on an ethos of service, and keep consistency in your leadership and succession planning,” something, Crisp laments, so far only the Western Cape health department has managed to do.
He had much more to say, some of it very revealing of the government’s intent, but after an hour Crisp had to leave us for his meeting with the NHC (a meeting of the minister, health MECs and directors-general). We were not yet converted, but at least we were questioning our questioning. We had heard another side of the story. If nothing else, Crisp convinced us of the need for an informed and evidence-based debate on NHI.
Perhaps now is the time to dream an impossible dream again. Perhaps now is the time for all the stakeholders in the health system to be neither no-can-do naysayers or sycophantic yay-sayers but engaged and independent activists prepared to put shoulder to the wheel and give NHI a chance.