Access to healthcare for all

This is the eighth edition of this weekly blog aimed at suggesting immediately implementable ideas to help South Africa and was posted to facebook on 20 September 2025.

Please send suggestions to suggestions@nationaldialogueblogsa.com

Our constitution and our humanity demand that everyone has access to healthcare.

Access means that it must be possible for you to reach it in time (so close by), that you don't then just wait and die in a queue when you get there and that you can afford it.

So - what can we a country afford?

What?

1)              The Government should contract with the largest medical funders and pay them to supply general practitioner (doctor) outpatient care for all citizens including a limited basket of tests and treatments.

2)              The government should rescind the current “prescribed minimum benefits rules” (PMB) which require full treatment (all tests and treatment options) for all members for a group of diseases. Implementing instead a more rational approach allowing funders to offer a number of packages which cover certain defined benefits – to suit different pockets.

3)              Government also needs to rescind the guaranteed insurability aspects of the current system – which makes it advantageous to young healthy people with no children to avoid contributing to med aid as they can join later with no penalty of they develop a chronic disease or have children. This undermines the cross subsidisation of healthcare.

4)              Government should make it mandatory that all employed people take an option of at least a private med aid “hospital plan” if they earn more than a certain amount. The option gradually increasing the higher the earnings.

Why?

1)              Most South Africans do not have their own transport and walk or rely on public transport. The cost, difficulty and time associated with getting to state doctors (based at hospitals) make it inaccessible to many. This causes people to present late when their illness is already severe or complicated. The barrier of distance also makes it difficult for people to keep visiting for check – ups of their chronic illnesses such as diabetes, HIV, high blood pressure - so that they tend to take their medicines off and on (again resulting in more severe problems).

2)               GP OUTPATIENT HEALTHCARE IS THE MOST COST EFFECTIVE AND IMPORTANT LEVEL OF CARE. There is no sense offering high-cost treatments for severe complicated problems that could have been prevented by low-cost simple treatments. Think stroke and high blood pressure, Diabetes and heart attack (or renal failure or gangrene), strep. throat and rheumatic fever, childhood gastro and death and HIV positive versus AIDS.

3)              We must find a way for private capital to pay to build “points of service” for low level care close to the people. Government does not have nearly enough clinics close enough to all communities and does not have enough money (CAPEX) to build them. The ONLY way that private capital will build facilities close to people is if that capital spend will be profitable.

4)              Most rural clinics do not have any doctors at all. Yet, we have one doctor for every 3000 people on average. If we deduct some who provide specialist hospital based care – that leaves for arguments sake say 1:4000. That means we should have roughly two doctors every square kilometre in Khayalitsha for example (which is one within 500m of every home or within 5 km in a rural area such as Swayimane in KZN).

5)              Given that the state will pay for an “outpatient medical aid” if this plan is instituted, doctors will borrow money from banks and build surgeries wherever people are (at their own expense and risk). Working for themselves, they will manage themselves and work hard and manage their own costs. They will naturally spread out to avoid competition – becoming the opposite of the “hospital-based” system we now have. This will cost government nothing and if the doctor makes an error and builds in an inconvenient spot and his/her practice fails – the loss will be his/hers alone. The criticism that poor areas are underserviced by private healthcare is ONLY because there is not medical aid cover for those people.

6)              Imagine how much more likely a patient would be to attend regularly for a check-up and to get their medications if they can see a doctor after a short walk and not have to pay a taxi fare, take off a whole day, sit in a queue of hundreds and see a different doctor every time.

7)              These doctors will have internet connectivity with funders and biometric identification – allowing patterns of attendance and diagnosis and treatment that will improve the continuity of care. This will also assist with potential fraud.

8)              They will also provide vaccination and check ups for children and pregnant women.

9)              For the 9 million people already receiving private healthcare, this will reduce the cost of their medical aid contribution – so an average R200 a month increase in their taxes will be budget neutral for them. The state will thus only need to find the budget for the circa R200 a month for the rest of the population from the existing DOH budget.

10)   Our private healthcare system has interlocking adversarial financial interests that work together to make it the most cost effective, excellent healthcare system in the world - there is no need to invent a new system. It is a GOOD thing that medical funders, doctors and hospitals are always arguing. It is that conflict that controls the cost and improves the quality. There is no need for the various new standard-checking entities such as OMRO and OHSC the department of health is now establishing. They are a massive waste of money which could be given to actually caring for sick people. In fact, the WHO specifically warns against just establishing more and more entities instead of actually fixing the problems.

11)   Our medical aid funders have world class technology for tracking disease trends, service provider patterns and for detecting fraud and over-servicing. Why not use them instead of creating a new fund from scratch as current NHI plans to do? The new fund will have no experience, no proven systems and even if it is built in the best possible way, will take decades to catch up to where our private funders already are. 

12)   Once again it is better if government is the ref and not a player and ref too. (No Ref will find that his own players are offside – so government does not hold its own hospitals to nearly the same standard as it does private hospitals).

13)   Catching diseases early and so preventing the complications of many conditions will ease the burden on state hospitals too, saving billions.

14)   The increase in the number of people having “hospital plans” (and being able to afford them because of the fact that government is covering their day-to-day GP costs) will further unburden state hospitals and will make the private funders more sustainable as more healthy young people will be members.

How?

1)              Government can talk to private healthcare funders, private general practitioner doctor groups and academic doctors and make up the list of benefits supplied of a “minimal GP outpatient medical aid”. Start with a budget of for example R200 per person per year and see what can be fitted into that. DO NOT start with a wish list and then see what it costs – the number resulting will be too large to afford.

2)              This must be a service for all South Africans for the following reasons: a) The extra administrative costs to exclude people who can afford medical aid is just wastage. b) As soon as some people can get a government service that others cannot, there is a door open for corruption. c) It is better that the people who have a voice in society also get the same service as the voiceless. d) All people on private medical aid are taxpayers in any event – so the extra cost of paying this small amount for them to get healthcare will ultimately come from their pockets in any event.

3)              Doctors will need to sign an agreement that will allow their practices to be inspected if their statistics imply over servicing.

4)              Doctors will agree to charge a minimum co-payment (of say R20 per visit) to 80 % of their patients. This will reduce the likelihood of patient driven over-servicing but still allow the doctor to charge no co - payment for truly indigent patients. Note that taxi fare to get to the “free at point-of-service care” currently offered by government is always more than R20 – so the R20 co-pay is cheaper.

Why Not?

1)              This will cost around R140b a year which will need to come out of the health budget.

True, but it will, however, improve the health of everyone far more than any other healthcare expenditure. In addition, as there are not currently general practitioners in areas where poor people live – as they could not make a living there in the past. It will take a few years for the obvious business opportunity that a large, underserviced community presents to be filled by our young (increasingly unemployed and emigrating) doctors – so the cost will not immediately be at that level – it will start low and grow to that level.

The cost of this GP level healthcare will no longer have to be carried by our state hospitals and clinics which should free up money to help pay for this.