Blink and you’d have missed it, so brief was the mention of the healthcare budget in finance minister Enoch Godongwana’s inaugural budget speech.

I had wondered whether two years into a global pandemic that has changed the world fundamentally and made SA’s existing challenges more acute, we would see any drastic re-prioritisation or re-budgeting from the National Treasury.

But look a little closer at the “fine print” of the full national budget document, and you’ll see that National Health Insurance (NHI) remains a central priority for the health department. However, so too is fiscal responsibility for the National Treasury, which the finance minister reiterated this week.

So, how does a country with a debt-to-GDP ratio of almost 70%, which has just received international funding from the World Bank to the tune of $750m (about R11.3bn), and also has an official unemployment rate of almost 35%, give life to something as ambitious (and expensive) as the NHI? The answer is step by step, milestone by milestone, and budget by budget.

Though it was not addressed in the minister’s speech, the step-by-step approach to NHI was evident in the full 1,000-plus page documentation supporting the budget. The health budget contained within has a dedicated section explaining the government’s phased implementation of NHI, outlining an R8.8bn allocation to fund NHI-related activities and programmes over the medium term.

Activities include the department of health undertaking to strengthen and improve the public health system and infrastructure.  More than R270m of the funding has been allocated to proof-of-concept contracting primary care units through capitation arrangements, a new development.

The department’s centralised chronic medicine dispensing and distribution programme is an established part of the improvement activities and is going from strength to strength. In 2018/2019, the programme served 2.6-million patients, but just three years later this has almost doubled to 4.6-million patients in 2020/2021 (a 77% increase in patient numbers in just three years).

Projections in the detailed budget documents indicate the programme intends to reach 6-million patients through the programme by 2024/2025. The programme, which the health budget cites as an NHI project, is a good example of the joint use of public and private sector strengths to deliver healthcare to South Africans.

To bring chronic medication to a large number of public sector patients the department of health has contracted the private sector, which has the logistical capabilities to deliver medicine to even rural distribution points, and in some cases to a patient’s door. A remarkable achievement though partnership.

The worthy promise of NHI lies in its potential to address the inequitable access to healthcare that plagues the country, a result of a confluence of factors that built on past inequality. Yet as economists always say, there is no such thing as a free lunch, and unfortunately there is no such thing as free healthcare, either.

Care in the NHI may be free at the first point of service, but the cost will need to be borne. A fiscally responsible approach is necessary to realise this dream, and the truth is that NHI implementation will need to keep pace with SA’s economic context. Budget allocations made as NHI implementation progresses will be a fine balancing act to ensure optimal and net overall economic benefit.

It was heartening to me to note in this budget that the NHI grants for healthcare revitalisation and strengthening projects are continuing and that were no surprises. Budget allocations made as NHI implementation progresses will be a fine balancing act to ensure optimal and net overall economic benefit.

The government is steadily working towards realising its NHI dreams through steadily working towards removing barriers to NHI implementation.  The progressive realisation of a comprehensive, yet fiscally responsible, system of NHI will benefit all South Africans.

This is an ambitious task that will require astute management throughout in a country as fiscally strained as SA. But we certainly have started this journey, and the private healthcare sector is poised to assist.

• Banderker is CEO of AfroCentric Group, one of SA’s largest listed health companies and owner of Medscheme, SA’s largest medical scheme administrator.

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