31 July 2019: South Africa: Scenario planner and strategist, Chantell Ilbury, presented the results from the Healthcare Scenario Planning 2030, which outlined a range of possible outcomes of the implementation of the National Health Insurance (NHI). These scenario outcomes range from successful implementation of the NHI which translates to universal and affordable access to healthcare to all South Africans, to a complete failure of the NHI driven mainly by distrust, poor leadership and discord between private and public health institutions on the other extreme.

The healthcare scenario planning results were presented to delegates at the 20th annual BHF Conference, highlighting common denominator strategies that would be successful under various scenarios.

Forty-four healthcare industry players participated in the scenario mapping and these comprised of funders, national and provisional governments, municipalities, clinics, hospitals, healthcare providers, service providers, regulators, associations and coordinating bodies, political players, patients, academic and training structures, and other players like private hospitals, the Competition Commission, unions and the media.

“Various stakeholders in the sector have their own views about the NHI, which over the last few years has been an uncertain arena for the healthcare sector. Stakeholders in the healthcare sector required details of how it will look and how it will be funded. The healthcare industry conducted this scenario planning in order to get a sense of the possible outcomes of implementing the NHI, considering the various agendas arising from the multiplicity of players in the healthcare space. It is important that we needed to have frank conversations and understand all the dynamics that may shape and influence different outcomes. This is what this exercise sought to achieve,” said Ilbury.

She pointed out that the scenario planning exercise considered the state of healthcare in 2030 as it was close enough to enable an understanding of what changes would have to take place in order to produce an effective, optimised, well-run healthcare system.

Following extensive discussions and deliberations, the following healthcare scenarios were mapped out:

Scenario 1: Clean Bill of Health: In this scenario the doctor is competent, the treatment is solid, the patient follows their advice, and a clean bill of health emerges. This is the best-case scenario. It is based on the fact that if healthcare sector cohesion and positive government leadership are both present, then clear regulatory guidance, combined with collaboration in the sector, will result in a level playing field, a clear path to growth and access to quality, affordable healthcare. In this scenario, the NHI rollout is successful, with provision for the role of private funders.

Scenario 2: Non-adherence: In this scenario the doctor dispenses good medical advice but the patient either ignores it or looks for alternative therapies. In this scenario, despite positive leadership by senior government, key players within the industry still find little ground for agreement and collaboration. A protectionist mindset throws down stumbling blocks in the path of clear developmental initiatives provided by the government. As a result, healthcare provision is patchy, and the sector flounders overall. The NHI is driven by the state and little provision is made for private healthcare funders.

Scenario 3: Waiting Room: This scenario describes a patient who has an idea of what is wrong and has done all they can to alleviate their plight but are now waiting for the necessary authorisation to get help. What this means is that the key players in the healthcare sector are collaborating but successful implementation is scuppered by a lack of government leadership. There are pockets of excellence within a sector that is otherwise characterised by poor delivery. The NHI rollout stumbles and private healthcare picks up the ball 

Scenario 4: ICU: This is a description of a dire outcome where the patient is kept alive by the occasional input of intensive resources. There is some hope of recovery but the serious nature of their condition means that another nasty event could be fatal. This is the worst-case scenario where there is an ongoing failure by government to provide positive leadership. At the same time, there is discord between private and public healthcare providers. There is little hope of growth and the players distrust each other, resulting in a highly unequal provision of healthcare.

In the ICU scenario, the rollout of NHI is mired in mismanagement because the necessary support resources are not in place. The NHI is beset with scandals involving hundreds of millions of rands that are unaccounted for, and it applies to Treasury for a bailout. Ongoing failure by the ruling party to provide the framework for equitable healthcare has become the catalyst for dramatic political change.

The EFF is now in power and is unapologetically pushing for an urgent, completely socialised healthcare system with no place for private healthcare players. This triggers a flight by healthcare providers. There is medical aid attrition, drugs have become increasingly unaffordable, and out-of-pocket expenses are skyrocketing. With no clear and realistic vision from government and with growing discord between players in the healthcare sector, the sector is being kept alive by the inputs of specialised pockets of wardship. In this scenario, a complete collapse of the healthcare sector is unavoidable.

Ilbury said the feeling amongst most participants is that the healthcare sector is sitting in ICU, which is an unsustainable scenario in a population where most people don’t have access to quality healthcare. 

“What you have heard in this conference and what you will continue to hear is, how do we move to a clean bill of health that results in a win-win situation?”, she explained.

The process for thinking to the future includes developing an awareness of the context, scope and key players; intelligence, which amounts to gathering information relevant to healthcare such as the politics, economics and demographics of the country; synthesising the scenarios; decision making which takes into consideration what participants in the sector need to do to ensure that they reach the best scenario; and reflection, which also includes putting measurable goals in place.

“Relative to the population, there are only about 80% of South Africans who have medical cover. The South African healthcare sector is not a healthy sector and if you really look at it as a high-level strategic sector, it is a tale of two health ecosystems – the public and private healthcare ones.

“There is also a trust deficit in the sector. Healthcare is an emotive issue and when you get to decision-making, you start to get to protectionism and barriers to opening up to tough decisions that have to be made. The end-user has questions regarding the value of medical aid schemes or funders. We are in a period with large levels of uncertainty and because of that, we have insurance coming into play to plug the gaps in terms of the healthcare cost. We end up having many players who don’t trust each other so collaboration is difficult and will have to be a conscious decision going forward. The NHI becomes a vehicle to bring together the private and public sectors,” says Ilbury.

Dr Ntuthuko Bhengu, Commissioner: SA National Planning Commission, concurred with the notion that the healthcare system is in ICU. “It is characterised by limited access to healthcare services. One can argue that there is a lot that government can do to ensure that we are going to a better place, including dealing with corruption. It is not so much that policies do not exist. We have to acknowledge that the private sector itself is too expensive for South Africa. We have to look at the reasons for this and then it comes down to how we manage it.”

He cited largely preventable factors such as fraud, waste and abuse, as well as high rates of medical-legal litigation as major cost drivers in healthcare.

He also highlighted the fact that one of the key concerns is that South Africans are still unsure of the details about what the NHI entails and how it is going to be funded.

It is hoped that the scenarios will stimulate further debate and accelerate alignment in the healthcare sector as South Africa progresses towards universal health coverage. 

Participants in Scenario Planning 2030 included BHF, managed care organisations, the Health Professions Council of South Africa (HPCSA), insured and uninsured patients, public and private hospitals, The South African Nursing Council (SANC), funders, medical practitioners, South African Pharmacy Council (SAPC), health researchers, government, GEMS, emergency medical services, the Allied Health Professions Council of South Africa (AHPCSA), academia, National Department of Health, pharmacists, Hospital Association of South Africa (HASA), medical training facilities, regulators, the Minister of Health, pathologists, South African Medical Association (SAMA), the South African Reserve Bank, associations and coordinating bodies, The Office of the Presidency, Office of Health Standards Compliance (OHSC), South African National AIDS Council (SANAC), employer groups, political players, National Treasury, South African Health Products Regulatory Authority (SAHPRA), Parliament, business organisations, provincial departments of health, Council for Medical Schemes (CMS), TriPartite Alliance (ANC, SACP and COSATU), donor organisations (for example PEPFAR), municipalities, Financial Services Conduct Authority (FSCA), opposition parties, brokers, Competition Commission, unions, media and other entities.