Medical aids’ worst nightmare

Brace yourself for a complete overhaul of Botswana’s healthcare system. The proposed launch of Universal Health Insurance Plan and the National Mandatory Health Insurance will upend health provision as it currently is. No more would access to high quality health care be a privilege for few. The World Health Organisation (WHO) defines Universal Health Coverage as where “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care”. 

President Duma Boko announced in the 2024 State of the Nation Address (SONA) on Tuesday that he would be bringing to end the division and discrimination in provision of health services by setting up the universal health insurance Plan. As a socialist and staunch human rights lawyer, Boko is doing simply what comes naturally to him – people first. But beyond that, he is fulfilling a critical Sustainable Development Goal 3.8 which requires countries to have delivered universal health coverage by 2030. WHO has already decried that the world is lagging far behind in terms of meeting this target. It declared in 2023 that: “The UHC service coverage index increased from 45 to 68 between 2000 and 2021. However, recent progress in increasing coverage has slowed compared to pre-2015 gains, rising only 3 index points between 2015 and 2021 and showing no change since 2019”. 

According to WHO, some 4.5 billion people were not having universal health coverage in 2021. 

BOTSWANA’S HEALTH SERVICE APPLAUDED 

Even as WHO is concerned about the world’s slow pace of providing improved health services and coverage, its regional directors’ sentiments about Botswana are positive. At the WHO Africa regional committee meeting hosted in Botswana last year, Dr Jean Kaseya, head of the Africa Centres for Disease Control and Prevention (Africa CDC), praised the country, saying it was an example for the rest of the continent in health provision to its citizens.

He lauded Botswana for ensuring that its citizens were able to have “access to all the healthcare that they need” at a negligible fee. 

Dr Matshidiso Moeti, WHO Africa Regional Director, originally from Botswana, has equally glorified the country’s health system. “With a minimal nominal contribution, people have access to everything that is available in the country and transferred outside of it [for other treatment]. It is an example of how to make sure that payments are not a burden to the customer. I’m very proud of this. We could take many examples and I’ll just cite a couple. For example, the mother-to-child transmission of HIV has been reduced to less than 5%, and Botswana has been the first high-burden country in the world to achieve this milestone,” said Dr. Moeti (healthpolicy-watch. news). 

Every village in Botswana has a health service manned by a qualified medical doctor and a dedicated team; with the country’s majority of the annual budget mostly going towards health and education provision. 

CHALLENGES 

While health infrastructure has been well spread out and equipped with adequate human resource, challenges remain. That very infrastructure is now getting worn out – needing urgent repair and maintenance. The quality of service has become an increasing concern for locals, particularly as there is serious shortage of qualified personnel in many areas. Therefore, citizens with access to medical aid exclusively

prefer to be served by private practitioners; leaving out the unemployed, poor and the elderly to settle for the poor service in public hospitals and clinics. 

In their research paper, “Assessing performance of Botswana’s public hospital system: the use of the World Health Organisation Health System Performance Assessment Framework” Onalenna Seitio-Kgokgwe , Robin DC Gauld , Philip C Hill & Pauline Barnett (2014) presented a worrying picture of degenerating infrastructure, shortage of equipment and general poor service in the public health service. 

Setilo-Kgokgwe et al 2014 in their research work published by the National Library of Medicine quoted one respondent from their survey declaring – “Our hospitals do not have resources and there is shortage of medical doctors. It is possible to be booked to see a doctor after three months, when you come you are told he/she is not available because he is alone. You find one doctor helping so many patients, or you are told he/she is still out to help other patients while your own illness progresses and finally you give up and go home without assistance”. 

Shortage of key personnel in the country’s hospitals increased after the Covid-19 epidemic as nurses in particular sought greener pastures in the United Kingdom, leaving most hospitals running short of staff. They chose to migrate in protest against poor salaries and uninspiring working conditions. The remaining staff have been so overstretched that cases of negligence have grown. 

Nurses have also flatly refused to do pharmacists work – functions that they had always performed before – insisting that they need adequate compensation for it. They insist that otherwise Government should recruit and hire qualified pharmacists for the job. 

The poor supply and distribution of key chronic medicine also became a big issue in the past year; leading in some instances to needless loss of precious lives. The level of medicine supplies in public health institutions remains a key concern. 

MEDICAL AIDS 

Botswana boosts of four medical aid schemes – Bomaid, Pula, BPOMAS, and Momentum – which are run through member subscriptions. Members are mostly employees of private and public organisations who pay for their medical cover and their dependents. Members access the best local service from private doctors and can be easily ferried or flown from accident scenes to hospitals, including qualifying for service in hospitals outside the country. 

Medical aid operators have faced their own criticism. They are seen as being expensive, often imposing annual increments without considering cash backs for those who would not have used their services though paying subscriptions for many years. 

They are accused of being difficult for their members in times of great need. With caps on the limit of amounts one can claim for serious medical treatments, it means that their members are left without treatment when they desperately need it. 

The medical aids schemes have faced accusation of indulging in anti-competitive behaviour because they regulate their own prices and are actively involved in the market, selling their services. The Competition and Consumer Authority (CCA) has launched investigations against BOMAID for alleged anti-competitive practices after failed attempts by the medical aid scheme to block such investigation. 

In overall, the medical aid schemes have similarly gained traction and reported growing profits while complaints have remained about the service they render. 

IMPORTANCE OF UNVERSAL HEALTH INSURANCE PLAN 

It is still early days to pre-empt what the new government’s Universal Health Insurance Plan would look like but it is necessary to look at jurisdictions where it has been launched to provide a general outlook of what locals should brace for. Among the countries that are running a viable health insurance plan is the United Kingdom. Neighbours South Africa have just signed it into law though it is still facing stiff resistance. 

Countries pursue this to primarily address the problem of inequality in access to health care services. And it is anticipated that this is what Boko’s Government is trying to address – to fully resource the sector; get sufficient and well-maintained infrastructure; set up well functioning medicine distributing models; pay health providers sufficiently to ensure high quality service, cutting out on negligence that has become a serious concern currently. 

The UK National Health Service (NHS) has achieved various successes ranging from medical breakthrough; increased life expectancy; reduced child and maternal mortality; preventative medicine; financial protection; efficiency; and offered reduced pressure on carers, in particular women who are primary care givers. The UK launched the NHS in 1948. South Africa’s NHI provides the closest case that Botswana might follow. It is created by pulling together financial resources from taxes or pensions to procure healthcare services, medicines, and health goods from accredited providers. Its main aim, they say, is to provide universal access to healthcare, ensuring that health benefits are not based on one’s socio-economic status. 

While this has now been signed into a law, South Africa is contending with various protests against its implementation from the business sector supported by the Democratic Alliance – a political party which is now part of a Government of National Unity (GNU) together with the ANC which passed the NHI. 

Under South Africa’s system, medical aids schemes will still exist but will be limited to treatments that NHI does not cover. The country’s minister of Health, Dr Aaron Motsoaledi recently warned critics of the NHI in an interview on Health Beat, Bhekisisa’s TV show. 

“Once the NHI is fully rolled out, medical aids will only be allowed to cover top-up services for which it doesn’t pay, and this section of the NHI Act (Section 33) is staying as it is, even if it costs South Africa its government of national unity (GNU). You can’t come and tell me ‘I support this universal coverage, but it (section 33) must go.’ It’s like supporting a house, but the foundation must go. Don’t you know it’s going to collapse?” Motsoaledi said. 

BOTSWANA’S CASE 

It is early days for the new government that wants to pursue this route. However, President Boko has been upfront about the main reason he has appointed Dr Stephen Modise as Health Minister – to deliver on the universal health coverage. It is the same reason he used in appointing the Assistant Minister of Health, Lawrence Ookeditse, saying he felt comfortable in roping in the Botswana Patriot Front (BPF) because they shared the same philosophy on the need to roll out universal health insurance system. 

As they roll up the sleeves to produce the policy and set up rolling it out, the comfort is that at least the infrastructure is there. What they need to do is to raise the huge capital needed for the transformation by tapping on the pensions and taxes to resource hospitals repair, medicine procurement and high-quality distribution system; and engagement of qualified personnel that is well rewarded. 

The days where you and your neighbour go two different ways to seek medical treatment for the same ailment might be over very soon. It all depends on Dr Modise’s abilities.