NHI Silent on Covering Natural Healthcare
By Anthony Rees – National Chairman (TNHA)
SUMMARY
This report addresses the current exclusion of complementary and traditional African medicine from South Africa’s newly enacted National Health Insurance (NHI) Act, which aims to provide universal healthcare in South Africa. Despite the widespread use of these practices, they are not currently covered under the NHI framework. TNHA emphasizes the need for these practices to be included in the public healthcare system, citing their potential benefits, regulatory challenges, and the need for policy inclusion, collaboration, and financial support to ensure comprehensive healthcare delivery.
The current approach to healthcare, which predominantly focuses on treating illnesses while paying lip service to prevention, is unsustainable. This trend not only drains the health budget but also fails to address the root causes of poor health. To reverse this trend, there is an urgent need to invest in measures that support healthy living, enhance nutritional status, and promote disease prevention. Studies demonstrate that primary care is likely the best setting to integrate CAM and Traditional African Medicine into the NHI, because of their holistic approaches, focus on self-care, and strong therapeutic relationships.
The difficulty in witnessing a historic event as it happens lies not in recognizing it – that part is easy. The real challenge is in grasping its significance for the future, which is the true essence of historic events.
President Cyril Ramaphosa signs the NHI Bill at the Union Building in Pretoria.
The South African government, led by the ANC, has started what they call an important mission. On the 14th of May, President Ramaphosa signed the National Health Insurance (“NHI”) Bill into law, just two weeks prior to the national elections. This new Act aims to reduce the big differences in healthcare quality by introducing the NHI.
It sounds good, but there are problems. Poor infrastructure, medicine shortages, understaffed hospitals, corruption, and mismanagement have all made public healthcare very bad. In essence, NHI is a taxpayer-funded healthcare fund that will allow any SA citizen, permanent resident, refugee, inmate or special category of foreign national to receive “free” healthcare. The plan is to provide healthcare for everyone in the country by pooling money from different sources, negotiating better deals with healthcare providers, creating a single fund for costly medical care, ensuring good healthcare in both public and private sectors, and making it easy for people to access their NHI benefits and medical records anywhere in the country.
However, the new law doesn’t include services from statutorily recognized complementary medicine or traditional African medicine practitioners, even though the majority of South Africans use these services and previous promises have been made to integrate them.
The NHI has not detailed on what role, if any, Allied Health Practitioners registered by the Allied Health Professions Council of South Africa and Traditional African Medicine Practitioners which are to be registered under the Traditional Health Practitioners Council will play in the rollout of this new new scheme, despite a few token consultations with these statutory health councils having been held with the National Department of Health prior to the final draft of the bill being submitted to the legislature for approval.
Although Section 5(4) of the new Act eludes to various other health related Acts which may require amendments to align with this new legislation in coming years, including the Allied Health Professions Act (Act No. 63 or 1982) and Traditional Health Practitioners Act (Act No. 22 of 2007), there are no published details about how these two pieces of legislation will dovetail into the NHI scheme. Whilst a ‘health care service provider’ is defined fairly generically, the way the NHI Act refers to such providers appears to indicate that healthcare providers such as complementary medicine and traditional healers do not appear to be included.
Phytotherapists (Medical Herbalists) in a herbal dispensary.
ALLIED HEALTH PROFESSIONS (COMPLEMENTARY & ALTERNATIVE MEDICINE PRACTITIONERS)
Complementary and Alternative Medicine (“CAM”) is not considered to be a part of mainstream medical healthcare system in South Africa, although it has enjoyed statutory recognition and operated independently as a protected public healthcare choice in South Africa for decades.
The Allied Health Professions Council of South Africa, established by the Allied Health Professions Act, oversees eight complementary medicine professions that fall under complementary and alternative medicine sector. These include the diagnostic professions of Ayurveda, Chinese Medicine and Acupuncture, Chiropractic, Homeopathy, Naturopathy, Osteopathy, Phytotherapy (Medical Herbalism) and Unani-Tibb.
Other non-prescribing and non-diagnostic modalities represented include Therapeutic Aromatherapy, Therapeutic Reflexology, Therapeutic Massage Therapy and Therapeutic Reflexology.
The eight diagnostic and prescribing professions listed above could be considered ‘healthcare service providers’ under the NHI, but are not part of the existing public healthcare system. Graduates from professional CAM training programs at tertiary institutions can not intern at State hospitals or clinics, as neither the National nor Provincial Departments of Health accommodate them.
While many private medical insurance schemes recognize a few common diagnostic professions within CAM, and provide limited annual reimbursements for their private clinical services, they often lack understanding and support for the CAM healthcare approach. As a result, CAM practitioners are not reimbursed at the same level as conventional medical providers, and patients usually pay for their consultations and individually prescribed natural remedies out of their own pockets. Patients and consumers consulting registered allied health professionals tend to be of a South African middle-income grouping
Currently, there are about 1,900 diagnostic and prescribing practitioners registered with the Allied Health Professions Council. Even though South Africa has a shortage of medical staff and the government supports training CAM practitioners at two local universities, the state isn’t utilizing their skills. This is because CAM practitioners are not well-known or represented in the government, so their benefits in primary healthcare are often overlooked, even though they are well-trained as primary contact practitioners and diagnosticians.
Training for allied health practitioners in South Africa includes a five-year full-time degree and a one-year internship in a clinical setting, usually at university-run community clinics. The courses cover medical and scientific subjects in classical, clinical, modern, and conventional health sciences, as well as clinical medicine in specific disciplines. Additionally, prescribing courses are offered to certain professionals so they can prescribe and prepare complementary medicines with scheduled natural health ingredients, according to the Medicines and Related Substances Act (Act No. 101 of 1965).
If these valued practitioners are not accepted into the NHI, it will seriously harm all allied health professions, leading to fewer registered practitioners and possibly the end of some smaller represented professions. State subsidization towards the training in these professions at universities may also diminish as the government re-prioritizes its funding resources and limited facilities to expand medical training to meet the expanded NHI staffing demands.
Given the current situation, it’s unclear if allied health practitioners will be formally integrated into the NHI. However, we believe they are important for the future because they can provide high-quality healthcare, especially in preventive medicine and treating common lifestyle diseases that benefit from wellness-focused approaches.
A Sangoma (traditional healer) using the bones to devine ailments and psycho-spiritual ills.
TRADITIONAL HEALTH PRACTITIONERS (TRADITIONAL HEALERS)
The World Health Organization (WHO) defines traditional medicine (TM) as “health practices, approaches, knowledge, and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singular or in combination, to treat, diagnose and prevent illnesses or maintain well-being”.
According to the Minister of Health, there are an estimated 150,000 to 200,000 herbalists, diviners, and traditional birth attendants classified as Traditional Health Practitioners still awaiting the opening of the professional registers of the Traditional Health Practitioners Council, despite seventeen years having past since the passing of the Traditional Health Practitioners Act (Act No. 22 of 2007) into law. Up until 2007 the ANC-led government made good on its promises to incorporate this sector into the national health system however this process has hobbled along at a snail’s pace.
Despite their widespread use by an estimated 60 – 80% of our indigenous black population on a regular basis, and the important role they play in a primary healthcare setting, traditional health practitioners are not officially recognized or funded by the state or private medical insurance schemes. It must be noted that other African countries such as Ghana, Uganda and Nigeria etc, are all still grappling with how to integrate traditional health practitioners into their formal national health insurance schemes, despite being many years ahead of South Africa in achieving universal healthcare coverage.
The international People’s Charter for Health is a statement of shared vision, goals, principles and action and is the most widely endorsed consensus document on health since the Alma Ata Declaration singed by South Africa in 1978. The People’s Charter calls for the provision of universal and comprehensive primary health care, irrespective of people’s ability to pay. It calls on people of the world to support, recognise and promote CAM and Traditional Medicine systems and practitioners and their integration into Primary Health Care.
The topic of Traditional African Medicine was escalated to the national health agenda by the African National Congress Health Plan of 1994 where it was stated that “traditional healing will become an integral and recognised part of health care in South Africa. Consumers will be allowed to choose whom to consult for their health care, and legislation will be changed to facilitate controlled use of traditional practitioners”. The plan contained a powerful statement as the basis for policy which noted, “people have the right of access to traditional practitioners as part of their cultural heritage and belief system”. This came after the active suppression of traditional healers by the colonial and apartheid governments respectively.
Later, the ANC’s progressive National Drug Policy (NDP) of 1996 pledged our governments support of integrating Traditional African Medicine into our national healthcare system. Our government further refined and expanded upon this objective in its National Policy on Traditional Medicine in South Africa in 2008.
More recently the World Health Organization, in its Traditional Medicine Strategy for 2014-2023 report, emphasised the need for using traditional medicine to achieve increased healthcare. In May 2022 South Africa pledged to integrate Traditional African Medicine into our healthcare system at the BRICS High-level Forum on Traditional Medicine, and later President Ramaphosa reiterated this pledge at the BRICS Summit in August last year.
Many promises made by our government since 1978 have yet to be fulfilled. Traditional African Medicine has been neglected due to long-term policy stagnation and a lack of political will. It lacks the necessary foundation to be integrated into a universal healthcare system. This situation can change if the NHI makes it a priority to develop and empower traditional healers to play a significant role in healthcare delivery in South Africa. We can look to countries like China, India, Japan, Cuba, Brazil, South Korea, Thailand and Vietnam, which have successfully integrated traditional medicine into their formal healthcare systems and national health insurance schemes. .
To ensure that Traditional African Medicine can contribute effectively to primary healthcare, especially in rural areas without hospitals and clinics, we need to urgently address and remove the barriers to its inclusion.
MOVING FORWARD
Incorporating Allied Health Practitioners and Traditional Health Practitioners into our NHI will certainly be nuanced, considering the dominant allopathic (medical) mindset of the NHI architects and administration, however it will be a valuable process if correctly implemented. Here are several key strategies we believe can facilitate this integration:
1. Regulation and Standardization
- Certification and Licensing: Strengthen and capacitate the two statutory health Councils which certify and register Allied Health Practitioners and Traditional Health Practitioners. This will help to ensure that practitioners meet certain standards of care, stay within their discipline-specific scopes of practice, and can be held accountable.
- Training and Education: Provide appropriate training programs for Traditional Health Practitioners to enhance their knowledge and skills, particularly in areas where modern and traditional practices intersect. Allied Health Practitioners should be admitted to practice in state hospitals and clinics in order to be part of multi-discipline teams.
2. Collaboration and Integration
- Referral Systems: Develop a system where Allied Health Practitioners and Traditional Health Practitioners can refer patients to conventional medical facilities when necessary, and vice versa. This can help create a collaborative environment.
- Joint Practices: Encourage partnerships between Allied Health Practitioners, Traditional Health Practitioners and modern healthcare providers. This can be through joint clinics or collaborative treatment plans.
3. Inclusion in Health Policies
- Policy Development: Include CAM and Traditional African Medicine in national health policies and strategies. Ensure that Allied Health Practitioners and Traditional Health Practitioners are represented in policy-making processes.
- Insurance Coverage: Work towards including CAM and Traditional African Medicine practices in health insurance schemes. This can be done by defining which treatments are covered and setting standardised reimbursement rates.
4. Research and Evidence-Based Practices
- Scientific Research: Invest in research to validate the effectiveness and safety of CAM and Traditional African Medicine. This helps in gaining the trust of both the public and the medical community.
- Integration of Data: Develop databases to track the outcomes of CAM and Traditional African Medicine. This can help in assessing their efficacy and integrating successful practices into mainstream healthcare.
5. Community Engagement and Education
- Public Awareness: Educate the public about the benefits and limitations of CAM and Traditional African Medicine. Promote an understanding of how these and modern practices can complement each other.
- Cultural Sensitivity: Ensure that healthcare policies and practices respect cultural traditions and values. This helps in gaining the trust of communities that rely on these disciplines.
6. Financial Support and Resources
- Funding: Allocate resources for the integration of CAM and Traditional African Medicine within the healthcare system. This includes funding for training, research, and infrastructure development.
- Infrastructure Development: Develop facilities that support the practice of CAM and Traditional African Medicine, such as herbal gardens, traditional medicine clinics, and research centers.
7. Monitoring and Evaluation
- Quality Control: Establish mechanisms for ongoing monitoring and evaluation of Allied Health Practitioners and Traditional Health Practitioners and their practices. This ensures that standards are maintained and improvements are made as needed.
- Feedback Mechanisms: Create channels for feedback from patients and healthcare providers. This helps in continuously refining the integration process.
By taking these steps we can successfully include Allied Health Practitioners and Traditional Health Practitioners in our universal healthcare system. This will improve the overall quality of care and ensure that healthcare services are culturally relevant and widely accessible.
However, the main challenges to integration are the lack of funding and negative, misinformed perceptions of CAM and Traditional African Medicine. Collecting data on evaluation, research, and costs from these services is crucial for planning a truly integrated National Health Insurance (NHI) system. Despite limited current evidence, we believe that some CAM and Traditional African Medicine treatments could offer significant cost savings for the NHI.
For instance, a U.S study from February 2013 showed that natural health interventions can reduce hospital stays, lower costs, and decrease the chances of readmission.
A report by the U.S. Council for Responsible Nutrition (CRN) in 2022, compiled by Frost & Sullivan, demonstrated that using dietary supplements in a prevention-based healthcare system could save significant costs for both private and national health insurance.
Similarly, a 2016 review commissioned by the Australian Self Medication Industry (ASMI) reached the same conclusion about the potential health benefits and cost savings of integrating complementary medicines in Australia.
These studies demonstrate that primary care is likely the best setting to integrate CAM and Traditional African Medicine into the NHI because of their holistic approaches, focus on self-care, and strong therapeutic relationships. The current approach to healthcare, which predominantly focuses on treating illnesses while paying lip service to prevention, is unsustainable. This trend not only drains the health budget but also fails to address the root causes of poor health. To reverse this trend, there is an urgent need to invest in measures that support healthy living, enhance nutritional status, and promote disease prevention.
Ultimately, we hope that strong patient demand and political support will drive the integration of CAM and Traditional African Medicine with conventional Western medicine under the NHI scheme.
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