MEDICAL aid schemes are a big con. They are expensive, with decreasing benefits, yet members are paying increasingly out of their own pockets for less healthcare.

But some schemes, such as Discovery Holdings, are expecting headline profit above 30 percent.

In other instances there have been increasing incidents of medical aid schemes wasting members' money on ventures unrelated to health.

A national health insurance (NHI) system which makes quality healthcare affordable and accessible to all South Africans is urgently needed.

The post-1994 emphasis of the ANC government has been on boosting private medical schemes, with government employees and ANC leaders even using private healthcare.

But it is appalling that the discussion of proposals for a NHI are shrouded in such secrecy.

Making the formulation of key policies the preserve of a few will make the quality of the policies poorer.

Right now the public health sector is mismanaged, inefficient and short-staffed.

This requires that the NHI must be introduced in phases.

The first step must be fixing and upgrading the current public health system.

In some areas public hospitals are mothballed or whole wards stand empty amid a national shortage of beds, medicine and treatment.

The private health sector has been more efficient so everyone is going there despite it being terribly expensive.

If the public health sector is just going to take over the private health sector, without fixing the public health system first, the new system is likely to collapse.

Right now the government is spending the same amount on 7million medical aid members in the private sector as on 40million South Africans in the public sector.

Yet the 40million poor South Africans forced to use public hospitals don't have access to the private sector though this sector is subsidised by government funds.

The state funds the training of most public health professionals. But publicly trained and funded health professionals service mostly private sector patients.

Any NHI administration will have to be administrated outside the present public department, which just doesn't have the capacity to manage a complex new health system.

Furthermore, given the capacity of the private health sector, it would be a disaster were it not used in partnership with the public sector to implement the new NHI system.

The private sector must be roped in to manage ailing hospitals, albeit with a new focus on private universally accessible quality healthcare.

In a phased introduction of a NHI, in the first phase, a quota of the patient load of private hospitals, especially for essential treatment, could be reserved for patients who cannot pay.

At the same time, public hospitals must be fixed, mothballed hospitals and clinics put into use, money better managed and only the best appointed to positions.

It is foolish to think that poorly paid health workers working under dreadful conditions will miraculously perform better under a NHI without improving their basic working conditions.

If an NHI system is not introduced in a consultative spirit we might see another flight of scarce health skills.

During the first phase, medical aid levies must also be capped; and medical schemes prohibited from using members' money in non-health- related business schemes.

The reality is there must still be a place for medical aid schemes, even under a fully functioning NHI, but one that could offer a top-up cover for shortfalls in the new NHI system.

lThe writer is author ofThabo Mbeki and the Battle for the Soul of the ANC