The battle lines are drawn between the naysayers and supporters of National Health Insurance after the Bill was introduced to Parliament over a week ago, writes MedicalBrief.
Expert opinion on the NHI Bill before Parliament is divided between those who are wholeheartedly in support and others who are adopting a wait-and-see attitude, says a Cape Argus report. Implementing the NHI may fulfil the government’s constitutional obligation to provide quality universal healthcare for all, but the system has caused debate, with people arguing both for and against it ever since the idea was mooted.
Damian McHugh, head of health marketing at Momentum Group, said that while the medical aid supported universal healthcare (UHC) and there was no debate that inequalities existed in the health system as it was at present, “how we go about achieving UHC is the question”.
President of the Health Professions Council of SA (HPCSA) Kgosi Letlape meanwhile is quoted in the report as saying: “We hope that as we engage with the NHI Bill, we will persuade the authors (of the Bill) to talk about NHI contracting with providers, rather than accrediting them.” Letlape said: “We don’t want the NHI to become the new medical aids that are choosing who can live and who can die.”
At the same time, Anele Yawa, general secretary of the Treatment Action Campaign, said the organisation would wait until the Bill was enacted, before commenting on it.
On the subject of affordability, Ronelle Burger, an economist and researcher in the faculty of economic and management sciences at Stellenbosch University said: “According to the household surveys, the main constraint to having insurance is affordability. There are many people who would like to have insurance, but simply cannot afford it.”
Burger pointed out that there were no user fees for using primary health clinics and fees at hospitals were means-tested and seldom enforced and that this was echoed in the surveys, which showed that affordability was not a constraint to access to public care. “The demand for private care, amid free public care is interesting and important, and part of what we as researchers are trying to understand in more depth.”
The SACP, which is part of the #FriendsOfNHI, said: “We will continue pushing for the successful introduction of NHI in the interest of quality healthcare for all.”
While it may be political suicide to say so publicly, several senior government officials privately say the reforms proposed in the Bill are so ambitious that they are likely to be decades in the making, says a Financial Mail report. The envisaged reforms require huge restructuring of the health-care system, the creation of an enormous bureaucracy to register the entire population, new systems for contracting and paying service providers, and the accreditation of thousands of hospitals, clinics and private sector health-care professionals, ranging from GPs to neurologists.
Exactly what health-care benefits will be provided by NHI and how they will be funded remains murky. But, the report says, what is clear is that the government is determined to be seen to be tackling the problems gripping the health-care sector.
The report says while few people would take issue with the social solidarity principles that underpin the fund – namely that everyone should contribute only as much as they can afford to the fund, and that the rich and healthy should subsidise the poor and infirm – the problem lies with how the policy will be executed.
The Board of Healthcare Funders has come out in support of the Bill. According to an Eyewitiness News report, lead researcher at the BHF Charlton Murove explained: “There’s a disproportion of resources between the private and public healthcare sector. There’s underutilisation of hospital beds and professionals in the private sector.”
The ANC‘s parliamentary caucus is also backing the Bill, saying it’s the first step to free, comprehensive and quality healthcare. Acting caucus spokesperson Andile Mdleleni said: “The NHI will ensure that all South Africans receive free and quality healthcare.”
Private hospital group Mediclinic says it supports the government’s plan of providing universal health coverage, but has stressed that more clarity is needed regarding the legislation, reports Fin24. Mediclinic said the implementation of the system will require changes to a range of existing pieces of legislation, as outlined in the NHI Bill. It also raised concern that there was “some ambiguity regarding the scope of contracting for private provider services” with the NHI fund.
The company said it would “continue to collaborate and contribute in this process towards attaining greater clarity and certainty”. “Mediclinic will continue to actively engage in the development of the NHI to gain clarity and ensure that sustainable solutions are put forward that leverage private sector providers and funders to achieve the objectives of universal health care,” said Mediclinic.
And Discovery, whose share price has been knocked by the advancement of the Bill, says while the legislation would be counterproductive, it would not be a death knell for South Africa’s medical schemes. “Our view is that substantially limiting the role of medical schemes would be counterproductive to the NHI because there are simply insufficient resources to meet the needs of all South Africans – this is an unavoidable reality,” the group is quoted in Business Day as saying.
“Crucially, by preventing those who can afford it from using their medical scheme cover, the burden on the NHI will be increased and will drain the very resources that must be used for people in most need … This would be detrimental to all South Africans, and would undermine the objectives of the NHI as we understand it.”
Discovery said it understood that where patients chose not to follow the “referral pathways” envisaged under the bill, the NHI would not reimburse their care, and they would be able to claim from private health insurance. As such, it saw “a continued and important role for medical schemes” in the future.
Feral Haffajee writes in Fin24 that the national health insurance initiative is a further attempt at health reform but the idea is poorly conceived and will add to the burden of already stressed income taxpayers who have over recent years faced the highest tax increases. There’s more to come once the NHI Bill becomes law, although it’s important to bear in mind that that is only in 2026 – possibly much later – because the law as it stands faces many constitutional hurdles, she quotes Wits University health economist Dr Alex van den Heever as saying.
Haffajee writes that the NHI Bill creates a new architecture for health provision and could effectively eviscerate the private system, which is why listed company health share prices are in casualty. It is built on the assumption of an efficient, capable, tech-savvy and clean government, when the experience of the majority of South Africans is exactly the opposite, since the era when government first made the public health changes that made for better lives.
Haffajee writes in the Daily Maverick that the ideas in the draft law have been met with uproar by the medical aid industry, by organised doctors and individuals.
She says there are two main issues: the first is that the Bill is written as if State Capture – in which R1.4trn (perhaps even more) was stolen from the public purse by patronage networks – did not occur. The bill recreates structures and systems which suggest it will encourage exactly the same systems of State Capture.
Haffajee writes that the idea of national health insurance would be great if South Africa were Sweden, but it’s not. All South Africa’s big funds, such as the Unemployment Insurance Fund, the Workmen’s Compensation Fund and the Strategic Fuel Fund, are either appallingly mismanaged or subjected to looting. The administration costs of each are stratospheric and using them is difficult and time-consuming.
She says the Strategic Fuel Fund, which is meant to ensure South Africa has sufficient oil in an emergency, was subject to an instance of State Capture so brazen it beggars belief; in a 2016 case still to come before the courts, it appears that, under the guise of the rotation of oil stocks, the country’s supplies were sold off at far below market value, costing the public purse R5bn.
Haffajee writes that the uproar is because it is about health and choice. The system will remove choice and will drive up costs for income tax payers who are already burdened by high tax rates and many stealth taxes. It removes choice in how and when you are treated. The debate is coming down to a classic and historic one that creates a binary between equality and efficiency, but it need not be so if greater co-governance and practicality were written into the law.
Investec’s Nazmeera Moola writes in the Daily Maverick that despite its very laudable and necessary long-term aims, NHI will hurt growth in the short term, exacerbate job losses and threaten short-term stability. Moola writes that the NHI Bill also requires a capable state.
Moola writes: “We could view the Bill as providing a workable framework to healthcare reform, with an incremental implementation strategy. The lack of clarity in the Bill means that we could optimistically see room for private health insurance to provide an alternative to NHI for those that do not follow the NHI pathways. An alternate interpretation is that the only route for a range of medical cover will be through the NHI.
“Given the country’s experience with the government’s current provision of land reform, healthcare or electricity, few are likely to assume that a capable state will be created by 2023. Instead, most will continue to defer spending. And many with skills – particularly much needed medical skills – will look to emigrate.
“Therefore, despite its very laudable and necessary long-term aims, NHI will hurt growth in the short term, exacerbate job losses and threaten short-term stability.”
The NHI Bill will destroy smaller medical schemes while allowing bigger ones to benefit from forced consolidation, the South African Institute of Race Relations (SAIRR) is quoted in Business Live as saying. “It’s always interesting when medical schemes support the NHI. They are actually supporting something that’s going to lead to their business dying, which is very odd,” said Johann Serfontein, a senior consultant at health consultancy group HealthMan.
Wits’ van den Heever says in the report that most schemes and medical aid administrators told him in private conversations that they do not think NHI will work, but they support it publicly because it is the right thing to do politically. “There are many parties in the medical schemes system. Members certainly don’t support it. Some are supporting it to maintain inside tracks within the policy-making structures,” van den Heever says.
Performance in South Africa’s two-tier health system – the public and the private – has been worsening for some time, writes Van Den Heever in The Conversation. He writes: “Politicians have attempted to attribute the decline in the public sector to a myriad of ills, none of their making. These include migrants; insufficient funds; insufficient staff; medical schemes; lawyers suing them for medical negligence; the existence of two tiers and even the middle class.
“However, the real reasons place the blame firmly at their door. They are also largely responsible for the problems in the private sector.
“Institutionalised patronage within provincial and national government has destroyed the capabilities of public health organisations – both national and provincial.
“The country’s health ombudsman has also stated that the public health system is in a state of crisis. And the auditor general last year bluntly pointed out the country’s health services are in crisis.
“This view is widely shared by civil society groups working in the health sector.
“The planned NHI in South Africa has no equivalent in any setting in the world. It’s deeply flawed on a number of fronts.
“The public health system can only be turned around by a combination of governance reforms and decentralisation. This requires the implementation of supervisory structures, such as boards for hospitals, district authorities and statutory councils that are insulated from political appointments and interference. Politicians should be entirely separated from the operational aspects of health service delivery.
“For its part, the private sector requires the implementation of the health market inquiry recommendations. Some of these include setting up a pricing regulator to manage annual price negotiations for hospitals and doctors and the establishment of an information regulator to bring quality of care information on private and public health services to the surface.
“What South Africans don’t need is another five years of pretence that this team can create a brand new health system out of the ashes of the two existing systems.
A Health-e News report also comments on the mounting fears that the NHI Bill will not live up to its ambitious expectation and could be captured by private medical services. It says the Bill needs more time, to reflect and effectively respond to some of the critical issues that emerged from the pilot phase. In 2012, the first phase of the NHI focused on piloting a health system through the re-engineering of primary health care. This pilot assessed whether a primary healthcare package that included healthcare teams and intensifying referral systems could strengthen the public health system.
Public health users were hopeful, since this meant more resources and infrastructure. Budgets were allocated to provinces to improve primary healthcare services in districts, including contracting of doctors working in clinics. But provinces struggled to attract general practitioners. For instance, in 2015, the Eastern Cape used only 19% of the NHI budget.
The report says this has serious implications for public health users even as the minister pushes the Bill forward.
In addition to technical details of the Bill and governance concerns, NHI will be experienced at first-hand by the poorest and most vulnerable groups in South Africa, such as women and children from low-income communities. These same people are already bearing the brunt of the current unequal and deficient health services.
During the pilot phase, people were promised that clinic queues would be shorter because healthcare services would come to their doorsteps. In cases where a patient’s condition was critical, the NHI promised a referral system from the local clinic to a contracted doctor who would then refer them to a district hospital to be seen by a specialist.
This seems impossible to implement and sustain in the current form of the Bill. In 2016, the Office of Health Standards inspected more than 800 health facilities and the results were alarming. More than 80% of the health facilities that were inspected were non-compliant with the requirements for NHI implementation.
The results also confirmed already existing inefficiencies of public facilities such as a shortage of doctors, the long distances patients have to travel to their nearest clinic or hospital and shortages of medical equipment and drugs.
The report says the minister needs to guarantee that the NHI will not result in another Life Esidimeni, where Gauteng Health moved more than 1,500 mental health patients from state-funded care to 122 unlicensed NGOs, resulting in 144 deaths. It’s crucial for the minister to ensure this Bill will not leave patients stranded without the promised quality of care, which may result in avoidable deaths.
According to the Bill, a contracting unit specifically for primary health care will be established to manage the provision of primary healthcare services, and “identify accredited public and private healthcare service providers”.
The report says a growing concern, however, is how the government will ensure it doesn’t drift from its bold vision of “social solidarity” between the private sector and the public service. The threat of private industry capture, such as inflating costs for procuring health services, will result in poor people suffering the most. It’s clear South Africa needs an equitable health system, but how will the minister guard it against corruption and extortion?
The NHI must be beneficial for people, particularly those in rural areas and outside of big cities. The report says we cannot afford another form of State Capture at the hands of private health providers and at the expense of people.
Mark Heywood, editor of Spotlight writes in the Daily Maverick of his interview with the health minister that focused on the NHI Bill. Heywood writes: “I asked Mkhize whether at this time – a time when the health system would be best served by building trust and common purpose to save lives – introducing a highly divisive and contested bill that would divert attention and resources away from life-threatening problems, was a wise thing to do.” He says Mkhize doesn’t flinch. He thinks it is.
But, Heywood argues: “The danger is that the controversy over NHI – the litigation, the labelling, the polarisation, the fear-mongering, the doctors, nurses and specialists who see this as a reason to leave South Africa – will prevent us from fixing health systems. The sound and fury will also continue to provide a shield for politicians and the private sector, giving them an excuse to avoid direct accountability for corruption and failed management systems.
“Paradoxically, therefore, while NHI promises a revolution it might in fact be a prescription for continuing the status quo.”
Economist Dawie Roodt seems to think that the NHI is “not going to happen”. According to a Sunday Tribune report, his argument is that to implement the NHI the government would need plenty of money, which would place a bigger burden on its already strained coffers. “The NHI will not happen because this government just cannot organise anything. They are not going to get things right in time,” said Roodt.
He said the government needed to cut state spending by 15% or R200bn to stabilise its debt. Therefore, said Roodt, the billions needed to fund the NHI did not exist and no country or institution would lend South Africa that amount. “Even without Eskom, the debt levels of national government will exceed 60% of the gross domestic product,” he said.
Roodt said in the report that the NHI would only come into existence if the government expected the private medical industry to pay for it.
Heinrich Volmink, the executive director of the Organisation Undoing Tax Abuse (Outa), said it believed in the need for universal health care and equality of care for everyone, but was concerned by the bill in its current form because the government wanted to build a colossal system on the back of one that was already broken. Volmink said Outa would meet several experts in a range of fields and then give South Africans a chance to share their views in a public participation process.
The aim of the NHI Bill is to change the funding of healthcare by pooling medical aid and taxpayer money into a single government-run fund to improve the country’s healthcare. While the draft Bill has offered some details about how it will work, Times Select journalist Katharine Child has compiled a list of key questions which need to be examined.
* When will the Treasury paper on the funding and costs of NHI be released?
* How many human resources have been dedicated to the implementation of NHI?
* How can NHI work properly if the Health Department has not been capable of spending its NHI grants?
* How will the Office of Health Standards Compliance (OHSC) inspect and accredit so many doctors’ rooms, hospitals and practices?
* How will the NHI fund choose facilities when so few state facilities pass inspections?
* How does adding more private patients to the state sector help fix healthcare?
* Will provinces and central hospitals give up their health funding without a drawn-out court battle?
* Should the proposed law give so much power to one person?
* Is denying illegal immigrants the right to healthcare unconstitutional?
* Will prescribing what doctors charge ultimately drive them out of the country?
* Why remove healthcare from people who have it?
* Will citizens already paying for private medical aids buy into the proposal to redirect this money to the government?
* Is NHI based on research to show what works to fix SA healthcare?
Government ignored most of the legal objections raised by the National Treasury in finalising the Bill, according to Rapport. In a leaked letter of then acting DG Ismail Momoniat sent to the “NHI War Room” at the end of last year, Treasury warned of inevitable constitutional challenges that would follow based on sections of the Bill.
A major concern was the “barely visible” repealing of parts of s25 of the National Health Act contained in the NHI Bill, Momoniat wrote. That section deals with provinces’ functions and powers in healthcare which was simply repealed in a previous version of the Bill.
In the tabled version, s25 is still mostly repealed and replaced with a stipulation that provinces will have the functions and powers “as prescribed’ by the national Minister of Health. Momoniat complained that, in line with the Constitution, provinces cannot be made to give up their equitable share without consultations with the Premiers. Treasury further raised governance concerns in the Bill, asking why the Board of the NHI would have to report to the Minister. These controversial sections were retained unchanged.
The report says furthermore, Treasury objected to s33 of the Bill that stipulated that medical schemes would only be allowed to offer complementary cover. The section was partially redrafted after Treasury’s concerns, but substantially retained. It now says this will only happen at a future date determined by the Minister.
The biggest problem with the implementation of NHI is the structure of South African society, says a Daily Maverick report. With only 10m employed in the formal sector, the expenditure burden on those in employment will be massive compared with the proposed beneficiaries.
The report says those burdened are not only the privileged few; they include the public sector and many working-class South Africans in the formal sector. So, they may be asking, is there a legal way to resist? Lawyers are already thinking about this, since the government faces two constitutional issues with the implementation of NHI.
The report says the first concerns the provinces’ jurisdiction over healthcare implementation. The second problem concerns the constitutional protection of freedom of association.
Small, step-by-step innovations at the clinic and hospital level are where the real action lies in fixing South Africa’s healthcare system, writes Robin Sandler, a clinical psychologist in private practice in Cape Town in a Daily Maverick report. He says sourcing money in new ways at the top of the system is only part of the story. Variations of the single-payer system have worked well in several other middle-income countries – but in each case, the health system rises or falls according to how skilfully the details are worked out at the bottom of the system rather than the “big” ideas at the top.
Sandler says spending more to fix our health data and monitoring is probably the best investment we can make right now. Debates around the NHI should focus on the important stuff – and the important stuff in a healthcare system is as much about the detailed systems in rural clinics as it is about the variant of single-payer financing. The single-payer system in Britain has been built with countless incremental modifications over the past 70 years.
He says we should focus on manageable steps towards the UHC goal and rapidly improving our monitoring and evaluation so that we can tell what’s working and what needs further innovation.
Neil Kirby, director, healthcare & life sciences law at Werksmans Attorneys writes:
The question that must be asked is whether or not all South Africans are compelled to become members of the Fund as it is proposed in the NHI Bill?
There are also important implications for purposes of applying the Bill of Rights to the Fund, more particularly, the provisions of section 18 of the Constitution of the Republic of South Africa which provides that “everyone has the right to freedom of association.”
Whether or not mandatory membership of the Fund is desirable, will have to be tested against section 18 of the Bill of Rights. There are important Constitutional considerations to take into account when evaluating the overall impact and effect of the NHI Bill on the current architecture of, at least, the private healthcare sector in South Africa.
The overall implications of the NHI Bill, from a membership point of view, will have to be understood in the fullness of time and through the process of obtaining public comments on the NHI Bill as is currently envisaged through the Parliamentary process through which the NHI Bill must pass in order to become law.
Michael van Vuren, a partner at law firm Fasken, in a Business Tech report has outlined some of the key points of the Bill that South Africans should know about.
The report says these are:
Is the NHI compulsory?
What happens to medical aids?
What services will be covered by the NHI?
Who will pay for the NHI and how much will it cost?
What if I don’t want to use the NHI?
When will the NHI begin?
Nicholas Crisp, the former health of Limpopo Health, former acting CEO of the National Health Laboratory Services (NHLS) and consultant for the SA Health Products Regulatory Authority (SAHPRA), has been appointed by Mkhize as the head of the NHI office. Now, says a Daily Maverick report, even before the NHI Bill has passed Parliament, he has embarked on a plan to build the behemoth.
The report says, lobbied questions during the “winter of discontent” his answers – and he has answers for everything – brought with them the feeling of spring.
Dr Olive Shisana, the NHI advisor in the Presidency writes in Business Day: “The National Health Insurance (NHI) Bill introduced to the National Assembly aims to move South Africa towards universal health coverage. On one level, universal health coverage is an aspiration – that all people can get the services they need, of good quality, without fear of financial hardship. That ‘achievement’ is just an aspiration because every country, no matter how rich, does not provide everything for everyone.”
Shisana says in the report: “The ongoing development of medical technology and the reality that budgets are not unlimited mean that even the richest countries make choices – and in the good cases, explicit choices – about what their systems will and won’t guarantee for their populations in terms of health services and related out-of-pocket costs.
“Given the fact that private medical schemes cover about 16%-17% of South Africans – but nearly half of health spending flows through these schemes (which is the highest share of spending flowing through voluntary health insurance of any country in the world, one of the main reasons that South Africa is deemed an international outlier in terms of its health financing arrangements) – the inevitable consequence is that scarce health human resources serve the privately insured, where the remuneration is greatest, leaving fewer health workers to serve the majority of the population. Addressing this core driver of inequity in the health system is therefore central to any serious effort to move towards universal health coverage in South Africa.
The ANC study group on health has accused the Democratic Alliance (DA) of grandstanding and fear-mongering in its opposition to the Bill. “The NHI will bring about significant change to our society, not seen since the dawn of democracy in 1994. Despite this monumental feat, there exist counter-revolutionary forces who are hellbent on undermining the good work of the ANC-led government,” The Citizen quotes the group as saying.
“One such force is the Democratic Alliance which has already made a mockery of the bill, even before the NHI Bill is debated in Parliament. We as the ANC study group on health are not surprised by the barrage of attacks against the bill, in fact, we have long anticipated that such an onslaught by these reactionaries was imminent,” the group said.
The study group claims the DA’s alternative plan is “scant on everything universal health care”. “We as the ANC study group on health are of the view that the DA’s proposals on health should remain exactly that, proposals, as their understanding of universal health coverage, leaves much to be desired.”
The study group also disputes the DA’s claim that the NHI will be another state-owned enterprise.
The National Education, Health and Allied Workers’ Union (Nehawu) has called on Parliament to move quickly to enact Bill. According to a Polity report, Nehawu welcomed the strides made by government, specifically the Health Department, towards the full implementation of the NHI, saying the release of the Bill was long overdue.
Nehawu was adamant that the immediate and full implementation of the NHI would help mitigate the challenges in the public health sector. Nehawu said the private healthcare system had taken advantage of the poor quality of public healthcare to impose extortionate charges. “It is for this reason that Nehawu is opposed to the detractors of the NHI which include big hospital groups, medical aid companies and the DA.”
“The DA and their ilk must not for a second think that we will fold our arms while they seek to reverse the gains of our revolution. We will wage a relentless war against anyone who seeks to block the implementation of the NHI,” the union warned.
Special interest groups, organisations and members of the public will have the opportunity to have a say in the Bill during nationwide public hearings facilitated by the National Assembly’s portfolio committee on health in the coming weeks. The committee’s chair, Dr Sibongeseni Dhlomo, said in a Sunday Tribune report that everyone would have a chance.
“Everybody will be making submissions, some will be making it in our public meetings, and some through emails,” Dhlomo said, adding that no one would be able to say they were “shut down” and “never given the opportunity”.
He said in most countries where universal health coverage was implemented, the life expectancy of the population increased. He also cautioned those who questioned the readiness to implement the NHI that: “We can’t wait till all the ducks are in a row… we will fix clinics and hospitals as we go along.”
The portfolio committee on health will, meanwhile, be briefed by the state attorney on the constitutionality of the Bill, committee chair Dhlomo is quoted in a News24 report as saying. The party is questioning its constitutionality as it will seemingly take away the provinces’ constitutionally enshrined right to handle health services.
Dhlomo said as the committee started its work on the Bill, it would be important to get a presentation from the state attorney on the legal advice it gave to the Health Ministry on the constitutionality of the Bill. “The committee does not want anything untoward to delay public participation on the Bill. However, we still want to address concerns, hence the importance of starting with the state attorney,” said Dhlomo.
Cape Argus report
The arguments for and against the NHI
Financial Mail report
Eyewitness News report
Business Day report
Daily Maverick report
Daily Maverick report
Business Live report
The Conversation report
Health-e News report
Daily Maverick report
Sunday Tribune report (subscription needed)
Daily Maverick report
Times Select report
Report in Rapport (subscription needed)
Daily Maverick report
Daily Maverick report
Report on the Politicsweb site
Business Tech report
Daily Maverick report
Business Day opinion
The Citizen report
Sunday Tribune report (subscription needed)