Health Minister Aaron Motsoaledi recently had a meeting with the South African Medical Association (SAMA) – one of the organisations taking him to court about the National Health Insurance (NHI) Act – and says he is open to talks with others.
SAMA’s chairperson Mvuyisi Mzukwa, who confirmed the meeting with Motsoaledi, said “the discussion did not allow for in-depth engagement on specific issues”, adding: “The Minister requested that engagements continue on a monthly basis, with each session focusing on a single, clearly defined area of interest or key concern to enable more substantive discussion.”
Motsoaledi told Bhekisisa’s Health Beat that President Cyril Ramaphosa is also planning to meet Business Unity South Africa (Busa), after an initial meeting in 2024 when they discussed alternatives to the NHI.
Busa is concerned about the NHI’s potential negative impact on the quality of healthcare, taxpayers, the economy and investor confidence.
“There’s nothing wrong with talking,” Motsoaledi said. “The question is, what are you discussing and what is the ultimate aim? This country has always believed in talking.”
Serious concerns about the ability of the Health Department to manage a trillion-dollar NHI Fund were raised this month when Motsoaledi took action against three of his key officials for alleged corruption: the National Department of Health’s DG Sandile Buthelezi; the deputy DG for Hospital Services and HR, Percy Mahlathi, and the department’s CFO, Phaswa Mamogale, are now on precautionary leave.
If the Constitutional Court finds the public participation process was unsatisfactory, the Act would need to go back to Parliament and be argued again.
However, if the court finds that input was reviewed and considered satisfactorily, then the other cases can go ahead, but could, potentially, all be heard as one consolidated case — which almost all of the organisations taking Motsoaledi to court will oppose.
Universal access to healthcare
Universal access to healthcare means everyone can get the healthcare they need, when they need it, without going broke, but on the question of whether South Africa has a system for this, the Health Minister and experts disagree.
Health economist Susan Cleary, who heads up the University of Cape Town’s public health school, told Health Beat that South Africa “already has the start of a universal health system”.
Studies show that compared with other middle-income countries, South Africa’s spending rates (out-of-pocket payments) are actually low.
“The central challenge is not basic access, but rather quality governance system performance and financial sustainability,” Wits health economist Alex Van den Heever explained to business publication Currency.
Cleary said no definition of universal health coverage stipulates that all money spent on healthcare has to be poured into, and paid from, just one fund. Many countries have “plural” systems, where healthcare is funded in more than one way, often with a private and public system co-existing, she says.
Planned purchaser-provider split
Motsoaledi described the the purchaser-provider as an excellent idea. “That way, we hold each other accountable. Private medical aids shop around to check which healthcare professional or provider is the best; they choose the best quality.
“Under the NHI we want to do that. We can only buy good services, whether in public or private. If your services are not good, you have to get your house in order before they can be purchased.”
But Cleary warns that changing from our current NHS system to an NHI poses dangerous complexities.
“We’ve not adequately justified in replacing our current system with something more sophisticated and harder to manage – especially since governance is not our strong point,” she said.
A purchaser-provider split will require the NHI Fund to process millions of payments each year, enough to cover the healthcare needs of everyone in the country.
With provincial Health Departments’ record of late, including lack of payment to service providers, the government’s ability to manage such a system is seriously questioned.
In a recent Spotlight op-ed, Haseena Majid and Mogie Subban from the University of KwaZulu-Natal’s College of Law and Management Studies, cautioned: “When reforms are layered on to unstable administrative systems, the result is not transformation, but increased risk.”
The danger is that, if the NHI Fund fails, and most state-run funds are run badly (look at the Road Accident Fund and the Compensation Occupational Injuries and Diseases Amendment Act), there will be no back-up system left, because private medical aids and provincial health budgets would have ceased to exist.
In March, at News24’s On The Record summit, former Finance Minister Trevor Manuel advised: “You don’t build up the public sector by pulling down the private sector.”
Will the NHI reduce corruption?
The NHI Fund will be a trillion-rand pot of money that Currency editor Rob Rose warned would create “the biggest opportunity for corruption yet in a country with no real clue how to combat it”.
Motsoaledi, however, believes the Fund will stop corruption because it will be managed centrally and there are “built-in-mechanisms” in the Act – such as that the Fund will be managed by a CEO who reports to a board, rather than the Health Minister.
Such provisions, Motsoaledi insists, will prevent money from being looted.
Right now, he added, existing laws don’t allow him to put measures in place to prevent corruption in provinces, where most of the spending, and corruption, happens, as Health MECs report to Premiers, not the national Health Minister, and provinces control their own budgets.
The NDoH can therefore not instruct provincial departments on how to manage their money.
But the seniority of officials in the NDoH who were placed on precautionary suspension in March is cause for concern, experts warn, because it’s an indication of how senior officials of the NHI Fund could potentially behave.
“(If the allegations are true), they suggest that leadership levels of government drive the corruption,” Van den Heever told News24. “The irony that these are the very officials who would be responsible for the largest public procurement arrangement in South Africa cannot be avoided. Perhaps less of an irony and more of a burning red flag.”
Such officials, Van den Heever told Currency, “sterilise the accountability systems from the top and all procurement rules are circumvented”.
Buthelezi and his colleagues are accused of exactly this: over-riding procurement rules to buy services to run a disciplinary hearing with money from the Global Fund to Fight Aids, TB and Malaria.
On ‘negotiating’ a new deal
Two of the big issues highlighted by NHI critics are section 33 of the Act, relating to the future of medical aids, and that the Act gives the Health Minister huge power to influence who serves on the NHI Fund’s board, committees and the appeals tribunal.
Section 33 says medical aids will cease to exist in their current form as they will only be allowed to buy services that the NHI Fund isn’t already buying.
This is an issue being fought by Busa and other medical aid membership organisations. Although Motsoaledi told Bhekisisa he’d like to have a meeting with Busa, he was adamant private medical schemes can’t be part of the NHI.
“They have to be complementary,” he said.
Powers of the Minister
In the Health Beat interview, he told Malan that regarding the powers given to him by the Act: “I’m not a power monger.”
On the suggestion that the person who replaces him “may very well be one, and perhaps we should have more protection in the law”, Motsoaledi agreed.
“The NHI Act is not written in stone. If there is a strong feeling that the Act is not serving people as it should, then it gets amended, no question. But that is up to Parliament, not me.”
While he agreed that he could lobby the ANC and parties you work with to vote for changes, right?” he again agreed, then said: “But the ANC is no longer the majority party.”
And while the fastest way – in an ideal world – to roll out the NHI [if the ConCourt rules that the Act is, indeed legal, and court cases can go ahead] would be to work around court cases and agree on some of the issues, “this is not an ideal world”.
“We are negotiating with people who run healthcare as a business, who put it on the JSE,” he said. “If you allow the concept of finalisation of health to take root, whereby everything is determined by money, and money only, you never get it right.”
See more from MedicalBrief archives:
Leave NHI challenges to the court and lawmakers, state says
Government plays for time on NHI court cases
Government’s NHI claims are ‘fallacies’, says BHF
BHF calls for Minister’s powers in NHI to be slashed