As the first draft regulations for the National Health Insurance Act are soon to be released for public comment, stakeholders who say their previous submissions on the legislation have been ignored, are wondering if their input will be considered seriously now.
This comes as Health Minister Aaron Motsoaledi is doubling down on plans to impement the NHI and is yet to meet stakeholders opposed to sections of the legislation, notes MedicalBrief.
Motsoaledi has likened strategies used by opponents of the NHI to that employed by the apartheid government. At the International Pharmaceutical Federation Congress last week, he told delegates that the NHI had become “the modern-day swart gevaar of the apartheid government”.
Motsoaledi referenced tactics like the fear-mongering headlines used in the early 1990s to scare the public about Nelson Mandela’s imminent presidency, resulting in some white people hoarding groceries and candles “for when the darkness came when a black man ascends to the throne”.
He said this “type of strategy” was being focused on universal health coverage, but that there was a need to invest in sustainable and equitable health financing.
In a News24 commentary, Carol Paton writes at the end of the GNU lekgotla in July, President Cyril Ramaphosa addressed the division among the governing parties over the NHI and promised to “..bring stakeholders together to resolve differences and clarify misunderstandings”. He also noted that both the public and private sectors were needed to tackle the country’s healthcare needs.
On the same occasion, Motsoaledi said he would “meet all relevant stakeholders” to find out what they mean when they say “they support universal health coverage but not the NHI”.
But so far, Motsoaledi has shown no inclination to meet the stakeholders – medical professional organisations, the business community, and several political parties – who oppose the NHI.
Instead, he has embarked on roadshows to communities where he has been “well-received” as he “simplified the benefit of the NHI to ordinary people” who have asked him to fast-track its implementation, said his spokesperson Foster Mohale.
“There is huge interest from various stakeholders across the country who want to have engagement … on the NHI, and the Minister has committed to give them his audience and clarify any misunderstandings, especially from those who are against the transformative agenda of the country,” Mohale added.
In short, having promised consultation, Motsoaledi is doubling down and is now on a national tour to sell the NHI. He has also released an NHI video clip on WhatsApp and persuaded the ANC's communication department to issue a statement calling the public to “defend the NHI Act” from “certain sectors” that aim to derail it.
Meanwhile, regulations for sections 12 to 30 of the Act, covering the appointment of the board of the NHI fund, would be gazetted for public comment after the relevant sections of the Act had been promulgated.
Interested parties would have three months to comment. Once the board is established, a CEO will be appointed and administrative structures set up, reports Business Day.
NHI DG Nicholas Crisp added that funds would follow the creation of these functions, a process that could take up to three years, and that the department was collaborating with provincial Health Departments to test new contracting arrangements for primary healthcare, drawing on healthcare personnel from the public and private sector.
The project included maternity and child health services, care for the elderly and people with disabilities, and focused on rural areas.
The preparatory work was being funded with a budget allocation earmarked for its NHI unit. These functions would gradually shift to the NHI fund, along with the requisite financing, he said.
“The time horizon is obviously multi-year, and statutory changes and budget cycles will dictate the pace at which the financing reforms and fund shifts will happen.”
However, experts say with still no clear details on what NHI will cover, doubts persist about its ability to provide the same essential health services as private medical schemes, with experts saying “significant funding” will be needed.
Their concern is how the NHI plans to cover medical emergencies, maternity, chronic and severe health conditions, which medical aids cover as standard for 9m people under prescribed minimum benefit (PMB) regulations.
To match these private medical aid services, massive funding would be required according to Craig Comrie, chair of the Health Funders Association (HFA).
“Accessing these services … remains invaluable to South Africans,” he told The Citizen, adding that no one who belongs to a medical scheme can ever run out of these PMBs, which medical schemes are bound by law to cover.
“Medical schemes belong to members and part of the deal when you join is you are covered for these essential services – irrespective of how much you have contributed monthly.”
PMBs include various conditions that range from cancer, strokes, heart attacks and kidney disease, to some mental illnesses.
Comrie said more than half of medical scheme members have a monthly household income below R30 000, meaning that accessing private hospitals for major health events without health cover would otherwise be out of reach for many without incurring debt.
“An ageing medical scheme population brings an increased prevalence of chronic conditions and this, along with a declining ratio of doctors to care for people, means prices will rise.
He said the industry was committed to collaborating on “workable solutions that will make access to advanced medical treatments more equitable in the future”.
“In contrast to the state’s road map as described in the NHI Act, people … want freedom to get treatment options where cost is not the only deciding factor”.
Paton notes that while the department said legal attempts to stop the NHI would be resisted, after several months, the government has still not filed a single opposing affidavit for either of the cases challenging the NHI’s constitutionality.
She writes:
Among the court papers filed by the Board of Healthcare Funders is an incriminating 2018 letter from the Treasury to the Presidency, outlining a series of constitutional problems it felt should be addressed.
None of these concerns, including usurping the provinces of their powers and responsibilities, or curbing the freedom of individuals to do business, was even slightly considered in the final Bill that appeared four years later.
More importantly than noting some of the finer details of the legal arguments ranged against him, Motsoaledi would be well-advised to recall the experience of his Cabinet colleague Gwede Mantashe in June 2021, writes Paton.
Under pressure to raise the 1MW licensing threshold for private power projects to 50MW, Mantashe claimed the call to raise the threshold was not shared by the masses but suited the agenda of the elite and, particularly… white renewable energy businesses.
He claimed the country was not ready for a higher licensing threshold, that “there would be chaos if lifted so high”. He then took things further, claiming in his Budget speech that year that his department had done a survey of 10 000 people showing “overwhelming support” for his proposal of a 10MW threshold.
“The majority in the market say they are not ready for this 50MW. It is an academic debate,” he told MPs.
After numerous press inquiries about the survey, three weeks later, the Department issued a fresh statement to say that there had been no survey, offering the equally absurd claim that 10 000 people had emailed the department in response to the invitation for public comments.
A month later, Mantashe faced the media again, this time sitting alongside Ramaphosa who announced that the threshold would be lifted to 100MW. Mantashe confessed that “his arm had been twisted”.
Motsoaledi has cast the battle over NHI in a similar light – as being opposed only by the wealthy and supported by the poor. Of course, the most vociferous opponents of the NHI are members of medical aid schemes who stand to lose access to first-class medical care.
But just as the lifting of the licensing threshold benefitted everyone, and not just the wealthy businesses that built the power plants, reforms to the funding of the healthcare system that are careful not to destroy private medicine can benefit both those who belong to medical aid schemes and those who don’t.
The key is the newfound commitment to universal health coverage, the principle that no one should be deprived of treatment because they cannot afford it, and the same principle that underpins the NHI and the reason behind its existence.
The difference is that Motsoaledi and other NHI evangelists insist that for the NHI to raise sufficient funding for the care it hopes to offer, private medical schemes and private healthcare must be cut down substantially in size and ultimately phased out – but for a tiny sliver to remain to service the super, super rich.
They argue that it would then be possible to channel a large portion of the money people spend on medical aid premiums into the fiscus through taxation.
It simply won’t work, because it is not possible to mobilise that amount of money (up to another R200bn) from taxpayers.
And, as the squeeze, or the threat of the squeeze, is put on the private medical sector, it will shrink and decline. Business confidence, only barely beginning to grow again, will sink back into the doldrums.
This is before we even begin to consider the institutional nightmare of rearranging the provincial health system into a centrally funded NHI fund that will buy all of the health services the population needs, or before we contemplate a government with a poor administrative and governance record as the guardian of such a large pot of money."
The Citizen – Uncertainty looms over NHI’s coverage of essential services
BusinessLIVE – Health department gears up to publish first NHI regulations
News24 article – How strong is Minister Motsoaledi's arm? (Restricted access)
See more from MedicalBrief archives:
Motsoaledi stands firms on medical aids under the NHI
Motsoaledi to increase push for NHI
NHI tug-o'-war for GNU and new Minister