After taking many by surprise with the signing of the NHI Bill last week, President Cyril Ramaphosa and government Ministers adopted a more placatory tone, emphasising that they were still open to talks with stakeholders and that the implementation process would allow for changes, notes MedicalBrief.
But several groups are nonetheless continuing with legal action against the legislation, which has also sparked fresh concerns of an exodus of medical professionals from South Africa.
Presidential spokesman Vincent Magwenya said “… we have noted the concerns … The President is giving thought to a mechanism to allow for more engagement and collaboration with business, labour and other social partners as we begin to roll out the implementation of the NHI.
“Implementation will be in a phased manner, there is no element that is going to happen overnight or be managed in haste. Our legal framework also allows for amendments to be made.”
In the same vein, Finance Minister Enoch Godongwana told the Sunday Times the criticism was premature as the government was yet to outline its implementation plan and the cost of implementing each phase.
He said that the R200bn estimated cost was being used by people opposed to the fund as a scare tactic.
“People must wait for us and the Department of Health to develop the plan of implementation and the cost of each phase, and then they can start asking us those questions about affordability.
“We have not outlined the phases of implementation. People are just throwing numbers. Where does the R200bn come from?”
He said the government was already subsidising medical aids through annual tax credits. “It costs us R34bn per annum. You cut that and medical aids become unaffordable. The costs are going to go through the roof.”
He said focus should be shifted to improving public hospitals in preparation for the implementation of the NHI, and upgrading public facilities “to accommodate more patients”.
News24 reports that with South Africa already battling medical specialist shortages, member organisations have warned that these may be further exacerbated by the NHI, which could trigger a wave of emigration.
There is concern that countries like Canada, the UK, Ireland and New Zealand are already actively poaching specialists, and while the organisations said they were prepared to do legal battle against the Act, nevertheless there was still likely to be an exodus of some members.
In a 2023 survey among its members, the Radiological Society of South Africa (RSSA) said 36% of them were “likely” to emigrate, while 23% were “uncertain” and 41% were “unlikely”.
Safety, security and NHI
Dr Richard Tuft, executive director of the RSSA, said the main reasons radiologists were considering leaving were safety, security, and the NHI.
“We split the survey into the private and public sector, and saw that 25% of radiologists in the public sector are likely to leave, so this isn’t a private sector issue; this is across the whole radiology profession.”
He added that although 1 102 radiologists fell under the RSSA, including training and retired radiologists, there are only 800 actively working radiologists in South Africa.
“In the private sector, we have about 4.5 radiologists per 100 000 people, and the public sector is half of that. Overall, we have about two radiologists per 100 000 people.”
Tuft said these numbers were extremely low compared with other countries. The Organisation for Economic Co-operation Development (OECD) countries have 8-16 per 100 000 people.
"Among radiologists considering leaving, 19% are 35 or younger, and 45% are between 36 and 45. This means 64% of radiologists under 45 are thinking about leaving. That is problematic because the young specialists are the very people we need to keep,” he said.
Limited funding, rising demand
Dr Caroline Corbett, former president of the South African Society of Anaesthesiologists (SASA), said the society had more than 2 000 members, “but not all of them are still in the country because anaesthesiologists are very mobile and highly sought after internationally”.
The number on the WHO maps for resources was 2.7 specialists per 100 000 people, she added.
“This is grossly insufficient to provide access to anaesthetic care for our nation. We’re a critically low resource, and unfortunately, also a scarce resource globally.
“Many other countries – from Canada and the UK to Ireland and New Zealand – are actively poaching South African anaesthetists because we are well-trained. Many are leaving to work in healthcare systems that are perceived to be more supportive of healthcare workers in general.”
“If there's only one funder – the NHI – we believe this will drive people away because doctors will be forced to accept the fees the state is prepared to pay. I think we’re going to see massive immigration,” Tuft said.
Scarce ophthalmologists and court action
The Ophthalmological Society of South Africa (OSSA) said all medical specialist skills are in short supply, with ophthalmologists representing a particularly small fraction of the entire medical specialist community.
“Ophthalmology is not one of the major undergraduate training areas, meaning that doctors in training may have limited exposure to the discipline.
“The training to become a doctor and then an ophthalmic surgeon is difficult and overall takes at least 13 years,” OSSA said.
OSSA has 383 ophthalmology and registrar (trainee ophthalmologists) members,
While the organisation, like others, supports universal coverage, it rejects the NHI Bill in its current form.
“There is a distinct lack of emphasis in the Bill on specialised service areas like ophthalmology.”
OSSA, the Federation of Surgeons of South Africa and the South African Health Processionals Consortium, were all disappointed with the signing of the NHI Bill into law, saying they would join legal action against it.
The reaction comes as healthcare groups, business organisations and others were taken by surprise when the Bill was signed last Wednesday, saying they had been under the impression the President would not sign until their concerns had been met.
They told TimesLIVE they had gained this impression after numerous prior meetings with Ramaphosa, with one saying they had left the meetings “strongly” believing the Bill would not be signed in its current version.
This week Union Building insiders confirmed the President had been under “extreme” pressure from business not to approve the Bill. “There was a very strong lobby against it…even at times from people close to him,” said one.
Critics have accused Ramaphosa and the ANC of using the new Bill to galvanise support before the elections, with the criticism and dismay from organised business marking a departure from the cordial working relationship the private sector has forged with the Presidency over recent months.
Ramaphosa has leant heavily on the business sector in attempts to transform energy and logistics challenges affecting economic performance.
Business Unity South Africa CEO Cas Coovadia said the Act was “unimplementable and damaging to the healthcare sector, to the economy more broadly, and to investor confidence”.
“What is especially troubling is that the President is proceeding despite extensive constructive inputs from a wide range of stakeholders, including doctors and healthcare professionals, civil society, public sector unions, academics and business. The unfortunate consequence is that this version will hamper, rather than promote, access to quality healthcare for everyone.”
Martin Kingston of Business for South Africa said the group had met consistently with the President to discuss its reservations, and was disappointed he had signed the current version despite its problematic provisions.
But rather than immediately going to court, he said they would instead work with the government to correct provisions it believes are unworkable.
“None of us has a choice. We need to fix and address defects in the legislation and ensure it is fit for purpose. Currently it is not. The best way to achieve that is to engage openly and transparently to ensure we accommodate all perspectives in determining the correct outcome, and that we manage expectations and build confidence in the process,” Kingston said.
Similary, the head of Life Healthcare said litigating against NHI was the “last and least desirable resort”, according to a BusinessLIVE report.
“The minute you sue, your relationship goes,” said Life Healthcare CEO Peter Wharton-Hood, advocating for “constructive engagement” and closer collaboration between the public and private sector.
“The demand and capacity is there, but it needs sensible commercial deliberations,” he said.
Private hospitals had spare capacity that could be used for public sector patients, but not in all domains, he said. For example, Life Healthcare had no spare capacity in its intensive care units but could potentially double the number of renal dialysis patients it currently serves.
However, legal challenges will be going ahead from others, including from the SA Medical Association (SAMA), with chairperson Dr Mvuyisi Mzukwa saying the Bill failed to address health system issues, and that the body’s legal team was preparing to launch a legal challenge “in the relevant courts”.
“The NHI is not a viable solution to realise universal health coverage for the South African population,” he said. “It is our duty to advocate for equitable access to affordable essential healthcare services – and it is a cause we are ready to fight for.”
SAMA CEO Dr Mzulungile Nodikida said they were not opposing universal health coverage, reports News24.
“We remain firm in our commitment to championing health and the well-being of all South Africans, and remain resolute in our endeavours to actively participate in the realisation of universal health coverage. But it is also our duty to advocate for equitable access to affordable and essential health services as a basic human right, and to ensure the highest achievable quality health outcomes.”
In its current form, the NHI “really fails to address the county's complex health issues, so we just can’t support it”.
In May 2023, the association said the Bill was developed with disregard for the legitimate concerns and recommendations of experts, particularly on critical issues like the introduction of contracting units for primary healthcare, benefits packages and reimbursement models, among others.
At the time, issues were also raised about the government's ability to efficiently manage the more than R500bn budget.
Mzukwa said trust in the government was severely eroded, particularly due to the mismanagement of Covid-19 funds.
Civll rights organisation AfriForum has also announced its readiness to join a class action against the NHI, with an interim application to suspend the application.
In a statement in PoliticsWeb, it said it has “committed to see the legal battle against NHI through till the end”.
AfriForum’s board of directors had already signed a resolution confirming it would file a lawsuit against the government and that this lawsuit would continue until all remedies had been exhausted.
While Netcare CEO Richard Friedland said he welcomed the President’s comments indicating a desire for further engagement with the private sector, the hospital group was nevertheless also seeking legal advice, and would work with the Hospital Association of SA and Business Unity SA on its response, reports BusinessLIVE.
“We believe very strongly in public and private sector collaboration in ensuring universal health coverage is attainable and sustainable. That opportunity has been denied to the private sector,” Friedland said, adding that the decision to ignore private sector input on the Act has set the government up for legal confrontation that could have been avoided.
“This entire process has been a missed opportunity, because by not engaging and by largely ignoring input over several years from very astute industry … and stakeholder bodies, this process of implementation … will be unnecessarily delayed. It could have been avoided had government engaged in a constructive and sincere manner, but unfortunately that wasn’t the case.”
Meanwhile, government said for the NHI plan to be even minimally effective, a significant – and costly – overhaul of South Africa’s medical records will be required to fit within a common, shared Digital Health Platform.
Developing this, and expanding digital inclusion, was essential, the government said.
My Broadband reports that according to the Department of Health’s National Digital Health Strategy for 2019 to 2024, the platform will include establishing cloud infrastructure and “an environment for supporting sophisticated data science activities”.
“This platform will include the creation of reusable frameworks and artefacts that promote success,” it says.
The department says this will help co-ordinate and provide technical resources to support a range of activities, aimed at achieving:
• Overall quality and continuity of care;
• Adherence to clinical guidelines and best practices;
• Efficiency and affordability of services and health commodities by reducing duplication of effort and ensuring effective use of time and resources;
• Health-financing models and processes;
• Regulation, oversight, and patient safety from increased availability of performance data and reductions in errors; and,
• Health policy-making and resource allocation based on higher-quality data.
Other priorities include establishing a complete electronic health record to help with patient management, and digitising health systems and business processes.
News34 article – SA Medical Association to mount legal challenge against the NHI (Restricted access)
My Broadband – NHI needs massive overhaul of digital medical records in South Africa
BusinessLIVE – Litigating against NHI is a last resort, says Life Healthcare CEO
News24 – Critical healthcare specialist shortages in SA could worsen with NHI, medical bodies warn
TimesLIVE article – Ramaphosa ‘open’ to more NHI talks (Restricted access)
See more from MedicalBrief archives:
NHI Bill signing sets stage for protracted battle in courts
Don’t wait for NHI to start health sector reform, SA experts urge
Doctors’ petition urges NCOP to reject NHI Bill