South Africa is one step closer to implementing the National Health Insurance (NHI) system, after the National Council of Provinces (NCOP) voted in favour of the NHI Bill yesterday despite widespread opposition from health professions and business. But it will be a long and challenging battle before the Bill becomes law, writes MedicalBrief, as legal action is almost certain to follow soon.
Fin24 reports that eight of the nine provinces voted to approve the Bill, unchanged. The Western Cape voted against it.
ANC secretary general Fikile Mbalula said at a media briefing earlier on Wednesday that party members had to ensure the Bill went through. He said anyone who was opposed to it should approach the courts.
“It is a historic day and a historic achievement. We are putting in place a framework … to transform health services, create equity and make sure the perpetual division of South Africans – at least in health – can come to an end,” said Health Minister Joe Phaahla during the debate on the Bill yesterday afternoon, which saw ANC MPs emphasise the party’s 1955 Freedom Charter promise to provide free medical care and its ambitions to eliminate SA’s two-tier health system, a BusinessLIVE report notes.
Only 14.9% of the population can afford medical scheme membership, which provides cover for generally high-quality private healthcare services, while the rest of the population depends on over-burdened public healthcare facilities that vary widely in their capacity to provide care.
The Bill lays the groundwork for sweeping reforms to SA’s health system intended to realise the ANC government’s ambitions for universal health coverage. It creates a single NHI Fund that will purchase services from public and private providers that will be free at the point of delivery, and prohibits medical schemes from covering services provided by NHI. Details of how it will be financed have yet to be spelt out, but the ANC has consistently indicated it intends to redirect the money employers and individuals pay to medical schemes into the NHI Fund by taxation, a proposition critics say is unviable.
“As South Africans battle to put food on the table how can we possibly think of raising taxes to fund NHI? This ANC vanity project is a last-ditch effort for votes that will affect our pockets deeply,” said the DA’s Dennis Ryder.
“It is a perilous gamble, a reckless leap into the unknown that threatens to intensify the very issues it purports to solve,” said his colleague Delmaine Christians.
The EFF’s Mmabatho Mokause said the NHI Bill would not close the gap between the services available to rich and poor, but simply enrich the private sector at the expense of SA, while the IFP’s Nhlanhla Hadebe said the Bill jeopardised South Africans’ current access to health services.
The Bill will now be sent to President Cyril Ramaphosa for assent. He has several options: he can send the Bill back to Parliament on technical or legal grounds, refer it to the Constitutional Court to determine whether it is in line with SA’s constitution, or sign it into law.
MedicalBrief reports that the Hospital Association of South Africa (HASA) said it was disappointed and concerned that the NCOP passed the Bill without engaging with "the many constructive suggestions and proposals that we, business representative organisations, and many other healthcare stakeholders have tabled".
In a statement, HASA said: "We firmly believe the legislature has missed an opportunity to address several fundamental and critical issues that threaten the healthcare system's efficacy and that, therefore, urgently require resolution.
"While we support the Bill's stated objective of Universal Health Coverage (UHC), we have consistently noted the need for more clarity regarding the future role of medical schemes and the need to incorporate a multi-payer approach instead of the proposed single-payer regime.
"In addition, there needs to be far more detail regarding funding our country's most consequential initiative ever. Moreover, solutions to the deepening nurse and doctor shortage and the desperate need for adequate public health facilities to strengthen healthcare delivery remain elusive."
HASA urged the Presidency to recognise the compelling inputs into the NHI Bill and to address the issues raised by the private sector.
Business Unity SA (Busa) and Business 4 South Africa (B4SA) previously indicated they will petition the President not to sign the Bill into law, while Solidarity said it was preparing to litigate. The DA said it will petition the President to refer the Bill to the Constitutional Court to test its constitutionality, failing which it would seek to rally support from enough MPs in the National Assembly to ask the Constitutional Court to make that assessment on behalf of parliament. It has also briefed its lawyers for potential legal action.
The Fin24 report says the Bill, which has been in the parliamentary process since 2019, was pulled from the Order Paper last week when the NCOP chair, Amos Masondo, asked for a delay to consider a letter urging him to revisit the Bill.
The letter – written by Busa and B4SA – expressed grave doubts that the NHI in its current form could be implemented or would be good for the country. Business says SA does not have the resources to implement the NHI, which would require raising an additional R200bn in taxes.
The DA and Busa argue that the Bill is unconstitutional because Section 33 – which talks about phasing out the benefits for which medical schemes may reimburse members for – will limit access to healthcare rather than progressively expanding it.
Since the Bill was introduced in 2019, no changes have been made in four years, despite critical comments from the medical profession, the private healthcare industry, medical aid schemes, and other stakeholders.
News24 reports that DA said: “If the President does not heed our call, we will invoke Section 80 of the Constitution, which indicates that a third of the members of the National Assembly may petition the Constitutiona Court directly about the constitutionality of the Bill – either parts of it or in its entirety,” said the party’s chief whip Siviwe Gwarube.
The DA was not the only party in the National Assembly opposed to the Bill, she added.
“We believe we can put together a third of the members of the NA to petition the courts directly. If, for some reason, we are not able to do this, the DA has already briefed its lawyers about this Bill and the sections we oppose.”
In an unprecedented move, business organisations last week wrote to the presiding officers of the NCOP as well as Deputy President Paul Mashatile, leader of government business, urgently appealing to them to put a stop to the Bill.
The week before, the NCOP Select Committee on Health & Social Services adopted the Bill without any amendments to the version passed by the National Assembly, despite intense lobbying from Busa, Business for SA (B4SA), and healthcare professionals.
Meanwhile, Cosatu has also weighed in on the matter, with acting national spokesperson Matthew Parks pushing Parliament to approve the long-delayed legislation.
He said the country’s myriad healthcare crises required the creation of the NHI, and that “government and the NCOP should not place the profit margins of private industry above the needs of society”.
Presidency spokesperson Vincent Magwenya said last week that Ramaphosa “wouldn't simply sign” the controversial NHI Bill into law without giving due consideration to constitutional aspects and public participation processes.
Fin24 – NHI one step closer after NCOP votes in favour of bill
See more from MedicalBrief archives:
NHI heading for ‘Eskom-level stuff-up’
Government dodges issue of NHI funding model – DA
There may yet be a role for medical schemes under NHI, says legal expert