The National Health Insurance (NHI) poses one of the biggest challenges for the new Health Minister and the government of national unity (GNU), whose members are sharply divided on the scheme, writes MedicalBrief.
The ANC's Aaron Motsoaledi, who had a controversial stint as the former Minister of Home Affairs, takes over from Joe Phaahla – now demoted to the deputy position – who oversaw the final processes of pushing through the NHI Bill as law.
While some of the medical fraternity and civil society advocates were cautiously optimistic about the return of Motsoaledi, critics say that he had, after a 10-year stint in the health sector previously, left the public service in a worse state than he found it.
The problem with Motsoaledi is that if you only have a hammer, every problem looks like a nail, according to Dr Aslam Dasoo from the Progressive Health Forum in a Daily Maverick report.
He fears Motsoaledi’s hammer is the NHI, saying that under Motsoaledi’s watch, the country saw the biggest decline in access to health services across the board, as well as the biggest degradation in health services.
“This means that now the technically most proficient cohort in the public service, health professionals working in the state hospitals, are on their knees. It is an incredible indictment on this government that it cannot see that this moment presented an opportunity for a reset or a step change,” he said.
“The sector is on its knees, and it beggars belief and boggles the mind.”
He said the NHI was not the answer to fix incompetent provincial Health Departments.
Poor-quality healthcare
In a 2018 press conference, Motsoaledi addressed claims that the NHI couldn’t be implemented while the quality of healthcare remained poor, saying fixing the quality of public healthcare “is never going to be an ending event”.
“It is rather an ongoing and continuing process which has no end as long as the health system exists.”
While Life Esidimeni happened under his watch, Motsoaledi was, however, also the Minister under whose leadership the biggest cohort of patients in history was initiated on antiretrovirals. And he created the post of Health Ombudsman.
Russell Rensburg from the Rural Health Advocacy Project said Motsoaledi’s record in expanding coverage for HIV, TB and maternal health spoke for itself.
“Under his tenure, we also saw the implementation of the Occupation Specific Dispensation, increasing salaries for healthcare workers.
Blame game
During his previous stint as health Minister, Motsoaledi had announced a 10-point turnaround plan for health in SA, but failed to deliver on even one of them, said HIV clinician and Wits professor Francois Venter.
He pointed out that this was similar to what had happened under Motsoaledi at Home Affairs.
Meanwhile, the South African Medical Association (SAMA) said it was disheartened by the expansion of the Cabinet, with chairperson Dr Mvuyisi Mzukwa saying it was a “missed opportunity to reallocate crucial funds to our struggling healthcare
system”.
He said they were not focused on the “personalities of those appointed to the health portfolio”.
“We are committed to working … to address the pressing needs within our system. Our primary concern remains the health and well-being of South Africans.”
On the NHI, experts suggest that the implementation of the scheme may hit even choppier waters, Bhekisisa reports.
“The department believes the return of both political principals will ensure continuity and stability in the implementation of key health priorities, which include increasing life expectancy, strengthening health-system effectiveness, and the NHI (scheme) to enable the country to attain universal health coverage,” the health department said.
A total of 10 parties have joined the ANC in the new GNU: the DA, IFP, GOOD, the Patriotic Alliance, Pan Africanist Congress of Azania, Freedom Front Plus, United Democratic Front, Rise Mzansi, Al Jama-ah, and United Africans Transformation.
Combined, they represent 72% in the National Assembly, and with some staunch opposition to the NHI among them, there are likely to be some fireworks within government corridors.
Before the elections, the DA, for one, wanted the NHI Act to be dropped and told its voters the party had its own plan for how to get to universal health coverage. The IFP voted against the NHI Bill in Parliament and the UDM says on its website that “the danger with a national health insurance is that this will be maladministered”.
GOOD doesn’t directly refer to the NHI in its election manifesto, but the party did vote for the Bill in the National Assembly. The PAC also voted for the NHI and Al Jama-ah’s election manifesto promised to ensure the right to health by “supporting the NHI initiative”.
It is unclear what the UAT’s stance on the NHI is, although its website does include an entry on universal access to healthcare (yet without any further details). Its partners in the Progressive Caucus, such as the UDM and EFF, voted against the NHI.
The FF+ is completely against the NHI. “If voted into power, the FF Plus plans to scrap the National Health Insurance (NHI) Bill”, the party said in its election manifesto; the FF+ also has a view on transformation that directly opposes the ANC’s and that of many parties in the GNU: the FF+ says it will prioritise expertise over transformation to improve the quality of healthcare.
Variations of a theme
The NHI is only one plan to get to universal access to healthcare; many other countries use different strategies.
“NHI is a form of universal healthcare, but there are different models,” said Hassan Mahomed, a health systems expert from Stellenbosch University’s division of health systems and public health.
Will the NHI Act become a reality? And if it does, how will it look in practise and how long will it take for the law to change people’s lives?
“Speed is not a word that I will apply to the NHI. Even if the ANC had obtained a majority, it was going to take time – 15 to 30 years analysts suggest – to implement the NHI. It’s going to be a slow process,” said Mahomed.
At the moment, though, there’s “a lot of anxiety around the NHI”.
The experts explain what comes next.
1. It has been signed into law. Is it ready to be rolled out?
“No, not yet. As it’s been published now is more like a rough outline than a final picture, and it will need both further legislation and regulations so that it can operate – that’s why the President has not yet announced when it will come into effect (or he withheld the date of commencement),” said Ben Cronin, a law lecturer at the University of Cape Town and former state law adviser in the Western Cape.
Before the Act, or any part of it, can be rolled out, Parliament will need to enact further legislation (including ones providing for its funding) and the necessary regulations have to be written.
“Regulations determine the detail of how the final picture will look; it’s like adding colour and shading,” he said.
Only once the regulations (or the part for which they were written) are final, is the law ready to be promulgated, which means that the president’s formal announcement can be published in the Government Gazette.
2. Can the Act be overturned?
“The process for repealing an Act is not different from that of passing a new one. It will just require an ordinary majority on the day of the vote in Parliament,” said Cronin.
However, opponents of the Act might not need to fully repeal it to achieve their goals.
Parliament could thwart the NHI Fund by simply withholding the next pieces of legislation that will be needed to make the NHI work (like Bills introduced by the Finance Minister to allocate money to the Fund). This would “effectively scupper” the NHI Fund and make it a “car without an engine”.
To make any amendments, the usual law-making process will have to be followed, said Sasha Stevenson, executive director of the human rights law centre, SECTION27.
This means the Health Department will have to table an amendment Bill in Parliament, where it will again be debated, followed by input from the public. Only then can there be a decision as to whether the change is accepted or dropped.
Although regulations are easier to change than an Act itself, “you can’t fix a law through regulations”, she says.
3. How would the Act go forward, if at all?
Rolling out the NHI will be a gradual process. At the signing at the Union Buildings last month, Nicholas Crisp, NHI deputy director-general in the national Health Department, told Bhekisisa that once the regulations for a section or clause are ready, the Minister can propose by when that part of the Act should be promulgated, via publication in the Government Gazette, and that it’s ready to be put into effect, but the president decides on the specific date.
Crisp said because there’s no board or fund for the NHI yet, it’s impractical to bring the entire Act into effect simultaneously. However, its wording does allow for staggered roll-out dates, with an initial phase of four years (from 2023 to 2026) to set up a board and its administration.
Heads for four of the five chief directorates for the NHI’s branch within the Health Department – health product procurement; digital systems; service provider management; and healthcare benefits and provider payment design – were appointed in 2023. The chief director for risk identification and fraud prevention still needs to be appointed.
At the signing in May, (then) Health Minister Joe Phaahla said the department was already preparing regulations for the NHI Fund and its structures.
4. If it does go forward, what will happen first?
The first thing that needs to happen is that a board must be appointed (once the regulations for this are ready), Crisp said.
The board will, in turn, be able to appoint a CEO, and the board and the minister will set up technical committees to help with specialised knowledge.
An important one would be the benefits committee, which will work out what services the NHI will cover, said Mahomed.
“NHI-funded healthcare may be available if we have flu or pneumonia, or our children need immunisation, but what if I’ve got a rare form of cancer? Will the NHI pay for that? This benefits committee work is crucial in guiding the actual financial structure of the Fund.”
Working out the prices for treatment, and what service providers like general practitioners, physiotherapists, dentists and pharmacists who will form so-called contracting units for primary healthcare, will be paid, will require another committee.
5. How long will it take to implement fully?
Rolling out the NHI will take many years, experts say. Two phases for getting it off the ground are described in the Act. The first will run from 2023 to 2026, to set up the administration of the Fund and shifting the control of central hospitals from the provinces to the national health department.
“That’s also a bone of contention,” noted Mahomed, “because the national department has never managed services directly. But that’s one of the goals for the first phase.”
The second phase, from 2026 to 2028, is about “actually putting in place the building blocks for the NHI to function”, and things like setting up contracting units and how hospital services and emergency services will be funded by the NHI.
While the exact timeline for rolling out regulations is not fixed, experts say strengthening the health system must start now “rather than waiting for NHI to solve all problems”.
See more from MedicalBrief archives:
Digital strategy and working with private sector vital for NHI: Health DG
Let’s be pragmatic to make NHI work for us
Ramaphosa signs NHI Bill, but long road ahead still