The National Health Insurance Bill (NHI) has been passed by the National Assembly, taking it one step closer to becoming legislation although the road to the adoption of the contentious scheme is still a long way off, and it is almost certain to be met with legal action and more protests, notes MedicalBrief.
Health Minister Joe Phaahla has hailed the Bill as one of the most 'revolutionary' pieces of legislation to be passed since democracy, but has acknowledged that there was much spadework to be done before its implementation, which will be in phases.
The Bill, which will now go through the National Council of Provinces, was given the go-ahead on Tuesday, with 205 MPs voting in favour while 125 voted against it. This was despite vehement opposition from political parties, business, healthcare professional groups and activists, who warn that the Bill, in its current version, will not address the myriad challenges in the sector.
The Bill has also been adopted despite there being no model to show how it will be funded, and warnings from Parliament's own legal team.
The latest draft of the Bill has faced a barrage of criticism from the private sector in the three weeks since it was approved by Parliament’s Portfolio Committee on Health. Warnings were sounded by Business Leadership SA; the Board of Healthcare Funders and the Health Funders Association, which both represent medical schemes; the two biggest professional organisations for doctors and medical specialists; and SA’s biggest medical scheme administrator Discovery Health.
Business Day reports that during MPs’ consultation on the Bill, concerns were also raised by civil society organisations, patient advocacy groups, and Parliament’s legal advisers, who warned that it might be unconstitutional.
But Phaahla said the government was determined to implement NHI and it would defend the reforms all the way to the Constitutional Court.
“We live in a constitutional democracy. It won’t be the first Bill to be taken to court,” he said after it was debated in the National Assembly, while Cosatu parliamentary liaison Matthew Parks said: “South Africa cannot continue on a path where public healthcare is buckling due to under-resourcing, unfilled posts and long queues, while the private healthcare sector charges exorbitant rates and caters for the few who can afford it.”
Casatu called on the NCOP to “move with speed” to pass the legislation.
“It is critical government allocates sufficient resources to ensure the NHI Bill becomes a reality for all South Africans…”
DA MP Michele Clarke said the already burdened public health services would be unable to carry out the required mandate of the NHI, “especially since it will have to accommodate the more than 9m people who currently belong to medical aid schemes”.
Philip van Staden of the FF Plus predicted that healthcare would simply “crumble under the complete control of the ANC”.
“The truth is that the NHI is a political ploy to secure votes for the 2024 general election. It makes promises to everyone, but in all truth there is going to remain nothing for anybody.”
The EFF’s Naledi Chirwa said the NHI could be counted as one of the ANC’s “biggest scams”, reports News24.
“They manipulate people to tell us the NHI will bring us equality. It's not the eradication of a two-tier system. The only way to do this is to nationalise healthcare. This NHI is to sell healthcare to the private sector,” she said.
She echoed concerns that the Health Department had not revealed the true cost of the NHI to Parliament.
“The NHI is not easing the access to healthcare for the poor, because those who are living in rural areas will still be subjected to dilapidated health facilities. There is no development in most of those areas. In fact, public hospitals will only become more dilapidated and corruption will also be rife under the NHI. We reject this Bill and we will not be a part of it,” she said.
However, Phaahla staunchly defended the Bill, lauding its approval by the NA. “It is unjust that almost all healthcare professionals are trained at the expense of taxpayers,” he said. “And then once they become specialists and super specialists, they become available to only the top payer.
“The availability of top health professionals to only those on medical aids and even migration to richer countries is unjust. Members of medical schemes, even in this very House, are under tremendous financial pressure – and employers are also under pressure to increase that share of the contribution. It is not sustainable.
The NHI fund aims to cover all races, rich or poor, as well as legal, long-term residents. There will be one pool of healthcare funding for private and public healthcare providers
South Africans will no longer be required to contribute directly to a medical health scheme for quality healthcare, with the NHI being funded from general taxes and monthly contributions by employees to the fund.
Yesterday, the Institute of Race Relations (IRR) said South Africans should be “deeply” alarmed by the approval of the Bill and vowed to oppose its implementation with “all the resources at its disposal”, according to a BusinessLIVE report.
“In March 2022, finance minister Enoch Godongwana said that the government had not updated the cost model of the proposed NHI scheme since the 2019/20 financial year, before the Covid-19 pandemic.
"In 2019 (former) Health Minister Zweli Mkhize said annual costs were likely to exceed the combined total (R470bn) of public and private health spending that year. Both he and his successor, Dr Joe Phaahla, have been adamant the NHI must proceed ‘regardless of its costs’.”
The organisation went on to say: “The tax increases required to generate at least R470bn a year (and more likely R700bn a year by 2026) will be high.”
The IRR said implementing the Bill “will result in the exodus of many health professionals because they believe the NHI will ‘destabilise’ healthcare rather than improve it”.
“The IRR will oppose the NHI with all the resources at its disposal. The government should rather focus on fixing what is broken instead of breaking what works,” he said.
Trade union Solidarity alo said it was gearing up for a court challenge to the Bill.
Health-e News reports that the legislation will be implemented in phases from 2026 – but that Phaahla had conceded, during his address, that the public health system needed fixing.
“We must address the genuine fears of those who have access to private services where there are no queues, no waiting times, and no shortages of commodities except in a disaster like Covid-19, where even private hospitals ran out of beds and oxygen at some stage,” he said.
Fears of corruption and mismanagement also had to be addressed. “Not all public hospitals have been run like Tembisa Hospital….”
But the DA and others remain highly sceptical.
“Instead of going directly to the private paid doctors and hospitals, people will now be competing for treatment in the public health system with its severe staff and resource constraints. The last indicator of the national surgeries backlog was more than 168 000 cases,” said Clarke.
She added that without feasibility studies on the NHI, it was impossible to ascertain how many facilities would survive the government-free structures.
“These potential closures will further dismantle the sectors. Staff shortages are a massive problem and have been for years. And there will surely be a mass exodus of medical professionals if NHI is forced.”
Well-equipped health facilities and safety at hospitals and clinics were other concerns she raised. “Have they ensured that the facilities have working equipment, beds, medicines, and food? The DA can attest that many of the hospitals, and clinics are in inhumane conditions. It is still unclear which health services the NHI will cover.
“Will the department pay for hip replacements, dental care, appendix removals, dialysis, chemotherapy, TB and HIV treatments, or mental healthcare? We don’t know because you have refused to inform us. Possibly because you do not know.”
Both the IFP and the ACDP have also roundly rejected the Bill, with the former particularly concerned about the cost of implementation.
“In our opinion the Bill will deny access to healthcare services rather than promote it, because of the enormous amount of funding it will require,” says Magdalene Hlengwa, IFP MP, adding they were also worried NHI could further limit access to healthcare services.
The ACDP’s Marie Sukers said: “We believe the architecture of change requires critical elements to be present. The question begs whether the lofty aims of universal healthcare, for all, can be achieved under this administration, and whether the legislation before this house, when implemented, will move us closer to this aim.”
“We do understand some of the concerns about poor management, but we want to say even in the overburdened public services there are jewels. I can give you examples…” said the Minister after, again, outlining the imbalances in South Africa’s healthcare where 84% of people rely on public healthcare.
“This has led to a situation where the public health system is under tremendous pressure, while the private healthcare is over-servicing its clients leading to ever-rising costs to the members of medical schemes while the investors are enjoying huge dividends including from the JSE.”
By pooling private and public health funding, he said, “we can achieve access, equity and quality, but also drive down costs.”
Phaahla added that it was “untrue” to say the estimated 9m South Africans on private medical aid would now migrate to only the public health service, as the DA had pointed out.
“We all contribute to one pool (of resources) under one fund so we can access services both in the public health services but also in private health… The cost will be negotiated.”
However, reports Daily Maverick, the Bill forecasts medical schemes only offering services not available on the NHI, and is firm on set referral pathways.
And while the Health Minister appoints the fund’s board, no parliamentary role is envisioned in that process, heightening concerns over the lack of accountability also among medical associations like SAMA, which called for parliamentary supervision.
Exactly how the NHI would be funded remains unclear, although payroll taxes and personal income levies have been raised, even as value-added tax (VAT) hikes are understood to have been ruled out by National Treasury.
ANC MP S’dumo Dlamini, a one-time Deputy Minister, former Cosatu president and nurse by profession, said the NHI, once implemented, would supply “more resources for staffing, infrastructure, equipment and medicines and supplies… Healthcare will never be a marked commodity, it is a public good”.
Numerous private sector players and critics say the the provisions and stifling of medical schemes – and only being permitted to provide “complementary” cover for services not covered by the fund – will destabilise the private healthcare sector, and be at odds with the constitution because this would reduce members’ access to healthcare services.
The Bill has also been panned for what critics say are its weak governance provisions, which they say leave the NHI fund open to corruption.
“We want to assure South Africans that we are … paying deep attention to makes sure managerial and leadership risks are addressed,” said Phaahla.
“That is why we have said the NHI implementation is not going to be an event, but a process. We have said over and over again it will be in stages.”
Fatima Hassan, founder and director of the Health Justice Initiative, and a human rights lawyer and social justice activist, writes in Daily Maverick that under NHI, South Africans “are unlikely to be equitably able to access lifesaving, affordable medicines”, and that as the Bill stands, it is not what was promised.
Far from creating equal, fair and affordable medicine access for all, right now, and quite contrary to the narrative of government officials and ANC lawmakers, the Bill and the system it proposes is actually confusing, often unclear, and far off the social solidarity mark it promised, she wrote.
“It is too preoccupied with documentation at the risk of public health need (pandemics and health emergencies know no borders) and risks entrenching the status quo even further, by enabling at least four unclear, differently operated and parallel systems for medicine access.
"This means that wealthier people (including our MPs) will still be able to bypass NHI selection and buy more expensive life-saving and other medicines on their own/with others where the State does not procure these — except if you are undocumented and/or poor, in which case you risk losing access altogether to any avenue for healthcare (save humanitarian).”
All patients and the very sick should benefit from the best medicines and care science has to offer, not just the rich or the employed. “At the same time, Universal Health Coverage should better public health outcomes. But this is exactly what the NHI Bill does not do, as currently drafted.”
In the accepted draft (Version B), she wrote, are a few deletions, some instances of the curtailment of ministerial discretion and powers, the involvement of Cabinet in key appointment decisions, including the appointment of the CEO of the NHI Fund, the NHI board members and chairperson, and the members of the Appeal Tribunal.
There are now also additional requirements on managing the conduct of and dealing with the disclosure of interests among members of technical committees established by the board and also advisory committees … and the inclusion of all children, irrespective of nationality, to “basic healthcare services”.
“But this version (B) is being debated when confidence and trust in national and provincial government departments are worryingly low, amid growing xenophobia in state health facilities, paralysing allegations of corruption in government procurement, a healthcare delivery system in crisis also due to unmanageable levels of rolling blackouts, and more importantly, growing evidence of health products procurement corruption in multiple provinces.
“Regrettably, no single sector is really being listened to with a view to strengthening the NHI Bill, which does not bode well for government and the health department, and which are both likely to face differing and multiple decades-long legal challenges if the Bill is passed and then assented to later this year by the president.”
Hassan said the HJI was calling for, among other things:
• Specific measures to enable and promote public transparency related to medicine selection, procurement, and contracting processes;
• Improved transparency and mandated sharing of all deliberations of NHI Board and Ministerial Advisory Committees … and that the NHI prescribes by law that they publicly disclose any conflict of interest between their professional work, paid consultancies, and their duties on these committees.
• The need for explicit provisions on how selection decisions and prices on medicines not covered under NHI will be decided.
This involves figuring out how the current medicine pricing system (called ‘Single Exit Price’) that governs private sector medicine acquisition will be amended and/or extended. And whether this will also include medicines selected outside of NHI.
She wrote that it is clear “we need a fair, unambiguous, equitable, single-medicine pricing system for South Africa”.
“The NHI Bill being debated does not give us that. And while there is local and global goodwill to help ensure the future of medicine access is not further fragmented in South Africa or placed in jeopardy, the question remains: is our government willing to pause, genuinely listen and course correct?”
Health-e News article nhi: one step closer to implementation (Open access)
BusinessDay PressReader article – Nod for NHI Bill, flaws and all (Open access)
BusinessLIVE – IRR will fight NHI bill with ‘all the resources at its disposal’
See more from MedicalBrief archives:
NHI ‘will lead to emigration, corruption’
Litigation threats as NHI Bill passed by parliamentary committee
Fifty reasons why the NHI will not work