The National Health Insurance Bill is now law, with President Cyril Ramaphosa yesterday signing the highly-contested sted legislation five years after it was first introduced in Parliament, paving the way for universal health coverage in South Africa.
But, writes MedicalBrief, the status quo in the healthcare sector will remain as it is for a long time still as none of the mechanisms needed to implement the scheme have been put in place, making yesterday's signing a ceremonial gesture.
Still, the unexpected move by Ramaphosa just two weeks away from the national elections on 29 May set off a flurry of heated reaction from healthcare groups, medical schemes, business organisations and political parties, with several vowing to fight the legislation in the courts (see second Focus story).
“The NHI is a commitment to eradicating the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect,” the President said at a signing ceremony at the Union Buildings yesterday, BusinessLIVE reports.
“The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity,” he said.
While signing the Bill is politically significant for the ANC (predicted to lose its majority for the first time since 1994), it is only the first piece of enabling legisation for the sweeping reforms aimed scrapping SA’s two-tier health system, which sees 85% of the population largely dependent on crowded and dilapidated public health facilities while a minority can afford access to private healthcare services.
Medical schemes will, for now, continue to provide cover for private healthcare services, and patients will be required to pay out-of-pocket for private care if they are uninsured.
“The inequities and inequalities that characterise our health system are unjustifiable and require fundamental overhauling,” Health Minister Joe Phaahla said.
NHI was aimed at unifying SA’s fragmented health system and realising Section 27 of the Constitution, he said.
The NHI scheme is based on social-solidarity principles in which the rich and healthy subsidise the poor and sick, with healthcare provided free at the point of delivery regardless of a patient’s socioeconomic status.
Under NHI, a government-controlled fund will purchase services for all patients from public and private providers and medical schemes will be banned from covering services provided by the fund.
The next step will be for sections of the Bill to be proclaimed by the President, which he will do in consultation with the Minister. This can be a slow process: sections of the National Health Act, signed 20 years ago, have yet to be promulgated.
The government will need to establish the governance structure for the NHI fund, accredit service providers and register beneficiaries before it can start providing free services to patients under the scheme. It will also need to introduce measures for financing the fund, which have yet to be determined.
TimesLIVE reports that experts said not much was expected to change immediately due to the unrealistic costs of funding the project. They said the process would make no immediate difference to the healthcare system because it requires R200bn per year, which was “unrealistic”.
Wits School of Governance’s Alex van den Heever said increasing tax was not really possible.
“Whether it is VAT, corporate income tax or personal income tax, people will evade and avoid them. Then they will reach a ceiling, and high tax rates are a reduction in tax recovery. There is no fiscal scenario for this.
“There is never going to be any money above the normal increment adjustments. The government’s debt-to-GDP ratio is already extended,” he said.
Former South African Medical Association (SAMA) chair Dr Angelique Coetzee said the signing would just be the establishment of a “bank” for the required funds.
“It will take years before we see the NHI in full swing. It is important to understand that the term ‘NHI’ only refers to the funds required. We all agree that the country’s healthcare system requires reform, but the Bill, in its current form, is not going to be able to give us that reform because it is not economically viable.
“The health budget cuts this year were substantial. Already the department doesn’t have funds to appoint doctors. How are they going to implement this?” she said.
Years for implementation
Business Day reports that the Treasury’s chief director for health and social development, Mark Bletcher, said at the annual Board of Healthcare Funders conference last week that the Bill would probably take many years to implement, due to the present fiscal environment.
Budget pressures facing government would make it difficult to generate additional funding for NHI by raising taxes, he said.
In 2023, Discovery Health said its modelling of the latest version of the NHI Bill predicted that funding of R200bn would be needed to implement the law. This would need to be financed either by a VAT increase from 15% to 21.5% or by personal income tax increases of 31% across the board for employed people.
“Collecting R200bn as a payroll tax would require around R1 072 per employee per month. This increases to around R1 565 per employee per month for only those employed in the formal sector,” said Discovery.
In February, Finance Minister Enoch Godongwana allocated almost R1.4bn for the NHI grant over the next three years, reports Mail & Guardian. The health allocation includes R11.6bn to address the 2023 public health sector wage agreement and R27.3bn for infrastructure for the period, the minister said in his Budget Speech.
Godongwana said the allocation for the NHI was a demonstration of the government’s commitment to the policy.
On Tuesday, Ramaphosa told an ANC-sponsored lunch with business people that opposition to the NHI came from the well-off, reports Business Day. “This is what usually happens. The haves do not want the have-nots to benefit.
“I know it drives fear into the hearts of many people …just like when all our people were getting votes. It drove the biggest fear in the hearts of white people … because they thought when everybody gets a vote it means that the privileges that (they) always had are now going to disappear,” he said.
At his ANC lunch on Tuesday, when asked whether the Bill would withstand legal scrutiny and backlash, Ramaphosa confidently said: “Many laws are often challenged, but our duly elected people have voted for that piece of legislation, and that is the democratically elected representatives we all have.
“So… they have voted for that piece of legislation and whoever is unhappy has a number of avenues.’
He added: “Let me tell you something, my good friends, we are not a reckless government. We are a government that is focused on building a nation, reconciliation and making sure that there is equality fully in our country.”
His sentiments were echoed by the unions, which are overjoyed by his signature being put on the Bill.
Other reaction:
- Discovery CEO Adrian Gore said the Bill was deeply flawed, likely to be challenged on numerous fronts, and lacked a viable financing plan. “There is no funding plan yet and, given the country’s constrained fiscal position, low economic growth and narrow tax base, this can only be solved in the longer term. “We see no scenario in which there is sufficient funding for a workable and comprehensive NHI in its current form, hence our conviction that private sector collaboration is vital, and that full implementation of the Bill remains a long way off, likely decades,” he said.
- Profmed labelled the Bill “premature and unconstitutional”, while acknowledging there was a critical need for meaningful reform to the healthcare system, but such reform should preserves healthcare assets, “with a particular emphasis on protecting our doctors and nurses”. “As it stands, the Bill … restricts freedoms related to healthcare access and fails to provide assurances to medical schemes and healthcare professionals about their future roles,” it said in a statement. Instead of promoting equitable healthcare, the Bill could “inhibit the objectives of universal healthcare and infringe on the right to quality healthcare”. Profmed’s concerns include that nearly 9m lives are covered by medical schemes, which alleviates a massive funding burden. “If this coverage is limited, the already failing public health system cannot effectively manage these additional lives, which would be detrimental to overall quality of care in both the public and private sectors.” “One of the biggest gaps in the Bill is a retention strategy to keep doctors and specialists here. We also need to produce more doctors and specialists here and retain them before we can provide broader-based access to healthcare in South Africa.”
- Build One South Africa (Bosa) leader Mmusi Maimane challenged Ramaphosa, his family and his Cabinet to cancel their private medical aid cover and use public hospitals before he signed the Bill into law. “There must be no healthcare obtained overseas,” he said, adding that there was no hope that the scheme would succeed under ANC governance. “We will have profound skills flight and ultimately, it will drain the fiscus. This is a R500bn investment. The government is heavily indebted, incapable of managing financial resources and has ultimately allowed the public healthcare sector to collapse. The NHI as envisaged by the ANC is going to be devastating for this country.”
- Rise Mzansi’s Songezo Zibi described the NHI as a “misleading solution” proposed by the ANC. He said real improvement in healthcare would come from ensuring public facilities are accessible and well-resourced. “We must not allow the ANC to mislead us into thinking the NHI is a silver bullet, we need healthcare facilities that belong to South Africans.”
- ActionSA said it was disappointed that Ramaphosa had ignored its pleas not to sign the document, and avoid “a second phase of state capture”. "While the NHI is well-intentioned to address healthcare inequality …in its current form, it is opening the system to corruption as we saw during the Covid-19 pandemic when billions were lost through PPE and related corruption,” the party’s Kgosi Letlape said.
- SECTION27’s attorney Asiphe Funda told SABC News they had anticipated further engagements on issues of concern raised regarding the Bill. “We’re quite surprised … We were hoping for further engagement on some of the concerns that have been raised by civil society, as well as public healthcare users. So, there is shock from us, as we don’t think that the Bill in its current state is ready to be implemented.”
- SA Health Professionals Collaboration (SAHPC) spokesperson Caroline Corbett said the Bill lacked clarity on key elements, and in its current form, would have a devastating impact on the country’s ability to deliver quality healthcare. “It has been rushed through the legislative process without substantive engagement with healthcare professionals, or due consideration of our submissions,” she said. Critical issues like the standard of healthcare, vulnerability to corruption, limited availability of healthcare services, treatment guidelines, and fund administration all had to be considered, she said. “From a moral and ethical perspective, we are very concerned for our patients because the existing health infrastructure is inequitable, at best, and although the Bill alleges that it will address health inequity, it certainly will not. “It will worsen health, and infringe on people’s rights to quality healthcare access, and it will drive a lot of our mobile healthcare specialists out of the country and in certain instances, out of medicine.” The Bill, she added, “has taken the healthcare system down to its knees… we are being held hostage by a document that doesn’t offer solutions”.
- South African Medical Association board director Dr Zanele Bikitsha called parts of the Bill “immature”, saying the biggest issue was the certificate of need, which was the backbone of the document. “The certificate of need says [the government] will determine where services can be approved to be delivered, which means that as a doctor, you will be dictated as to where you can provide service. “We get that they are trying to ensure services are spread out equally and that people have access, but we don't feel the certificate of need is the right approach, and it also infringes on our rights as doctors.” The NHI Bill was great in theory, she added, but it needed to be fixed.
- Private Practitioners Forum CEO Dr Simon Strachan said they were disappointed but not surprised the Bill had reached this point. “Since its introduction almost two decades ago, we’ve participated in every opportunity to offer input and solutions, but have had no opportunity other than the public forum to engage with the Department of Health on how this will affect our patients and their access to quality healthcare.”
- Private doctors interviewed by News24 said they were would vehemently oppose and reject the Bill, with many threatening to leave the country or the medical profession altogether. The establishment of free universal healthcare for all citizens would see doctors, nurses, hospitals, and all health professionals being paid directly by the state at a rate set by the government, but many of them have plainly stated they refused to work for the government. Willem Gerber, a private doctor in the Eastern Cape, said the signing of the Bill “will break the country financially, and bring private health down to the level of public health, and medicine standards will be gone forever”. “I can safely speak on behalf of many doctors in private practice when I say I refuse to work for the state and I’ll leave the country or stop practising medicine.” Echoing similar comments, Dr Mahomed Ganie from Durban, who has worked in the private sector since 1995, said not much thought had gone into the Bill. “It’s a failed system in the United Kingdom,” he said, and questioned what would happen to people employed in the private health sector – medical aids, general practices and private hospitals.”
Medical unions, however, hailed the signing of the Bill, with Democratic Nursing Organisation of South Africa (Denosa) spokesperson Sibongiseni Delihlazo saying it was about time that there was justice for access to quality healthcare services for all, regardless of socio-economic status.
“As Denosa we are consistent in our full support of Bill and it should be implemented as soon as possible.”
He said the money made available through the NHI Fund would ensure there was enough medication, equipment and resources, and nurses would be able to provide comprehensive care services to patients.
The South African Medical Association Trade Union (SAMATU) has also welcomed the signing, reports Health-e News.
General secretary Dr Cedric Sihlangu said the NHI would go a long way to addressing disparities in the current healthcare system.
“This will alleviate the burden on our public health facilities while also improving the quality of healthcare services across the board,” he said.
BusinessLIVE – Ramaphosa signs NHI Bill into law
Business DAY PressReader article – Ramaphosa to sign NHI into law (Open access)
Business Day PressReader article – Legal storm is brewing over the NHI Bill (Open access)
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Health-eNews article – Mixed Reactions As President Sets To Sign The NHI Bill Into Law (Open access)
SABC News article – Section 27 surprised by imminent implementation of NHI into law (Open access)
See more from MedicalBrief archives:
Doctors’ petition urges NCOP to reject NHI Bill
Medicare boss warns of skills migration when NHI rolls out
Litigation threats as NHI Bill passed by parliamentary committee
Opposition parties reject NHI Bill in current form
NHI Bill vote delayed as doctors and business urge amendments