The South African National Health Insurance Bill:

What is it, when will it happen, and will it affect you?

The South African National Health Insurance Bill, 11 of 2019, envisages good and affordable medical care for all South Africans regardless of their financial means. The bill was introduced in parliament in August 2019. The NHI aims to provide all South Africans with the same health insurance irrespective of their income, and membership of the NHI will be compulsory for everybody. 

However, the bill has been deeply controversial and is still shrouded in uncertainty as to how it can and will work so, let’s take a closer look at it. 

What is the South African NHI bill? 

The preamble to the bill sets out its objectives as follows, and we quote in brief: 

• to achieve universal access to quality healthcare services
• to establish a National Health Insurance Fund
• to provide a framework for the strategic purchasing of healthcare services by the Fund on behalf of its users
• to create mechanisms for the equitable, effective, and efficient utilisation of the resources of the Fund to meet the health needs of the population
• to preclude or limit undesirable, unethical, and unlawful practices in relation to the Fund and its users
• to provide for matters connected herewith.

A further document highlights and explains these objectives in more accessible language. It aims to provide good healthcare and cheaper alternatives to medical aid by sharing the overall funds available for healthcare in South Africa among all the people. 

The healthcare somebody receives will depend on the care that person needs and not on what they can afford to pay. The healthcare services of hospitals, clinics, doctors, specialists, dentists, and healthcare workers will therefore be shared more equally by everybody. 

How will the NHI affect medical aids in South Africa? 

Private healthcare providers like medical aids have been greatly alarmed about the NH. What are the implications of the NHI for private medical aids in South Africa? Will they even be able to exist under the NHI? 

Section 33 of the NHI bill states that medical schemes will only be allowed to provide “complementary or top-up cover” that doesn’t “overlap with the personal health care service benefits purchased by the National Health Insurance Fund on behalf of users”. Though the bill does provide for private schemes to provide ‘gap cover’, Section 33 has been widely understood to imply that private medical schemes will, in fact, stop operating as their current members will be obligated to use the NHI.

Alan Fritz, of Medshield Medical Scheme, believes that these fears are exaggerated. By adopting new models that contribute to different minimum benefit packages, he believes that private schemes can co-exist with a national health system as is the case in countries like the UK, Australia, and others.

However, serious doubts and great uncertainty remain. The government is adamant that the NHI will be implemented under the leadership of the Deputy Director-General, Nicholas Crisp. This is despite the Department of Health and the National Treasury not being clear on how the complex system can be financed. 

The private sector has grave doubts about whether the government can establish and successfully run such a huge and complex system in view of the chaotic state of the current state-run health system. The government acknowledges a critical shortage of the skills needed for the NHI, but not what it intends to do about it. 

This unhappy state of affairs is being exacerbated by feedback that many private healthcare professionals say they will leave the country if the NHI comes into effect.

When will the NHI be implemented in South Africa?

Joe Phaahla, the Minister of Health indicated that the establishment and implementation of the NHI are informed by the 2017 White Paper approved by the Cabinet in June 2017. This White Paper recommended a phased approach towards implementation. It is therefore envisaged that the scheme will be implemented in two phases. The second and last phase will be starting this year and should be finalised in 2026.

NHI South Africa latest news

At the 2022 Public Health Association of South Africa Conference in Durban, the NHI was hotly debated. Whereas there was support for the basic principles of the NHI in South Africa, significant reservations were raised, with less unreserved support than expected from ANC Members of Parliament. 

Here are just some of the points that emerged:

• Though it is generally accepted that some form of national health insurance is needed, this bill must not be seen as a magical fix-it-all. The underlying problems bedevilling health care in South Africa need to be addressed vigorously. The deteriorating quality of healthcare in SA should be urgently addressed.
• The available resources, skills, and capacity are other crucial issues. 
• A greater focus on primary healthcare and health promotion, and less on curative and palliative care, was needed. 
• The new roles and responsibilities regarding finances and grants should be more clearly defined.
• The role of the private sector in the NHI needs to be more clearly defined. 
• The people entrusted with decision-making power in the NHI should be independent of political parties. The NHI’s Board shouldn’t be a party-political body. 
• A matter of grave concern is the vagueness around the financial aspects of NHI.

A recent High Court ruling declared that sections 36 to 40 of the NHI bill, referring to the issuing of a ‘certificate of need’, were unconstitutional. According to the bill, doctors and healthcare practitioners couldn’t start their practices without such a certificate. However, Joe Phaahla, the Minister of Health, said that this ruling wouldn’t stop the bill. 

Advantages and disadvantages of NHI in South Africa 

The advantages and benefits of NHI in South Africa are the following:  

• The undeniable and constantly growing inequality between the first and second-tier healthcare will be addressed. Currently, vast numbers of people who lack the funds for private healthcare simply don’t get it, as state-provided healthcare is hugely inadequate. The private sector draws most of the money, as well as the best doctors, specialists, and nurses. A national health insurance scheme will benefit enormous numbers of people.
• Healthcare in South Africa may improve overall with the NHI setting higher standards than those currently in force at many hospitals and clinics. South Africans with lower incomes will have access to healthcare they can’t afford now.
• Services in numerous public hospitals and clinics will be upgraded in order to meet NHI standards as regards hygiene, safety, and quality of care.
• Patients will know exactly how much they’ll have to pay. There won’t be any unexpected costs or running out of medical aid benefits. Members of the NHI will pay set amounts that will cover any treatment they receive via the NHI.
• Staff in the public health sector should receive better salaries as the NHI will be channelling more money into public health facilities.

The disadvantages of a National Health Insurance scheme could well include the following:

• As competition is a well-known driving force in any marketplace, the lack of healthy competition could eventually see standards and innovation lagging standards. When the government alone is responsible for providing and managing a huge and cumbersome medical service for South Africa will cutting-edge standards be uniformly maintained? Shouldn’t we learn from SAA and Eskom?
• Establishing the NHI is going to need stupendous amounts of money. Figures around R500 billion are mooted, and that’s just to get it started! Where will these eye-watering funds come from if not taxes? The pundits predict higher taxes for South Africans.
• It’s not clear what the NHI is actually going to cover since this will depend on the funding available which still isn’t clear.
• The number of healthcare providers and/or facilities may drop as many current public hospitals and clinics won’t be able to meet the new NHI standards. Fewer facilities, fewer hands to do the work! Emergency care may suffer, and long waiting periods might become the norm. 
• Patients used to the standards of current private health- and medical care may well see a significant drop in the standards they’re used to while they are still paying similar amounts.
• The country may well see a huge exodus of healthcare professionals who are unwilling to work under the new dispensation.

Conclusion 

Here are some of the issues that we believe NHI 2022 faces:

• Is the NHI sustainable? Many private healthcare groups don’t believe that it is.
• Does the government have the skills and expertise to set up and run this vast healthcare system in view of the failure of the current state-run healthcare system?
• Can South Africa afford a huge exodus of skilled healthcare professionals who refuse to work under the NHI’s harsh conditions?
• What will happen to medical aids? 
• Shouldn’t Treasury’s warnings be heeded that the funds to run the NHI are simply not there without raising taxes?
• Shouldn’t the Department of Health’s concerns about its vulnerability to maladministration/mismanagement/corruption be listened to?

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