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So what exactly is happening with the National Health Insurance (NHI), asks Sandisiwe Gugushe.

Access to healthcare services is a fundamental human right guaranteed by the Constitution of South Africa. Section 27 of the Constitution states that everyone has the right to access healthcare services, including reproductive healthcare, while emergency medical treatment cannot be refused to anyone.

The Constitution and the National Health Act 61 of 2003 (as amended) envision a single health system for South Africa. Still, there are also private healthcare service providers in the country. The State uses a means test to determine who qualifies for free medical services, and the Minister of Health may determine who is eligible for essential healthcare services.

Despite the Constitution guaranteeing healthcare as a fundamental human right, South Africa still has much uncertainty, debate, and unwellness 27 years later.

A Frank Dialogue—no mask required

Since introducing the National Health Insurance (NHI) Bill in Parliament, discussions about the plan have increased. The NHI promises to revolutionise healthcare in South Africa. Those favouring the NHI argue that it would help solve the massive inequalities in access to quality healthcare. Those against it, however, are sceptical about the practicalities of its implementation and have an ideological aversion to state interventions.

84% of South Africans rely on the State’s health services. The remaining 16%—who can afford it or have medical aid schemes—use private healthcare. Unfortunately, the country currently spends 4.4% of its GDP on only 16% of the population’s health services and only 4.1% for 84% of the population. Moreover, 80% of medical specialists in the country work in the private sector, as skilled professionals follow the financial resources. NHI aims to address this inequality by creating a single pool of healthcare funding for private and public healthcare providers. The NHI Fund will pay public and private healthcare providers on the same basis and expect the same standard of care. This would allow people in lower-income groups to consult doctors in private practice and use private hospitals, with NHI picking up the bill. By doing so, the burden of care would be more equally distributed across the private and public sectors. Some critics argue that the existing problems in public healthcare should first be solved and the service expanded before embarking on a project to achieve universal healthcare. The media frequently reports on the inefficiencies of the public health system, often with alarming details.

A much-anticipated dialogue occurred on an evening in September, where the country’s leading medical professionals and critical healthcare stakeholders gathered. It felt like we were all in the doctor’s waiting room, each waiting on our turn. Finally, the moment arrived, and the doctor was ready to see us. Welcome to FRANK DIALOGUE, sponsored by National Health Insurance and 3Sixty Global Solutions Group, with the esteemed presence of South Africa’s Minister of Health, Dr Joe Phaahla.

The panel comprises an impressive gathering of decision-makers in the healthcare industry:

  • Dr Nicholas Crisp, DDG National Health Insurance Dept of Health
  • Dr Rajesh Patel, Board of Health Care Funders, Head of Health Systems
  • Phumelele Makatini, CEO of the Health Funders Association
  • Dr Kgosi Letlape, Former President of the African Medical Association & Association of Medical Council of Africa
  • Facilitated by Prof. JJ Tabane, Editor of Leadership Magazine and founder of Frank Dialogue

Why care?

Public policy’s heart lies in the health and well-being of populations, which is crucial to achieving a healthy future. An individual’s economic prospects throughout their life are negatively impacted by ill health. Poor health can affect infants’ and children’s ability to accumulate human capital. At the same time, for adults, it can lower their quality of life and negatively impact their labour market outcomes. Disadvantages tend to compound over time. Almost everyone has experienced frustration with the care that is inflexible, impersonal, and bureaucratic at least once in their life. When such experiences accumulate at a system level, the result can be poor safety, poor coordination, and inefficiencies, costing millions of lives and causing enormous expenses to societies. This situation slows progress in achieving the Sustainable Development Goals to which all communities, regardless of their level of economic development, have committed.

The current reality

In South Africa, 22 medical aid schemes are available for the public to join. This is a significant decrease compared to the 144 schemes registered with the Council for Medical Schemes (CMS) in 2000. Despite the high and continuously increasing costs of private healthcare, which outstrip inflation by 5% annually, less than 20% of South Africans are members of medical aid schemes. Private healthcare fees are unregulated, making doctors and specialists charge whatever they want. Individuals must pay for medical treatments and procedures without medical aid or endure long queues at state-owned hospitals and clinics. The National Health Insurance (NHI) aims to provide everyone with access to healthcare services regardless of their socio-economic standing. However, critics argue that the NHI Bill will disrupt the private healthcare system, which is currently functioning well, and that the government should leave the private healthcare sector alone to reduce the burden on the State’s healthcare provision.

Is this a case of the Department of Health sneezing, and the country catching a cold?

The COVID-19 pandemic has highlighted how fragile global population health can be. South Africa has faced health challenges, which have been difficult to manage. Population health aims to improve populations’ physical and mental health outcomes and well-being while reducing health inequalities at the local, regional, and national levels. The National Health Insurance (NHI) is a fund created by the government to purchase healthcare services for all South Africans from public and private healthcare providers. This fund aims to ensure that people have access to free healthcare when they need it, regardless of their financial situation. To fund the NHI, everyone in South Africa will contribute through taxes and contributions per their income. This will prevent people from paying out-of-pocket for healthcare services, which often deters early diagnosis and timely treatment. Therefore, providing high-quality universal health coverage (UHC) is paramount.

What the panel had to say…

During the Frank Dialogue session, the Minister of Health emphasised the need for National Health Insurance (NHI). However, many practising doctors fear that the NHI will lead to them losing their jobs. They are deeply concerned about the NHI’s consequences for their profession. Dr Rajesh Patel, Head of Health Systems at the Board of Healthcare Funders (BHF), echoed these concerns. The Board of Healthcare Funders has requested a reduction in the Health Minister’s powers in the NHI scheme, stating that current provisions give too much power to one person and that certain conditions should be imposed before NHI can be fully implemented. Dr Patel believes that Section 33 contradicts the constitutional principle of administrative justice and allows the Minister to act arbitrarily. He notes that this allows the Minister to inform medical schemes without warning that they may only provide complementary cover.

Phumelele Makatini, CEO of the Health Funders Association (HFA), continued to state that as an association, they reject the NHI Bill in its current form. The association believes the Bill will undermine healthcare quality and obstruct achieving universal health coverage in South Africa. Makatini says they have raised several concerns about the NHI Bill, such as the need for clarity on how the NHI will be funded and its impact on taxpayers. Additionally, the HFA is concerned about the risk of corruption and mismanagement within the NHI Fund. The association is also concerned about the potential loss of skilled health professionals and jobs in the private health sector and the inefficiency and inadequacy of the public health system to deliver quality care under the NHI. The HFA has also expressed concerns about the restriction of choice and access for patients and providers under the NHI. “As the HFA, we believe the NHI may harm the existing medical schemes industry and the economy. However, we do support the goal of universal health coverage for all South Africans,” she said. “And have always been willing to collaborate with the government and other stakeholders to achieve this goal. We have proved this by developing and consulting the NHI and Medical Schemes Amendment Bill.”

Dr Nicholas Crisp, Deputy Director General of National Health Insurance in the Department of Health, stated that there are many supporters of the proposed changes, especially among the poor and marginalised citizens, various non-governmental organisations, and several political parties, as well as Cosatu. He added that the World Health Organisation also backs the initiative from the sidelines. Dr Crisp pointed out that the current healthcare system in South Africa needs to be simplified, more efficient, and deliver the desired outcomes that we should be getting for the investment we make.

What the audience had to say…

Kego from GrowthThink

“I have some inputs to share with you regarding the submission to Parliament. Firstly, I fully support the provision of National Health Insurance (NHI) to all citizens. However, private medical aid should also be allowed when annual subscriptions and allocations are cancelled. When I am healthy and can provide financial contributions to private healthcare, I would rather have those contributions to medical savings. When I am sick and more likely to require care, healthcare provisions expire. Medical aid should not be treated as short-term insurance. For example, if I contribute to a scheme for over 40 years, I should be able to enjoy free care in my golden years when I need it. I believe that healthcare contributions for NHI and private medical aid should go to one fund to cater to all citizens. Travel insurance for short-term visitors and long-stay non-citizens should also contribute to the fund to qualify for care. Private medical aid should contribute to NHI because when funds are exhausted, patients are discharged for respect in public healthcare facilities. Finally, any person found guilty of corruption involving the fund should get a jail term of no less than five years and pay a fine equal to the funds stolen. NHI should cater for primary healthcare, accidental care, and rehabilitation. Private medical aid, on the other hand, should cater for elective treatments, elective procedures, and loyalty programs like gym membership, etc.”

The Council of Medical Schemes (CMS) regulates the medical schemes industry in South Africa

The CMS supports the National Health Insurance (NHI) to provide universal health coverage for all South Africans. They believe the NHI will work with medical schemes to improve healthcare. The CMS has been actively involved in developing and consulting the NHI Bill and the Medical Schemes Amendment Bill to align the medical schemes industry with the principles and objectives of NHI. Additionally, the CMS has undertaken various projects and activities to prepare for the implementation of the NHI. These include conducting research, developing guidelines and regulations, engaging with different role players, and enhancing capacity and systems.

A guest who is a member of NUMSA

“I am requesting the Minister to consult NUMSA and allow us to participate in the development and implementation of NHI. There is a need for more clarity and transparency on how the NHI will be funded, managed, and governed to ensure accountability and prevent corruption. I am concerned about the potential threat of privatisation and commercialisation of health services under the NHI, which could undermine the principles of solidarity and socialisation. Therefore, I support NUMSA’s call for a mass campaign to mobilise workers and communities to demand a pro-poor and pro-worker NHI that guarantees quality healthcare for all South Africans.”

Recommendations from the evening

The best recommendations for the National Health Insurance (NHI) may vary depending on the different perspectives and interests of the stakeholders involved. However, the consensus recommends the following suggestions be considered:

  • Ensure adequate and sustainable funding for the NHI while promoting transparency and accountability in the management and governance of the NHI Fund.
  • Improve the quality and efficiency of the public health system by enhancing the coordination and integration of health services across different levels and sectors.
  • Involve and consult with various role players, such as health workers, medical schemes, private providers, civil society, and communities, in developing and implementing the NHI.
  • Address the social determinants of health, such as poverty, unemployment, housing, sanitation, education, and environmental justice, that impact the health outcomes and needs of the population.
  • Protect and promote the rights and interests of patients and providers, such as access, choice, quality, affordability, and equity, under the NHI.

By Editor