Read in magazine

Andre Walters delves into the National Health Insurance Bill by taking a look at the responses from both sides of the argument

The contentious National Health Insurance (NHI) Bill, which the National Assembly, the first house of Parliament, thinks would “achieve universal access to quality healthcare services” in South Africa, was recently passed, with Parliament adopting dramatic changes that have many organisations deeply worried.

The NHI will be a mandatory state-run medical aid. All South Africans who have the ability to pay will be expected to contribute to the fund, whether they’re medical aid members or not. It is said that the bill is about ensuring that every South African receives an equal share of our public healthcare system.

For example, our Health Minister, Joe Phaahla, said: “Honourable members, in simple terms what the NHI seeks to do is stop the two trains, that is, private health and public health, travelling on parallel tracks but both surely going toward crashing, while if they can be pooled together, there is a good chance of complementing each other.”

But opposition parties said they do not support the Bill as the healthcare system in the country is already facing challenges. However, the ANC pushed the National Health Insurance Bill through in the National Assembly with a majority of 205 members against 125 votes from the opposition parties.

Free healthcare is promised for all under South Africa’s proposed National Health Insurance (NHI) scheme. According to the National Department of Health’s official statement, funding would come from both the government’s annual healthcare budget and a new NHI levy. Members’ premium payments to private medical aid funds will be replaced by the NHI fee. Paying for services and medication covered by the NHI will be prohibited by medical aid funding.

It is said that the public health system in South Africa is in a healthcare crisis. Millions of impoverished and jobless people are not given the required care. Diagnostic tools, medical facilities, and hospitals are outdated. There is a dearth of trained workers as well as not enough doctors, nurses, and medication. In rural places, millions of people travel great distances to see doctors.

The National Department of Health claims that even though the NHI guarantees free healthcare, taxpayers will be responsible for paying for it, as well as the costs associated with running the provincial government health bureaucracies that administer the NHI. The National Institutes of Health claims that the planned NHI levy will reduce financing and care in the private health system by using the money people spend on private health insurance to pay for the NHI system. But, on the other hand, private healthcare will be eliminated, and more medical professionals, nurses, and people will leave the country.

Of course there are other issues. For example, although the NHI promises to provide everyone in South Africa with access to healthcare, Profmed’s CEO, Craig Comrie, raises serious concerns about issues that could impede development and jeopardise the standard of treatment provided to all citizens.

“We recognise the importance of the NHI Bill’s goals, but there are still some provisions in the Bill that we are concerned will make it more difficult for people and medical scheme members to get necessary healthcare services,” said Comrie. He emphasised that if these issues aren’t addressed, the Bill’s implementation in its current form might have significant effects on South Africa’s healthcare system, raising doubts about the system’s claimed benefits.

Let’s look at what the opposition, (the ‘Cons’), are saying:


They say the government does not have its house in order. Hospitals and clinics are already stretched to the limit and there are no doctors and nurses in public health facilities. The party said the passing of the Bill was a catastrophic development in the midst of the ongoing collapse of the public health sector.

The party statement said: “The NHI Bill will see the funding of all our health needs being centralised, suppliers (general practitioners, private hospitals, and public hospitals) catering to the needs of our people, and the payment of services being administered from the national polling fund of the NHI.”

The SA Medical Association (SAMA)

“SA doctors and medical professionals will leave if the NHI is introduced.” They imply that South Africa faces a dramatic talent flight in doctors and medical professionals because of the National Health Insurance scheme.

In essence then, why are they saying that we need the NHI?

The Department of Health says: “While we are trying to build a more equal society, healthcare is very unequal. The amount spent on the healthcare of each person with a medical aid is five times the amount that is spent on each person who relies entirely on public health facilities. The funding gap translates into a major gap in the standard of healthcare available to the rich and the poor. While eight out of 10 patients depend on public clinics and hospitals, the bulk of the country’s doctors, dentists, and specialists serve a small section of the population who can afford private healthcare. In a just world, the sickest people—not the richest—should receive the largest share of healthcare. NHI will bring us closer to allocating health services according to the real needs of our people. This is not only fair, but it will help us to build a healthier nation.”

The Health Department also says that South Africa’s two-tier system of paying for healthcare has failed to guarantee good quality healthcare for all.

At present, the government pays for the health facilities that assist the poor, while wealthier families use private doctors and hospitals and they pay for through their medical aids. This two-tier system of funding locks the poor out of reach of a large number of health professionals and facilities in the private sector. NHI will create a single pool of healthcare funding for private and public healthcare providers alike. The NHI Fund will pay public and private healthcare providers on exactly the same basis—and expect the same standard of care from both. People in lower income groups will be able to consult doctors in private practice and use private hospitals, because the NHI Fund will pay for it.

Here is a key question…

How will medical schemes be affected by this Bill? The NHI Bill states that when the NHI is “fully implemented”, medical schemes will not be able to provide cover for services that are paid for by the NHI.

And here are some more details regarding the concerns that have been expressed about the NHI Bill:

Medical Scheme Profmed

Craige Comrie, the CEO, said the government’s NHI process is like building a home, without describing how many rooms there are and, therefore, it is difficult to establish what the costs are, and how you are going to finance the home.

“The NHI will probably cost more than R500 billion per year, but that is not based on any specified list of services still to be determined. It may be important to reverse the thinking and look at what is affordable within the SA context and then use that money to fund a more pragmatic set of services within NHI,” he said.

BMC Health Services Research

According to Ntsibeng Valerie Mukwena and Zodwa Margaret Manyisa of BMC, the evidence suggests that the challenges include problems such as an increase in illnesses and a shortage of personnel to drive the project in South African public hospitals. They maintain that this is exacerbated by the existing situation of most government-funded healthcare institutions, which are characterised by bad administration, insufficient budgets, inadequate infrastructure, and insufficient drug supplies.


“The NHI is a huge, complex, and multi-decade initiative and a considerable amount of debate and effort will be required to make it workable.

“Our strong view is that limiting the role of medical schemes would be counter-productive to the NHI because there are simply insufficient resources to meet the needs of all South Africans. Limiting people from purchasing the medical scheme coverage they seek will seriously curtail the healthcare they expect and demand.

“It poses the risks of eroding sentiment, and of denuding the country of critically needed skills, and it is impacting negatively on local and international investor sentiment and business confidence. Crucially, by preventing those who can afford it from using their medical scheme cover, and forcing them into the NHI system, this approach will also have the effect of increasing the burden on the NHI and will drain the very resources that must be used for people in most need.

“We believe that medical schemes will continue to cover all of the healthcare services which they currently cover for the foreseeable future for a number of reasons:

  • There is uncertainty as to when the NHI will be considered “fully implemented”, and this is most likely to be quite far in the future due to resource constraints.
  • There is no clear definition of services to be covered by the NHI, and it appears that this definition will be expanded on an incremental basis.
  • Discovery is already actively engaging with the Department of Health on critical sets of issues, alongside the broader business community, and they say they will continue to do so in order to ensure that medical schemes and private healthcare remain a critical part of the healthcare system, together with the NHI.”

Business Leadership South Africa (BLSA)

BLSA fears that the Bill, as envisioned, would leave people ‘worse off’. BLSA’s CEO, Busisiwe Mavuso, felt that a system in which state provision becomes impossible and private health provision is effectively closed down, would leave the country’s citizens worse off.

“The system would impose a single-payer model in which the government is the only buyer of healthcare services for its citizens. It would relegate the private health insurance market to only complementary healthcare that is not covered by the state scheme. The NHI format proposed would be hugely expensive, drawing resources out of the rest of the government and the services it provides, while increasing the tax burden on all of us,” Mavuso said.

The Democratic Alliance (DA)

The DA MP and spokesperson on health, Michelle Clarke, wrote an open letter to President Cyril Ramaphosa, urging him not to sign the NHI Bill into law.

“Should the NHI come to pass, health services would collapse. To this day, the Department (of Health) has never made it clear which health services would be available under the NHI and which would be out-of-pocket expenses for patients,” Clarke said.

She said that the NHI would bankrupt South Africa beyond measure, while thousands would die, and skilled medical practitioners worth their salt would leave the country for better conditions.

“Mr. President, my request is simple: do not allow cheap political gain to cloud your judgment. You took an oath to protect this country.”

The Hospital Association (HASA)

HASA feels that approving the Bill without substantive consideration of the many valid and significant recommendations and contributions made by many participants during the parliamentary hearing is deeply regrettable and a missed opportunity by the Committee.

“The healthcare reform decisions taken now will impact on the sustainability of South Africa’s health system and will be deeply felt for generations to come.”

They said that they were disappointed that the National Health Insurance Bill had been approved by the Health Portfolio Committee without considering the recommendations raised during public hearings.

The South African Communist Party (SACP)

The SACP has said that the passing of the Bill has marked a decisive epoch of an irreversible rupture with the current unequal two-tiered health-care regime.

The party said that the irrational two-tiered healthcare regime has persisted hand-in-hand with income and wealth inequalities, which has worsened with every crisis of the exploitative capitalist system.

“South Africa cannot transform and upgrade its public healthcare sector without eliminating the imbalances between the private and public health sectors, which are skewed in favour of the minority-servicing private health sector,” said the SACP.

“The SACP is vehemently opposed to corporate capture of and profit-making from the NHI and its exploitation in any form. We are against corruption and the neoliberal policy of austerity, which has also contributed to delaying the advance of the NHI,” added the party.


They strongly condemn Parliament’s decision to accept the new Bill. The organisation has also already assembled a team of the country’s top legal experts, economists, and medical experts to oppose the legislation at all possible levels.

According to AfriForum, NHI is just one more of the castles in the sky that the government has built with the aim of campaigning for votes in light of next year’s national election.

Let’s summarise the pros and cons of the NHI argument:

The ‘pros’ include arguments like…

  • Lower overall healthcare costs. The government would control the prices of medical care through negotiation and regulation. And since doctors would deal only with a single government agency, there would potentially be a decrease in administrative costs.
  • Remove health-related barriers to education. Children with undiagnosed and untreated health issues may not get the full benefits of education. Ideally, the NHI should create improved access to testing and health care solutions that could address barriers to learning.
  • Promote equality. Access to healthcare should be determined by the needs of individuals, rather than by their ability to pay the exorbitant medical fees. With lower overall health costs and standardised services, every citizen can have access to the same level of care.
  • Improve social security. Better access to healthcare can prevent future social issues like crime and welfare dependency. Meanwhile, the NHI may also help to support vulnerable groups like the elderly, or women living in poverty, who have fallen through the cracks of the current inequitable health system.

There are many arguments that are raised by the ‘cons’. Here are just a few:

  • Long wait times. Patients may face long wait periods for elective procedures as government funds would be focused on providing basic and emergency healthcare.
  • Decreased quality of care. If they aren’t financed well enough by cost-cutting governments, doctors may cut back on care to lower costs.
  • Potential for corruption. Public confidence in the state’s capacity to run large institutions is at a record low. Growing evidence of public sector corruption does nothing to breed such confidence. This is no more clearly illustrated than the financial crises gripping state-owned entities like Eskom and SAA. The new NHI Bill does nothing to assuage these fears.


The NHI Bill has been tabled in Parliament and is now in the hands of the Portfolio Committee on Health, which will hold formal hearings.

While the NHI Bill certainly raises some serious concerns, the need for structural change to improve healthcare for all in SA is widely recognised.

Andre Walters is a veteran broadcaster.

By Editor