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Is our healthcare system in trouble with the new NHI on the scene? Andre Walters investigates…

The new National Health Insurance (NHI) Bill that was recently approved in our Parliament has become a source of great contention, not only on social media among ordinary people, but also among organisations that work in the areas of health, social security, and financing.

In fact, the new bill has even been described as “unimplementable, unaffordable, unclear, and unlikely to happen any time soon”, and it is likely to affect each and every one of us. For example, the chairman of the Social Security Systems Administration at the University of the Witwatersrand, Alex van der Heever, says: “From the beginning, the bill was so flawed, they [the governing ANC] were in a predicament, where they could either try to amend the framework in Parliament, or give the ball back to the Department of Health and ask them to rework it, which would be very embarrassing.”

And so the strong comments about the negative impact of the bill go on and on. Here is another example: Peter Montalto of Intellidex (a research and consulting firm that specialises in capital markets and financial services in Africa) is quoted as saying that the NHI is unlikely to happen within any reasonable timeframe as it is “logistically impossible” and that there is a lack of clear information about funding.

Also in reference to the funding of the NHI, Joe Phaahla, our Health Minister, has said that, in contrast, it “seeks to pool resources of those who can only contribute to the fiscus through indirect means such as VAT and other collections and those of us who are able and are already making fragmented contributions into 81 different schemes into one pool which can purchase services from both the public health system and private providers from lowest level of care up to the highest”.

Does that sound complex to you? Well, it certainly does to a lot of people who have gone ballistic in their social media comments. Here are a few examples of such tirades:

  • “Looting the public health system should come with a mandatory charge of murder, because people are dying to fund the lifestyles of the scum who loot. The Minister, his advisors, and the rubber-stamp MPs should all be tried for treason.”
  • “The atrocities inflicted on the poor through catastrophic failures of the public health system have undoubtedly accounted for many unnecessary deaths.”
  • “Anyone with any sense and in need of healthcare would be compelled to save for trips to other countries to get healthcare—what is offered in SA is nothing short of disgusting.”
  • “The Department of Health keeps on saying that anyone who opposes their particular form of NHI is against Universal Healthcare and that they don’t care about the poor. This is not true. It is precisely because we care about the level of care available to the most vulnerable in society that we CANNOT have this disastrous version of NHI.”
  • “It is not the concept of free healthcare that I oppose, but the ‘who’ (the corrupt ANC) and the ‘how’ (the zero plan about forcing our private Healthcare System into disastrous directions). We need to fight this tooth and nail.”

But not all comments are in opposition. Here is just one example of the opposite view: “It cannot be disagreed that the private scheme sector is fragmented and over-expensive and that the private health providers appear very profitable for shareholders (for example, their resilience during COVID-19). The medical practitioners also seem well rewarded. The public health system has all but collapsed and is ridden with incompetence and corruption. Righteous but well reasoned objections are all very well but unless all parts of the private sector come up with a viable solution, one can see the NHI being forced upon the country and the economy, and with dire consequences.”

Nevertheless, the angry comments still continue to outweigh the ones that offer positive support for the new NHI. For example:

  • “Surely everybody knows by now that the NHI Bill is just a pathetic attempt by The Mafia to create a new source for looting, now that all the traditional sources have been looted almost empty. The only discussion should be how to get rid of The Mafia.”
  • “The ANC is an organisation that thrives on theft from SOEs. They’ve plundered colossal amounts of money from Eskom, Denel, SAA, Transnet, and the SABC. They urgently need another cash cow to fund the retirement packages of the party’s cabinet ministers. The NHI will tick all the boxes. Huge cash inflows, massive and confusing administrative requirements, all run under ANC control, and, like the already bankrupt SOEs, no court cases or convictions for those that get caught. One should look at private-public partnerships graduating progressively towards the main goal of the NHI.”

And then, a man called Johan Buys, says: “Somebody at the medical research council confided that we spend more on administrators than we spend on nurses. National, provincial, metros, and districts are stuffed with very highly paid pen-pushers. We don’t have a budget problem (R260 billion). We have a problem with an efficacy-of-spending problem. We spend far more per GDP, or per capita, than our comrades in China or India. But, whereas they are having results like longer life expectancy at birth, we are not.

“I had TB in 2021, it wasn’t fun but thankfully all is fine now. TB is fought by state clinics, not the private sector. In the nine months of treatment I never visited a private provider. Nurse Betty at the clinic soldiered on despite the absence of visiting surgeons general that are supposed to review people in person.

“If we reduced TB deaths by 10% it would have a greater impact than entirely eliminating all road deaths in SA. Which do you think is easier? If we fed R200 billion more to national health, I expect ¾ will be spent per year on administrators instead of on people like Nurse Betty.”

In contrast, the Health Minister, Joe Phaahla, is quoted as stating that those who say the NHI is unaffordable are basing their opinions “on highly inflated costs amongst some of the private providers who are under pressure to keep delivering super [sic] profits”.

And now, we get back to costs. The 2023 Budget allocated R259 billion to healthcare. Of this, R113 billion goes to district health, R49 billion to central hospitals, R46 billion to “other health services”, R40 billion to provincial health, and R11 billion to the management and maintenance of facilities.

Some of the experts agree that the problem is not a lack of funding for the public healthcare sector. They state that the amount SA spends on healthcare as a proportion of GDP far outstrips that of other developing economies. Instead, it is said, we have a governance problem.

There’s a substantial reduction in accountability in the governance framework and people have basically been stealing money from the state systematically.

And they’re not being held to account for that. For example, the Board of Healthcare Funders (BHF), which represents all medical schemes, except Discovery Health Medical Scheme, also agrees. They say: “To summarily ignore the many who voiced their concerns regarding governance structures and operational efficiency concerns, the concentration of risk in a single-payer system in an unstable economy featuring endemic corruption, and the many other concerns raised by state attorneys is short-sighted and highly unwise.”

The BHF has consequently urged the government to consider a multi-payer model to be aware of the risks that are involved and to have a roll-out based on milestones, not dates, and to take note of concerns that the proposed NHI is susceptible to corruption by proposing alternative governance structures.

Clearly, therefore, looking at all these comments, one must agree that there appear to be many unresolved issues.

For example, the law firm, Webber Wentzel, is saying that despite approval by the National Assembly, there are many unresolved questions and concerns about the practical implementation of the NHI.

“Many stakeholders and experts have raised concerns that [it] is simply unaffordable, particularly as it would require an extensive administrative apparatus.

“A related concern is the extent to which the NHI will rely on the public healthcare system to deliver services, and the capacity of that system to provide an acceptable quality of services.

“Given the dire state of public healthcare in our country, it is surprising that the government persists with plans to spend vast resources on implementing the NHI. Those resources would greatly improve the delivery of quality healthcare—and access to that care—if they were deployed directly in the public health sector.”

In addition, other key issues that are seen to be unaddressed are said to include:

  • The extent of benefits to be covered by the NHI Fund and the rate of reimbursement—both of which are crucial to assessing the affordability of the NHI and its impact on the provision of quality healthcare;
  • The rules on portability, which will allow patients to be treated by service providers other than those with whom they are registered;
  • The referral pathways between service providers;
  • The coding systems to be employed; and
  • The relationship between the fund and medical schemes.

And here is another key question: what role will private medical schemes play and will they even continue to exist? As it stands, the NHI Bill stipulates that, once the minister has determined that the NHI is fully implemented, medical schemes “may only offer complementary cover to services not reimbursable by the fund”. It also says patients are entitled to “purchase healthcare services that are not covered by the fund through a complementary voluntary medical insurance scheme”.

What this is saying, is that medical schemes may not cover services that are covered by the fund. Since the fund is intended ultimately to cover a comprehensive range of benefits, medical schemes will shrink dramatically, or even disappear.

The Webber Wentzel law firm is therefore warning that this new regime is likely to face constitutional challenges because it infringes on the right of people to access healthcare services. It is forcing many people who currently access private medical care via medical scheme funding to rely on what is currently ‘a woefully inadequate public healthcare system; the property rights of medical schemes and their administrators; and the right to freedom of trade, occupation and profession’.

So the final key question is this: Is our healthcare system now in trouble with the new NHI on the scene? There can be no doubt. It does appear that there are many reasons why we should worry about this situation and that it must all be sorted out, sooner rather than later.

Andre Walters is a veteran broadcaster.

By Editor