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Dr Fundile Nyati takes a closer look at the current situation surrounding the National Health Insurance Bill

“To be or not to be, that is the question: Whether’tis Nobler in the mind to suffer The Slings and arrows of outrageous Fortune, Or to take Arms against a Sea of troubles, and by opposing end them: to die, to sleep no more; and by a sleep, to say we end the heart-ache and the thousand Natural shocks That flesh is heir to? ’Tis a consummation. Devoutly to be wished. To die to sleep, To sleep, perchance to Dream; Aye there’s the rub.”

As we begin the leap year 2024 in South Africa, those of us who have been closely following the developments in the political ideology and subsequent long drawn administrative and legislative processes towards the birth of a proposed radically different and transformative era of the National Health Insurance system of healthcare delivery that theoretically should ensure the end of the current health inequity with regards to access to affordable quality of health care for all citizens of the country, irrespective of one’s class or income level.

When it come to the national health system in South Africa post-apartheid era, as a country we have come a long way, yet we are still very far from ensuring that this basic human right called health as enshrined in our national constitution is enjoyed by all our compatriots. As we began the then new democratic dispensation in 1994 under the ANC-led Government of National Unity, the most immediate task that faced them was how to amalgamate all the previously separate health departments from the then Republic of South Africa’s four provincial administrations (TPA; NPA; CPA; and OFS), independent homelands (TBVC states), self-governing territories (non-independent homelands) into one National Health System wherein ones race or ethnic group would not be a major determinant of access to quality healthcare.

That first national government administration of 1994-1999 which was led by our founding President Nelson Rholihlala Mandela carried huge expectations from majority of our citizenry to usher-in real and tangible change from the past colonial and apartheid policies, towards a better life for all our citizens, a major departure from the divisive institutionalised policies of separate development based on the colour of one’s skin, texture of one’s hair, and mother language they spoke. By the end of that first national and provincial government administration, a unitary national system of healthcare governance had been established under the strong and decisive leadership of Dr Nkosazana Dlamini-Zuma.

In our national constitution, which was subsequently unveiled in 1996, there was a clear separation of powers between the mandate of the national department of health, and the respective powers of the nine provincial administrations. Essentially, the national department of health was seized with formulation of a vision of healthcare of the country in line with the National Constitution, the development of national strategies, priorities, policies, and programmes to ensure the realisation of that national vision of healthcare. The mandate of the respective provincial and local governments of health was largely to ensure delivery of healthcare services to the population.

It is worth noting that then newly formed nine provincial health departments started at different levels with regards to health services infrastructure and resources in general depending on which geographical territories they inherited from the apartheid era, for example the highly populated Eastern Cape provincial health department would inherit chronically under-developed and under-resourced Transkei and Ciskei homelands. On the other hand of the scale, a less populated and highly developed province like the Western Cape would inherit a much more developed and better resourced geographical territory.

Therefore, from the word go post-1994, it became patently clear that the unacceptable disparities from the past would in some way still rare their ugly heads even under the new provincial health departments, unless there was a deliberate and conscious decision to address the colonial and apartheid legacy infrastructural development and other historical challenges. The then new national and provincial administration that were mindful of those historical disparities were however hamstrung with regards to correcting them, as they became critically aware that the inherited national fiscus would not be able to afford implementation of such corrective measures at historically disadvantaged provinces.

The net effect from the inability of the respective national and provincial health departments administrations to correct the glaring historical disparities with regards to access to quality health services is that in South Africa the chances of surviving a major ill-health incident depends largely on which province one lives in, and on whether they have deeper financial resources or are privileged to have health insurance (medical schemes) or not.

To properly illustrate the real consequences of the unacceptable disparities from the colonial and apartheid past, one has to just look at the amount of COVID-19 related deaths a province like Eastern Cape experienced from those who presented with moderate to severe COVID-19 disease that necessitated hospital admission into High Care or even Intensive Care Units, as opposed to those people who live in the Western Cape, who also experienced moderate to severe COVID-19 disease in the public health facilities. Much more people whose lives could be saved died in the more rural under-resourced provinces like the Eastern Cape, as compared to those who were lucky enough to live in better developed provinces like the Western Cape, or Gauteng.

At this point, I must also hasten to mention that the unacceptable state of poor health services delivery in some historically disadvantaged provincial health departments cannot be attributed to the disparities of the pre-1994 era, but as also as a result of poor leadership, mismanagement, corruption and malfeasance by public officials, further weakening the ability of the respective previously disadvantaged provincial health departments from meeting their constitutional mandates to their respective populations.

The other matter that I think is worth highlighting regarding the inequity of access to affordable quality health services in South Africa is that those disparities that previously race based, have metamorphosized into population class differences, whereby those in middle- and high-income strata who have access to private medical schemes, are almost guaranteed better timeous access to quality healthcare services, as opposed to their compatriots from lower income strata.

It does not take any rocket scientist for one to know that the respective income levels/strata is largely an indirect indicator of race in South Africa, with the majority black Africans, Coloured, and Indian population at the bottom, and the White population at the higher levels (with a sprinkling of black faces also in those privileged levels). It is also important for me to clarify that not all blacks are at lower income levels, as much as not all whites are at the higher income levels, but when one looks at most of those racial populations, then you will find more blacks at lower income levels, and more whites percentage wise at middle to higher income levels.

So, the issue of gross health access inequities in our country are closely related to many social determinants of health, many of which have historical roots. In a country where the constitution preaches and guarantees equality, it can’t be accepted that the disparities can continue, 30 years after the dawn of democracy, or 28 years since our National Constitution was adopted as the supreme law of the country.

This then brings me to re-stating the fact that in our South Africa Constitution, under our Bill of Rights, health is a basic and equal human right for all.

Section 27. (1) of our national constitution Bill of Rights says “Everyone has the right to have access to:

  • Healthcare services, including reproductive healthcare;
  • Sufficient food and water; and
  • Social security, including, if they are unable to support themselves, and their dependants, appropriate social assistance.

Further, Section 27 (2), imposes on the state a duty to take reasonable measures within its available resources to achieve the progressive realisation of this right. So, when one considers that in South Africa, 30 years since the dawn of democracy, majority of its citizens still have to enjoy this basic human right as enshrined in our constitution, then the government of the day is empowered by the very constitution to take reasonable lawfull measures in order to address the constitutional non-compliance.

Furthermore, South Africa is a member country of the World Health Organisation (WHO) and was part of the resolution at that multi-lateral global forum which resolved that all member counties must have some version of Universal Health Coverage (UHC) in place by the year 2030. For those who may not know what Universal Health Coverage is, its definition is that “it is a system of healthcare service in a country in which all people have access to the full range of quality health services they need, when and where they need them, without financial harm”.

In South Africa, since around 2009, the national government through the national department of health has been working with relevant multiple stakeholders in healthcare towards a legislative process that would introduce a National Health Insurance (NHI) Bill in the National Parliament through democratic processes therein. Extensive public participation processes outside parliament and in parliament have taken place for over a decade in relation to the envisaged NHI Bill, culminating in the NHI Bill being adopted by the Portfolio Committee on Health in Parliament in May 2023, and by the National Assembly in June 2023. Few months later, on the 6th of December 2023, the National Council of Provinces adopted the NHI Bill, with Eight out of Nine provinces giving it a thumbs up, with the exception being the Western Cape that gave it a thumbs down.

The adoption of the NHI Bill by the National Council Of Provinces marked the last parliamentary process in the long and tortuous road that this Bill has travelled to that point, and is now only awaiting the President of the country, President Cyril Ramaphosa to consider it, strong opposition and legal threats to it by various opposition groups, non-governmental organisations, industry bodies, professional bodies, the list goes on.

Many of these stakeholders outside parliament and opposition parties in parliament are ready to take the NHI Act to the courts of law, all the way to Concourt to test its Constitutionality, and the main gripe that the public participation processes in its development ignored most of their inputs, especially on the contentious Section 33, which basically says that once NHI is fully implemented, the medical schemes as we know them will cease to exist, instead only complementary or top up medical schemes will be allowed only to cover those health services that are not covered by the NHI Fund as per the NHI Act and its regulations.

So, the threats of legal action against the Presidency should he sign the NHI Bill into a NHI Act is very real, and many in opposition have amassed a strong and deep war chest to challenge it aggressively at the Apex Court in South Africa, thereby delaying its implementation by forcing the NHI Act to be referred back to national Parliament for further consultation, especially on section 33, as well as the enormous powers of the National Minister of Health as contained therein.

So, back to my opening famous quotation, “To be and not to be” from William Shakespeare’s legendary play, ‘Hamlet’, the main protagonist in the play in his sololiquy in Act 3, Scene 1 is sized with deep thoughts about matters of life and death. He is considering and weighing issues of mortality on whether it is better to live or die. He is in a state of quandary on whether to kill his uncle subsequent to the death of his father, and the intense emotional events following his death, and the role his uncle played in his death. So, he is literally weighing heaving matters of death, trying to decide on whether if living or death is best.

Back to the NHI Bill before the President of the country awaiting his signature, he just like Hamlet is weighing seriously matters of Life and Death the NHI Bill before him is seeking to address once a for all to ensure compliance with our National Constitution with regards to universal access to healthcare. As we have seen during the recent COVID-19 pandemic, and the daily reality of quality health access inequity for most South African people, there is a daily reality of preventable deaths and substandard quality of life for many who can’t access quality healthcare, which he cannot ignore anymore.

So, surely the big question in his Presidential mind, as well as the minds of his legal and political advisors, is the wisdom of whether to sign or not to sign the NHI Bill into a NHI Law, especially being mindful of the massive war that awaits his signature of the NHI Bill into Law. He has to do the right thing as per our constitution, yet he can’t simply ignore the mountain of opposition that is out there to this apparently contentious NHI Bill.

With 2024 being the year of National Elections, and the issue of health access inequity being top of mind of most South Africans, and the governing party with its back on the wall on many fronts of service delivery, my prediction is that the president will sign this NHI Bill into Law imminently, without sending it back to Parliament for further engagements. There is a huge political will to get this long drawn matter of rolling out the NHI Fund and NHI funded health system as soon as possible. On the sidelines of the Government Lekgotla, Minister in the Presidency, Khumbudzo Ntshavheni is quoted as saying that the signature of the NHI Bill into NHI Law is imminent.

Judging by the level of strong opposition by formations and industry players with deep pockets, the presidency will have won the battle of signing the NHI Bill into Law, however the long drawn big war awaits its signature, and therefore delay in its implementation is a given.

South Africa has been deeply polarised by this NHI Bill, and will be further polarised once it is signed into law, however the government has an obligation to govern, so an element of courageous leadership is demanded on the office of the presidency, especially by the majority that are still disenfranchised with regards to healthcare, 30 years into the much vaunted democratic dispensation.

In conclusion, our President is damned if he does sign the NHI Bill and is damned if he does not do so as well. In Sepedi there is an old proverb that “Ke Kgomo Ya Moshate, wa e gapa o molato, wa e lesa o molato”. So, he must apply himself looking at the issues raised on both sides, and do what is in the best interests of the country.

Dr Fundile Nyati is the Chairman and CEO at Proactive Health Solutions.

By Editor