South Africans have until Friday, September 15, to file written submissions on the National Health Insurance (NHI) Bill.

The bill was passed by the National Assembly in June and is presently with the National Council of Provinces for approval. Should the green light be given, it will land on the desk of President Cyril Ramaphosa, who will have to decide whether or not to sign it into law.

The right to healthcare for all, irrespective of socio-economic status, is enshrined in the Constitution (Section 27) and, as a health financing system, the NHI is envisioned to do this. Funds will be pooled to give South Africans access to quality, affordable personal health services, and medical treatments that will be administered by accredited providers.

With the proposed NHI, the government will buy healthcare services from healthcare providers in the public and private sectors. In essence, what this supposedly means is that South Africans will be able to go to the nearest doctor, hospital or clinic that has a contract with NHI and not worry about how much it will cost them as the NHI will pay.

The NHI will offer comprehensive healthcare, ranging from primary healthcare to specialised tertiary and quaternary (specialised and uncommon treatments) levels of care.

It is proposed that citizens will be free to belong to medical aids, but they will not be able to opt out from making contributions to the NHI. However, government has said that when the NHI is fully implemented, medical schemes will provide cover only for services not covered by the NHI Fund. This includes cosmetic surgery that is not medically indicated but done as a matter of choice, expensive dental procedures performed for aesthetic purposes, medicines not included in the national essential drug list, and diagnostic procedures outside the approved guidelines and protocols.

Even though the Department of Health has indicated that it will take up to 15 years for the NHI to be adequately implemented, critics are vocal in their opposition. Some of the major issues raised are:

• Uncertainty and vagueness about how the NHI will be funded, considering that an estimated R500b a year will be needed to effectively run it.
• An increased burden on taxpayers that could see personal income tax being raised by up to a third and VAT to 21%.
• The potential for corruption and misappropriation of funds.
• This diminishment of the role of medical aid schemes as they won’t be able to fund any services covered by the NHI.
• The risk of medical practitioners seeking more lucrative employment opportunities overseas.

Caxton Local Media spoke to role players across the board about the contentious bill. Here is what they had to say.

Foster Mohale: National spokesperson – Department of Health

 “The per capita spend in the private health sector is around R27 000 compared with R5 400 in the public sector. This disparity implies that currently as a country we spend almost five times for a person in the private health sector compared to the public sector, despite the public sector catering to more than 80% of the national population as compared to 16% in the private.

“The NHI is directed at reversing this inherent public-private divide, through creating a single strategic purchaser that is aimed at integrating funding pools and harnessing health system resources to benefit the entire population.

“The implementation of the NHI does not imply the destruction of the private health sector. Instead, the NHI is designed to ensure that all individuals, irrespective of their race, gender, employment status or other such factors, receive quality personal healthcare services when they need them, without facing financial barriers.”

Michéle Clarke: Shadow Minister of Health – DA

“This is merely an election tool for the ANC; the country cannot afford the NHI and there are many reasons why it will not work.

“The NHI would give the minister [of health] far too many powers and duties. He would essentially run the day-to-day business of the fund, rather than have oversight responsibilities. The minister will also have unvetted powers to make far-reaching health regulations without necessary oversight.

“The South African Medical Association has confirmed that the implementation of the NHI will see hundreds of doctors emigrating overseas.

“The NHI Bill requires every citizen to register online, but fails to take into account the millions of people who do not have access to electricity and water, let alone the internet. People living in rural areas will not have access to the necessary equipment to capture their biometrics, necessary to access the NHI.”

Clarke says the bill assumes that poor individuals can travel hours to a ‘certain service provider in the hopes of being able to register as a patient, all while the cost of living has dramatically risen’. It will dissuade people from seeking medical attention, she says.

“The NHI fails to take into account the shortages of emergency medical services equipment, like ambulances. Often the nearest ambulance to transport patients is hours away.

“Public healthcare standards are already abysmal and the NHI will abuse patients’ rights to quality healthcare.”

Dr Katlego Mothudi: Managing director – Board of Healthcare Funders

 “It is important to note that the NHI is just one of the tools required to drive the pursuit of universal health coverage. Many other health system strengthening components must be attended to as well. Fixing the health finance distribution with the introduction of the NHI does not fix the entire health system.

“The NHI has to be implemented alongside good governance, leadership, and stewardship. The state of governance in the country – with a history of poor management of institutions and issues such as corruption, as well as the enormous powers given to the minister of health – are concerning.”

Mothudi says there are other major concerns, such as the various clauses that are not constitutional or might not pass the constitutional test. One example he gives is the limitation of healthcare access that ‘people currently enjoy from medical schemes’. Mothudi also questions if private healthcare practitioners are being treated fairly or if ‘their right to practice their craft’ is being infringed upon.

“The bill does not provide all the answers required to fix the status of the healthcare system, and all the other work that has to be done prior to the NHI implementation should be considered.”

Nicolien Welthagen: Manager – Solidarity Research Institute

 “Notwithstanding the evident objections, pilot project failures and extensive criticism, the government persists in the NHI’s implementation. Against the backdrop of an already vulnerable healthcare system and a wavering economy, the government’s approach towards NHI planning is deemed reckless and irresponsible and would probably destabilise the current state and private sector healthcare systems.

“It is proposed that the NHI will not permit private medical funds when it is fully implemented [the bill says that private medical insurance will be permitted, but with major limitations]. Private healthcare institutions will be centrally managed by the state; looking at other state-owned institutions, it is a dire prospect. A very small base of taxpayers will be forced to pay for a huge part of the population who will not be able to contribute to the fund. The general public can expect inefficient and low-quality healthcare when the NHI is fully implemented.

“It cannot work,” she says, adding that in her opinion, all NHI papers and bills are ‘characterised by vagueness and dearth of substantive details concerning the scope, mechanics and execution of the NHI’.