NHI Bill: A bleak prospect in its current form

NHI Bill: A bleak prospect in its current form

4 April 2024

In the beginning of 2024, President Cyril Ramaphosa reiterated that the National Health Insurance (NHI) Bill would definitely be implemented in due course.

Here is an update from two of our strategic partners, the Health Funders Association (HFA) and Board of Healthcare Funders (BHF) – these views are aligned with that of Fedhealth Medical Scheme.

What to expect of the NHI Bill in its current form

In its current iteration, the NHI Bill would mean that South Africans inherit a healthcare system tied to the bureaucracy of unfriendly processes to access care (listed as NHI services). This process, devoid of choices of where and how to access healthcare, is going to be the biggest compromise for a healthcare consumer without alternative care and who has to depend on the State’s single-funder structure.

As the Bill stands, it would signal a profound seismic shift in South Africa’s healthcare dynamics. Exactly how this will work in practice appears deliberately unclear, with crucial details around funding and the list of services that will be available on the NHI not yet defined nor budgeted for.

Currently, any procedure or service listed as being covered by the NHI cannot be paid for privately or with medical scheme cover. Everyone will be at the mercy of a single state funding system for these services, and this greatly diminishes the right to freedom of choice in how and where a person can access healthcare in South Africa.

Patients requiring standard procedures such as tonsillectomies and hip and knee replacements, would have no option but to live in discomfort until their turn comes up on the NHI’s waiting lists.

How do universal healthcare models work abroad?

Considering the United Kingdom’s (UK’s) comparatively well-funded National Health Service (NHS), which has been held up as a model for SA’s NHI, certain procedures typically have significant waiting lists often longer than a year, while patients receive ongoing pain management treatment. However, UK patients still have the right to go the private route to access life enhancing procedures sooner outside the public health system. Many other European countries struggle with the same issue of growing costs and where national budgets can’t keep up, queuing becomes a national pastime.

It is worth pointing out that the UK’s GDP per capita to support the NHS is $46 510 USD, compared to a mere $7 055 in South Africa. The public health system of Denmark, which has a GDP per capita of $68 007, is another country that has been held as an example of what South Africa’s NHI aspires to achieve.    

Health economists and top funders are skeptical that the National Department of Health (NDoH) will be able to deliver universal health coverage at current levels of quality across the board, especially given the NDoH’s R200 billion NHI price tag, more taxes will be needed per annum.

Craig Comrie, CEO of the HFA and Profmed says: “The message from our perspective is don’t panic. This is a policy conversation and implementation will take decades – we’ve yet to see a money bill and we’ve heard extraordinarily little from the finance minister Enoch Godongwana or other senior cabinet ministers on how this will be financed. The reality will only kick in when they define what benefits the NHI will pay for – and you can only define that when you have a budget.”

Where to from here?

We need to be realistic about how we get closer to Universal Health Coverage as a society, and we cannot afford to put all our eggs in one untested basket and hope for the best. Bringing the public health system closer to the private system to improve access to quality healthcare for everyone while maintaining the option for additional funding mechanisms would advance the aims of UHC more speedily.

Medical schemes are non-profit funds established to fund private healthcare and remove the pressure on public health services, thereby reducing queues and government funding. Currently, people who belong to medical schemes are removing the obligation from the State for funding their healthcare needs, while still contributing tax to sustain public health services.

Nationalising healthcare funding as proposed under the NHI Bill is a risky step, as removing private funding diminishes opportunities for the retention of specialist skills, general infrastructure investment and the development and long-term management of health resources.

Alternative models have been discussed that would allow the improvement of public health facilities with combined public and private funding and proposals of partnerships to improve the quality of the public health system while reducing costs to those with medical scheme membership.

A single, centralised funder model is not essential for speeding up progress towards the goals of UHC, it is possible to get there without incurring the constitutional pitfalls of the NHI Bill as it stands now.

Quality healthcare should be available to everyone, irrespective of the capacity to pay for it. There is more than one path to Universal Health Coverage (UHC), and there are quicker and more effective ways than the NHI Bill to bring our current two-tiered health system into closer alignment with its stated objectives. It is possible to work towards the aims of UHC while protecting and building South Africa’s health assets and protecting constitutional rights.



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