NHI Bill | All SA’s health funding eggs in one basket?

Protect SA’s rights and health assets for all.

By Craig Comrie, chairperson of the Health Funders Association (HFA).

Tuesday, 23 January 2024, in a resounding declaration at the ANC’s 112th-anniversary rally, President Cyril Ramaphosa recently proclaimed that the National Health Insurance (NHI) Bill is destined for enactment, a fait accompli that leaves no room for dissent.

Should the current iteration of the NHI Bill be signed into law, citizens face a stark reality: 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 who has no alternative care and is effectively tethering their fate to the State’s monolithic singe-funder structure.

As the Bill stands, it would signal a profound seismic shift in the very fabric of 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 if the NHI is not yet defined nor budgeted for.

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.

As the Bill stands, 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.

Consider that under the proposed NHI model, patients requiring standard procedures such as tonsillectomies and hip and knee replacements, among others, would have no option but to live in discomfort until their turn comes up on the NHI’s waiting lists.

If we look at the United Kingdom’s comparatively well-funded National Health Service (NHS), which has been held up as a model for SA’s NHI, procedures such as these typically have significant waiting lists often longer than a year, while patients receive ongoing pain management treatment. Then again, UK patients still retain 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 aren’t able to keep up, queuing becomes a national pastime.

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

We have 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.