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Healthcare at a Crossroads – Examining the National Health Insurance (NHI) Bill.

This article is a follow-up to our recently published commentary concerning developments pertaining to the NHI debate subsequent to the NHI Bill (the Bill) being rubber-stamped through parliament’s portfolio committee (PPC) on health by an ANC majority. Since the PPC approval, various industry players have released a broad range of articles which can be summarised by the following recurring concerns:

    • The significant knock-on effects this will have on the provision of private healthcare,
    • Calling attention to the issue of trust which has been severely eroded in the government’s ability to responsibly manage the over R700 billion budget – especially given how Covid-19 funds were misappropriated among various other corruption scandals.

Various concerns and unanswered questions remain regarding the impact that the approval of the Bill will have. Based on this we outline the common themes voiced by certain key stakeholders who have rejected the Bill in its current form.

No expected change soon

Discovery Health is of the view that nothing changes for medical schemes in the near future, since the Bill is yet to be promulgated into law and is likely to be subject to protracted legal challenges. 

The funding of the Bill remains unclear, and the timeline for implementation is likely to be more than a decade according to the representatives of the National Department of Health. For a start, and besides lengthy court processes, the Bill will require the approval of Parliament prior to it being considered by the National Council of Provinces. Following that, formal parliamentary sign-off and presidential promulgation will be required.

The playbook

According to Busi Mavuso (Business Leadership South Africa (BLSA) Chief Executive), said instead of learning from the energy crisis and working together with the private sector, the NHI scheme appears to lean into the worst of the government’s tendency toward populism and nationalisation.

Certain sources go as far as to imply that the ANC’s stance is fundamentally aimed at the uninformed ordinary South Africans. In their view, it is expected that Government will continue to promote a pro-NHI agenda and drive an anti-opposition sentiment with an accompanying subtext popularising the notion that the present-day crumbling public health system is through no fault of the governing party.

The South African Medical Association (SAMA) for its part states that while NHI intends to improve the health and livelihoods of South African citizens, in its current form the Bill sets up the healthcare system for failure and goes on to say that governance within the healthcare sector must be strengthened, with transparency and accountability at its core.

Red flags

BusinessTech reported that parliament’s legal team have already stated that parts of the Bill will be open to legal challenge on constitutional grounds. In broad terms, various sources agree that these echo criticisms levelled against the Bill, arguing that the provisions are vague – particularly around funding – and that not enough modelling and testing has been done to see if the country is even equipped to implement it.

As reported by Business Day, Ryan Noach, the CEO of Discovery Health, said despite detailed and constructive inputs from multiple stakeholders, he was disappointed that the portfolio committee elected not to take the opportunity to make amendments to the Bill that would enhance both the feasibility and effectiveness of the NHI Fund. Through this lens, he too believes that it is highly likely that this Bill will be challenged through various legal avenues. This view was endorsed by the Health Funders Association (HFA) which represents approximately 73% of open medical schemes and 50% of total medical scheme membership in South Africa. In addition, HFA said that adding nearly nine million lives covered by medical schemes onto an already over-burdened and failing public health system would be detrimental to the quality of care.

According to former Health Ombudsman Professor Malegapuru Makgoba, the South African health system is dysfunctional and a mess - an alarming statement that underlines similar sentiments being expressed by the critics.

Conclusion: a path to better choices

Certainly, on the existing record (endemic corruption throughout all levels of government structures) it is only fair for South Africans to be circumspect about a centralised fund being managed by the governing party with no oversight by independent civil society bodies.

The common perception is that the public healthcare system is not at the stage that would make universal healthcare possible.

Furthermore, it is also clear to most that the fiscal room for such an expensive undertaking does not exist. The first clue was the lack of any mention of the NHI by Finance Minister Enoch Godongwana in his latest budget.

As both the private and public sectors are equally invested in a well-functioning healthcare system, solutions can be reached through a cooperative relationship and constructively adopting practical policy steps while accepting that some trade-offs will have to be made.

In the meantime, the NHI remains a work in progress in terms of policy and planning, and as highlighted earlier there is a long road ahead and nothing changes as it relates to medical aid schemes.

Moreover, it is crucial to highlight that the utilization of medical scheme funds for the financing of the National Health Insurance (NHI) is explicitly prohibited. Additionally, it should be noted that the publication of the NHI's money bill, encompassing the crucial financial component of the plan that requires funding from the National Treasury, is currently awaiting completion. Dr Ryan Noach, CEO of Discovery Health reinforced these sentiments in an interview with Newzroom Afrika stating that there is no need to panic; “The NHI Bill in Section 33 talks about full implementation of the NHI before full impact on the medical schemes and in the Department of Health’s own terminology from the time the act is promulgated. Their view is that it will be ten to fifteen years prior to being able to fully implement the NHI. Our view as administrators of medical insurance plans, [is that] it takes huge sophistication and many years to get [it] right. So, there is a long time before the NHI is a reality.” The interview also covered the funding of the NHI and how it will work should it become active and if medical schemes will still cover certain health needs in the future. Noach reiterated the blended fund approach Discovery health recommends.

About the Author

Charleen Rix
Head: Health Consulting, Sasfin Wealth

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