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South Africa’s NHI Bill: clarity needed, and a long road ahead

By Xolisa Phillip, in Johannesburg
Posted on Tuesday, 17 September 2019 12:43

Private hospitals will apply for accreditation to become providers under the NHI Bill. REUTERS/Siphiwe Sibeko

The South African government’s quest to establish universal healthcare for its citizens is a step closer following the publication of the National Health Insurance (NHI) Bill.

The bill was published on 8 August, ushering in a 30-business-day period of public inputs – and a flurry of criticism and supposition in the media. If all goes smoothly for President Cyril Ramaphosa he could be signing off the bill by July next year. But first it must go to the portfolio committee on health, the National Assembly and the National Council of Provinces for deliberation. These bodies require a simple majority (50% + 1) for adoption.

The governing African National Congress (ANC) resolved to introducing an NHI at its 2007 52nd elective congress held in Polokwane, Limpopo.

A win for the reds

The publication represented a coup for the South African Communist Party (SACP), which forms part of a three-way political alliance with the ANC. Back in 2003, the SACP was the first to make the call for South Africa to introduce an NHI.

  • Sixteen years after that fateful call, Parliament opened a public comment process in August on the NHI Bill.
  • South Africans from all walks of life, including NGOs and private sector players, were given 30 days to make inputs.

Health is wealth

The provision of healthcare and the state of public health institutions are politically charged topics. The type of access to healthcare that citizens have is also a marker of the deep inequality that separates the haves and the have-nots in South Africa.

In the recent past, the most visible examples of this were the Life Healthcare Esidimeni tragedy in Gauteng and the cancer care crisis in KwaZulu-Natal.

  • A total 143 public sector psychiatric patients died in unfit facilities in Gauteng.
  • The shambolic state of public healthcare facilities in KwaZulu-Natal resulted in the collapse of the province’s ability to take care of cancer patients.

Clearing the way

The NHI Bill provides some clarity on the implementation of universal health coverage and the establishment of the NHI Fund, according to Dr Jonathan Broomberg, CEO of medical aid provider Discovery Health. Discovery runs one of the biggest open medical schemes in South Africa and accounts for just more than 30% of the market.

Discovery believes the NHI is workable, in tandem with an incremental implementation strategy.

“We believe the publication of the NHI Bill creates an […] opportunity for active collaboration between the department of health and the private healthcare sector,” Broomberg said.

Pros and cons of the NHI Bill

According to Discovery Health, factors that could lend themselves towards a workable NHI include:

  • The initial focus is on priority projects where there are vulnerable groups in dire need of improved access to care in areas such as cancer treatment and mental health.
  • The focus is on primary and preventative care as the foundation of universal healthcare.

The Bill, however, lacks clarity on several issues:

  • the details around the future role of medical schemes
  • the NHI referral pathways and use of services
  • the NHI package of benefits
  • how the NHI will be funded.

The National Treasury is expected to release a paper on NHI financing.

Not a done deal

“We are studying the Bill, and will engage with the minister of health and the department of health […] to understand the implications of the Bill before commenting in detail.

“We also believe limiting the role of medical schemes will be counterproductive for the NHI, as it will increase the burden on the NHI,” Broomberg said.

The Hospital Association of South Africa (HASA) would engage on the NHI Bill in depth, according to chairperson Dr Biren Valodia.

HASA represents private hospital groups including the Johannesburg Stock Exchange-listed Netcare, Life Healthcare and Mediclinic.

Busting myths

“The majority of stakeholders in health are convinced the NHI is the solution to the unequal, fragmented system that characterises healthcare in this country,” said Dr Lwazi Manzi, the spokesperson for health minister Dr Zweli Mkhize.

It is Mkhize’s task to persuade the private sector and other roleplayers about the NHI’s rationale. His planned NHI charm offensive includes a packed programme of roadshows to ensure widespread buy-in of the scheme.

These roadshows will double as a myth-busting campaign. One of misconceptions the minister wants to debunk is the notion that the NHI “will destroy the economy”.

Building trust

Dr Anban Pillay, the deputy director-general at the department of health in charge of the NHI process, has the job of making sure there is a sound policy proposition on the table from a departmental perspective.

And from the department’s point of view, the publication of the NHI Bill “is just the start of a long process”, says department spokesperson Popo Maja.

Maja concedes the NHI Bill will not address the trust issues in South Africa’s public healthcare system. “This must be earned through real dialogue, consultation and a willingness to listen,” he says.

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