In May 2023 I wrote a post titled “National Health Insurance … will logic prevail?” Now a year later, in May 2024, it appears to me that emotion and political necessity rather than logic has prevailed certainly amongst the ruling party. I do not intend to repeat an analysis of what is contained in the now NHI Act signed by President Ramaphosa but rather to consider the consequences of his doing so 15 days prior to a general election in which the political party which he heads faces for the first time possible, but probably unlikely, election defeat.
The President has defended his actions with the argument that the delay since the NHI Bill was passed by parliament in December 2023 until its recent signing into law was purely due to the “normal” procedures required after a bill is referred to the President for ratification. He contends that the timing of his very public televised signature on the document bore no relation to the upcoming election. Few other, than those in support of his political party, will be convinced by this contention.
Notwithstanding the fact that National Health Insurance now forms part of the legislation of this country, it remains uncertain whether it will proceed beyond the paper on which it is written. Many in the health sector and others representing civil society have indicated their intention to take the NHI Act on review as far as the Constitutional Court. From a personal perspective I found several of the statements that accompanied the signing of the Act very unfortunate. Firstly the President stated that South Africans medical scheme members are a privileged minority and spoilt. He conveniently ignored the fact that these South Africans pay with after-tax income for this “privilege” and in addition through the taxes that they pay as law-abiding citizens they fund healthcare for those dependent on the public sector. Secondly, the Minister of Health suggested that those who are opposed to the implementation of NHI are a group resisting transformation and have done so since the advent of a democratic South Africa in 1994. Both these statements are unacceptable to me as a law-abiding tax paying South African committed to the political change before and after 1994 and one who has worked all my professional life in the public sector but based on logic and facts opposed NHI in the form that is now envisaged in the Act. The statements, however, fit conveniently with the populist narrative that any opposition to NHI is somehow resistance by the elite benefitting from the status quo to any change that will favour the poor. The proposition that the changes envisaged may possibly benefit no-one is considered unthinkable.
I have written on many occasions about the deficiencies that exist in the South African public health and offered solutions based on my long-standing experience in the South African public health sector. I have acknowledged that there are areas of excellence in the public sector that in various ways provide healthcare that is better for the patient than that received in the private sector. On the other hand it is not surprising that the private health sector better resourced per patient day equivalent offers more immediately accessible and at times better quality healthcare than that provided in the public sector. However, as was highlighted in the 260-page report by the 2009 Healthcare Market Enquiry undertaken by the Competition Commission there are certainly aspects of private healthcare that require greater regulation and control. It appears however, that either due to inertia or intent the recommendations contained in this report were largely if not entirely ignored by government.
A process of apparent public participation with numerous submissions and oral presentation was undertaken but during the process from the initial 2011 Green paper document to the 2017 White Paper, subsequently a draft Bill and finally the Act as signed by the President, little if any significant change resulted from what was initially tabled in 2011 to the Act signed in May 2024. This suggests to any impartial observer that the decision to implement what was contained in the Green Paper had already been made in 2011 and that sadly the rest of the process was purely very prolonged window dressing. I would refer the reader to Alex van der Heever’s recent cogent response to the signing of the NHI Bill by President Ramaphosa entitled, “The NHI is clearly a dream that never was nor is likely ever to be” published in the Daily Maverick1. I am inclined to largely agree with van der Heever that what is outlined in the NHI Act is in fact unimplementable in a South African context, not the least due to the facts that it is unaffordable even with the purported 30-year implementation time frame and that the management capacity do do so is lacking.
It is laughable, if it were not so cynical, that the Premier of Gauteng was recorded as saying that, “After 29th May, any citizen can go to any hospital, private or public, to receive the best treatment and afterwards the government will pick up the bill.” I have also viewed his attempts to back track and explain that what he said was “taken out of context”. I am afraid that it again speaks to crude populism rather than the considered logic that one would expect from a senior and seasoned politician. In many ways the Premier’s comments reflect a narrative of blind acceptance of party dogma at all costs. This dogma encompasses an acceptance that centralisation of all health funding in South Africa should be administered through a single fund and that funding now paid to medical schemes as after-tax member contributions will automatically be transferred to this central fund. It also rests on the premise that the private sector will, at a centrally determined tariff, be prepared to be contracted to undertake healthcare for all South Africans other than that which the NHI deems to fall outside what is required by the South African population. By inference it is assumed by those currently dependent on the public health sector that the healthcare that they will receive from a future NHI, the Rolls-Royce service alluded to by the President, will equate what they perceive to be currently provided in the private sector. Unless clouded by the dogma that apparently clouds the Premier of Gauteng’s thoughts and massive, unaffordable tax hikes on those who are employed, it seems as Alex van der Heever writes that NHI as it is currently formulated in the NHI Act is a “dream that is never likely to be.”
The sad reality is that despite the tribulations and poor healthcare currently provided in many areas by the South African public health service, South Africans have access to healthcare either in the public or private health sector that far exceeds that available in many countries. That the inequity in South African society is also reflected in the inequity in access to healthcare for many South Africans is an incontrovertible fact. It is also a fact that Universal Health Coverage (UHC) which should ensure everyone has access to essential health services without financial hardship is a noble goal to which South Africa should strive. The fact, however, is that NHI, as currently formulated is not in a South African context the mechanism to achieve this when facts and logic rather than political dogma prevail. NHI pilots in the last few years have taught us little other than that without competent management and a clear goal failure is inevitable. Rather than NHI South Africa as an immediate focus must ensure that funds spent in the public health sector are effectively utilised. Public sector funding could certainly be augmented by the removal of all tax rebates granted for medical scheme memberships while ensuring that issues such as perverse incentives and excessive charges are regulated in the private sector as proposed in the 2009 Health Market Enquiry. In many ways if this were achieved South Africa would be further down the road towards UHC than chasing for political reasons the quixotic goal of National Health Insurance.
It is not too late for facts and logic to prevail and through meaningful dialogue to take a step back from the brink!
