INTRODUCTION: Section 27 of the country’s constitution states that everyone has the right of access to healthcare. The National Health Insurance (NHI) bill, which has been passed in parliament, is the manifestation of this provision. Its aim is to ensure that all South Africans have access to quality health services. It will totally change the medical landscape in South Africa – but it comes amid both accolades and dire warnings. Proponents of the NHI see it as a vehicle for much-needed change in a healthcare system riddled with inequalities. The World Bank describes South Africa as one of the most unequal societies in the world. A successful NHI would introduce a radical shift towards health equity to create a more equal society. 

The NHI bill has been contentious since its inception. There have been multiple court challenges, with more to come, and numerous different voices have been raised against it. The aim of the NHI is good and noble. But the NHI bill is bad law because it fails to provide reasonable certainty. Several court rulings have flagged this. The NHI will be a mandatory state-run medical aid. It will be available for all South Africans irrespective of their socio-economic status. Your health needs, not your financial status, will determine what form of service you get.

A new healthcare system: South Africa’s two-tier healthcare system has failed to guarantee good quality healthcare for all. Those who have the financial resources, or medical insurance, use private healthcare practitioners and facilities not funded by the state. Those who do not have medical aid use public practitioners and the facilities provided and funded by the state. Due to the state’s incompetence, its current healthcare system has failed to provide good quality healthcare for all. We will move to a uniform “one-tier” system. under the NHI, the new normal will be “medical aid for all”. Everybody will be able to consult doctors in private practice and use private hospitals, because the NHI Fund will pay for this care. The reality is that in a just world, the sickest people – not the richest – should receive the largest share of healthcare.

NHI Cards: The NHI will use its central healthcare fund to pay both private and public medical providers. It will pay both these providers on exactly the same basis and expect the same standard of care from them. Lower income groups will be the major beneficiaries of the NHI, while higher income groups might be worse off. With the new system you will have to register for NHI at a NHI registration centre and you will be issued with a NHI card. It will be a “one card fits all” system. The present system of different medical aid plans and cards will disappear.

A shock to the system: For South Africans who do have medical aid plans, the NHI may be a shock to the system. South Africans within a certain income bracket will have to make additional mandatory monthly payments towards healthcare in addition to carrying a higher tax burden, plus they may have to settle for lower standards. Medical aid schemes will not be able (or allowed) to offer any services that are offered by the NHI. The NHI will set the maximum medical service levels allowed. Private medical insurance will only be able to provide for “complementary or top-up cover” that doesn’t overlap with services covered by the NHI. 

Cas Coovadia, CEO Business Unity SA (Busa), has sharply criticised this. Busa has consistently said the NHI bill is unworkable and unaffordable. It pointed out that the government’s estimate cost of R480bn a year is far too low and would require increasing personal income tax by almost one-third, VAT from 15% to 21% or applying a payroll tax that is 10 times higher than the current Unemployment Insurance Fund. This would cover only very basic healthcare, it said.

Funding: The bill is vague on how the NHI Fund will be financed. Recent estimates have put its cost at more than R480bn a year. And what will happen to medical aid schemes? Section 33 of the NHI bill is unclear and open to the interpretation that these schemes will disappear. We cannot allow medical aid schemes to simply disappear. The NHI Fund will get a large amount from general taxes. Every person in South Africa will contribute to the fund because we all pay some kind of tax. The fund will eliminate direct, out-of-pocket payments at the point of care – there will be no co-payments. Critics fear that with South Africa’s limited tax base and sluggish economy, the NHI might lead to increased tax burdens.

What are the disadvantages of NHI in South Africa? It will be a blow to freedom of choice as all South Africans will be forced to make use of NHI, regardless of whether they want to or not; The healthy paying for the sick and increased burdens on taxpayers; Uncertainty and vagueness surrounding the financial aspects of the NHI. Critics cite potential administrative and funding challenges, pointing to the public sector’s track record of poor management and corruption. It will be a blow to doctors. Private healthcare groups have warned that the planned implementation of the NHI scheme could lead to a wave of doctors and other skilled professionals leaving the country due to the additional working and earning restrictions placed on them. Organised business has described the NHI bill as mockery – yesterday it appealed to the National Council of Provinces (NCOP) to delay its vote on the controversial NHI Bill and send it back to Parliament to have another look at it. South Africa has excellent private healthcare and modern private medical facilities which should not be ruined by an idealistic, impractical, and costly NHI.

BOTTOM LINE: Universal access to healthcare and the ideal of a national system of health insurance are important concepts which relate directly to core human rights. In an ideal world it may be conceivable. However, it is often the case that the ideal falls short in practice. It is a case of: “The map is not the territory”. The NHI bill is no exception. The transition from the existing two-tier system to the new one-tier system will be complex and turbulent with potential job losses at medical aid funds. The NHI cannot be avoided. Even politicians shun state hospitals in favour of private healthcare. But to benefit all and live up to its potential, it should be fully thought through, planned in detail and not rushed. It will affect all of us.