A key part of the National Health Insurance Act is the requirement of private healthcare facilities to obtain a Certificate of Need (CON) in order to practise. Now it, this component has been struck down by a Pretoria High Court judge. Judge Anthony Millar struck down the Act’s key section, saying that it was “akin to an attempt to indenture the private medical service in the service of the state”.
The case had been brought by the Solidarity Trade Union, the Alliance of South African Practitioner Associations, the South African Private Practitioner Forum, the Hospitals Association of South Africa (HASA) and a number of healthcare providers and owners of healthcare establishments.
Sections 36 to 40 of the NHI Act would introduce a Certificate of Need (CON) scheme, essentially tying down doctors to a specified geographical location, which would be the only location where they could render their services.
It is declared that sections 36 to 40 of the National Health Insurance Act 61 of 2003 are invalid in their entirety and are consequently severed from the Act.
Judge Anthony Millar’s ruling
Any new healthcare facility would have to apply for a CON, which would be valid for 20 years. Existing facilities would have two years’ grace period to apply. This would applicable to hospitals, clinics, pharmacies and even to private rooms set up within the home of the practitioner. Operating without one would be a criminal offence – punishable with a fine, five years in prison or both.
It had been argued that because the regulations for CON had not been promulgated, the applicants’ argument was “hypothetical” and not “crystallized”. In Tuesday’s ruling, Judge Millar cited previous rulings and the constitutionality of the matter was still worth testing.
The CON scheme was extensive, Judge Millar noted, and would impact not only healthcare practitioners who worked in healthcare facilities and their employees, but also “juristic persons“, ie corporations or other organisations that can be legally liable.
In terms of its constitutionality, the applicants’ argument was that, “at least six constitutional rights are infringed. They say it tramples on their rights including where they want to reside, send their children to school and the communities they belong to.”
Judge Millar noted, would mean that setting up a hospital was a hefty investment of R500 million or so, and there was no provision any support. Taken together with the 20-year CON validity, would serve to discourage private investment and became a “blunt instrument” with which the Director-General of Health could control private healthcare in the country.
Even though this provision was ostensibly to serve many, this could not come at the cost of individual freedoms, among them Section 22 of the Constitution which provided for the freedom to choose an occupation within the rule of law.
“The scheme is silent on the extant rights of both the owners of private health establishments, private healthcare service providers and private healthcare workers. Such extant right include their integration and professional reputations in the communities which they presently serve together with the significant financial investments and commitments made by them to be able to render the services that they do.”
Since health establishments are purpose-built and hard to convert for other use, this constitutes a de facto deprivation, he wrote.
“It does not behove government in pursuing transformation, to trample upon the rights of some ostensibly for the benefit of the many.”
‘Effective indenture’ of private healthcare
While the legal teams for President Cyril Ramaphosa, the minister of health, Dr Aaron Motsoaledi, and the director-general of health, Dr Sandile Buthelezi, argued that the public healthcare sector was overburdened, Judge Millar replied that this amounted to the effective indenture of the private healthcare system.
Among other problems, contesting CON issuance was without recourse and by turning down a certificate the DG could essentially deprive the affected parties of income, as doing so would see them prosecuted under Section 40.
The ruling was welcomed by healthcare professional associations.
As reported in the Daily Maverick, Solidarity chief executive Dr Dirk Hermann said, “This judgment is a major blow to the total NHI [National Health Insurance] idea, as the principle of central management is a core pillar of the NHI Act itself. A more extensive consequence of this ruling with regard to the certificate of need is that parts of the NHI Act are now probably also illegal in principle.
“The NHI in its current format cannot be implemented as the essence of the NHI is central planning – and this has now been found unconstitutional.”
In a statement, HASA said that it regretted that the matter had to come to court. “We would have preferred achieving the objective of a stronger health system through a negotiated and collaborative effort to increase the number of medical students and nurses in medical training facilities to address the healthcare system’s needs,” the association stated.
In a press release, the South African Health Products Regulatory Authority (SAHPRA) has hit back over what it terms “unfounded fallacies and misrepresentation” that has been “churned out by some media organisations without verification” over its draft B-BBEE Policy.
SAHPRA states that this policy “is proposed in order to comply with requirements of the Broad-Based Black Economic Empowerment Act, 53 of 2003, in particular Section 10(1)(a), which demands of all state entities to enact policy that can encourage inclusive economic participation.”
It states that the draft B-BBEE policy does not set “racial requirements” for the registration of medicines, as the first falsehood suggests, stating that it is not reflected in any of the documents.
The second falsehood is that “SAHPRA will use the B-BBEE to assess medicine registration applications and thus affect access to medicines”, which it says is a deliberate misrepresentation. The product registration processes “would continue to solely rely on the safety, quality, efficacy, and performance of the health products.”
The third falsehood is that the draft policy is aligned with NHI, seeking to exclude certain persons from state procurement. SAHPRA says that the policy is a move develop sector codes and/or criteria to comply with the B-BBEE Act, as has been done in other sectors of the economy.
SAHPRA states that the fourth and final falsehood is that the policy will deny participation by pharmaceutical SMEs as they may be unable to get B-BBEE certificates. The agency contends that compliance affidavits will be an acceptable alternative, and that in any case, the B-BBEE level of a business does not affect the medicines registration process – which will remain the case even after policy implementation.
Children lining up to see the dentist at the Ekuphumleni Community Hall, near Whittlesea. (Photo: Sue Segar/Spotlight)
By Sue Segar
The Keready project uses mobile clinics to take healthcare services to rural areas. Sue Segar spent time with the project as they took eye, dental, and other healthcare services to communities in the Eastern Cape.
In the small Eastern Cape town of Bizana, hundreds of children stream into a large hall at the Oliver and Adelaide Tambo Regional Hospital on a brisk Tuesday morning in May. There’s a festive but orderly vibrancy in the air – the scene made all the more colourful by different school uniforms and young voices from tiny six-year-olds to learners in their late teens.
They’ll be assessed, and helped by doctors from Keready – an organisation offering mobile health services in many far-flung communities lacking healthcare services.
For weeks leading up to today, outreach teams from Keready’s mobile clinic operation have gone from school to school, asking teachers to identify children with eye problems. Today they arrived on various forms of transport – some on the back of a bakkie – from deeply rural communities as far as 100 kms away. Most of the children have little access to health services, particularly eye care, so the response is substantial.
I have travelled here with three doctors and an admin assistant from Keready’s East London office. They join other healthcare staff, including from the health department, for this two-day mega outreach in partnership with the Umbono Eye Project.
“Over the past three months, school educators identified 492 learners from 26 schools who have impaired vision,” says Ewan Harris, a pharmacist and consultant by training and a former deputy director-general of education in the Eastern Cape, who heads up Keready’s Eastern Cape team. “We will attend to these learners and if necessary, provide them with prescription spectacles and meds.”
Ntombizedumo Bhekizulu, a teacher at the Mhlabuvelile Senior Primary School at Ludeke Mission, has come with 16 children, “the ones who struggle to see what we write on the chalkboard”.
Bulelwa Mqhayi from Nomathebe Primary School in Isithukutezi adds: “It’s great that they can help these kids. Most of the parents are unemployed and on social grants and don’t have the money to take the kids to specialists. The clinics don’t help us with eye problems.”
The youngsters will also have a range of other health checks and will be sent to see one of the doctors on site if found to be in need of further health assistance. The health department has deployed a mobile dental unit, an audiologist, as well as a medic to provide advice on family planning and reproductive health.
A child being signed in for a health check at Bizana. (Photo: Sue Segar/Spotlight)
Before arriving at the registration desk, the children have already been given deworming tablets and a Vitamin A supplement, provided by the health department, while each group is given a health talk on age-dependent topics ranging from hand hygiene, to TB and HIV.
After handing in their registration and consent forms, the children go through basic vision screening tests by a team of “eye care ambassadors” – young people supported with employment opportunities through the Social Employment Fund, which is managed by the Industrial Development Corporation.
If the school children fail the eye screening test, they are sent to see optometrist Johan van der Merwe.
In between patients, he tells Spotlight he’s already found a number of “low vision candidates” and one who might need to be placed in a special school. “I’ve just done a full refraction on one child … It’s clear that he has a lens defect,” says Van der Merwe. Placing his hand on the head of another small boy, he continues: “This little one has been very quiet … he’s struggling to communicate. He needs thick lenses, or an operation by a specialist.”
Van der Merwe, who has been an optometrist for 22 years, joined the Umbono Eye Project permanently almost two years ago after volunteering his services once a week. “Before I joined, I was working in a mall in East London. I never saw sunlight.” He adds: “It has been very rewarding to make a difference to these children.”
Optometrist Johan van der Merwe assesses a child at Bizana. (Photo: Sue Segar/Spotlight)
At another mobile site, health department dentist, Dr Unathi Mponco, has been busy with youngsters suffering from a range of dental ailments. “There were sore teeth, rotten teeth, mobile teeth, and some children had very swollen gums…. Whatever I can treat on the mobile truck, I deal with here – otherwise if they need X-rays or the cases are more serious, I refer them to the hospital’s dental unit for a comprehensive exam,” she says.
In a mobile van outside the hall, health department medic Siyabonga Chonco has been consulting teenage girls all day offering family planning services. “The Alfred Nzo district has the highest rate of teen pregnancies in the Eastern Cape. We are trying hard to curb teenage pregnancy,” he says.
The teens are invited to ask any questions and to say whether they are sexually active and ready to take contraceptives. Chonco says in almost every case, he senses great relief from the learners to speak to an impartial young person. “They tell me that, at the clinics, the older nurses can be quite harsh…. They open up to me, especially with questions about contraceptives.”
He says broadly, young people are interested in long-term contraceptives. “They don’t want to have to go to clinics all the time.” Some will walk away with a contraceptive implant – a flexible plastic rod about the size of a matchstick that is placed under the skin of the upper arm to prevent pregnancy over three years – while others will choose injectables or pills.
At the end of two days in Bizana, the team has seen nearly 750 youngsters from about 40 schools, with 432 having had their eyes screened and 52 eligible for specs. For six of those children, the spectacles will be life-changing, says Van der Merwe.
Doctors Eileen Kaba and Anda Gxolo consulting with their little patients. (Photo: Sue Segar/Spotlight)
Apart from a few “high” prescriptions that might have to be ordered from overseas, a member of the team will deliver the specs personally to each learner, an occasion which is a highlight for the team. “When we first put the glasses on their faces, you just see smiles. The parents are so thankful. It makes this so worthwhile,” says Van der Merwe.
Keready is working closely with the provincial departments of health and education. The NGO recently received the Eastern Cape’s Batho Pele Award for enhancing healthcare in the province.
“We could never reach all these children as government,” says TD Mafumbatha, mayor of the Winnie Madikizela-Mandela municipality, adding “this is what collaboration looks like”.
But where did it all begin?
Keready, loosely translated as “We are ready”, was set up in February 2022 to encourage young people to vaccinate against COVID-19.
One of the people behind Keready is Harris, a pharmacist and consultant by training and a former deputy director-general of education in the Eastern Cape. Harris was working as a consultant for the Fort Hare Institute of Health, when he was asked to help design the Eastern Cape’s COVID vaccine rollout strategy.
“The COVID programme was a success because, through advanced digitisation, we were able to map the 84 000 communities in South Africa to their nearest schools, clinics and hospitals,” he says.
And it is out of that awareness of the spatial distribution of healthcare needs that Keready was born.
After the COVID programme ended, Harris, as national lead for the project, was tasked with setting up Keready’s offices in four provinces, including employing provincial leads, and staff as well as doctors and nurses. “Our vision was to give young doctors the opportunity to manage at the highest level, under our guidance.”
Implemented by DG Murray Trust (a South African philanthropic foundation) in partnership with the National Department of Health, Keready is funded by the German government through the KfW Development Bank.
The project reached full scale late last year with 46 mobile health clinics in four provinces: Eastern Cape (8), Gauteng (16), KwaZulu-Natal (13), and the Western Cape (9).
These mobile clinics move into different communities every day. At times they use a loud-hailer to attract people. Sometimes they are based at schools, other times at taxi ranks and other hubs of activity.
People of all ages who visit the clinics are provided with a range of health services, including screenings and tests for HIV, TB and diabetes, as well as given family planning advice and immunisations. Medication is prescribed, and, where possible, dispensed on the spot.
Keready also runs a WhatsApp line where youth can ask young doctors and nurses any health-related questions and get straightforward, non-judgemental answers.
When learning about Keready during a walkthrough of exhibition stands set up at the Birchwood Hotel in Boksburg during the 2023 Presidential Health Summit, President Cyril Ramaphosa described the movement as “NHI on Wheels” because of its efforts in addressing universal health coverage.
From Bizana to Whittlesea
Two weeks later, I am again travelling with the same Keready team – this time to Whittlesea, outside Queenstown. Over two days, we visit the Ekuphumleni Community Hall and Kopana School in Ntabethemba. A highlight of this outreach is that teenage girls will be supplied with sanitary pads, thanks to a collaboration with pharmaceutical and healthcare company Johnson & Johnson.
On day one, hundreds more pupils than anticipated arrive. School principals were over-enthusiastic in spreading the word of the outreach resulting in taxi-loads of pupils from unexpected schools arriving. Irate teachers try to negotiate a way for their pupils to be seen.
Teacher Nolitha Tuta tells me many of the children she’s brought are from child-headed households and some have had little to no access to healthcare services.
While waiting in the queue, a mother of a child from Bhongolethu Primary School describes how she walked for hours to bring her child for eye testing.
Children line up for their health checks at the Kopana School in Ntabethemba. (Photo: Sue Segar/Spotlight)
Despite having waited until the end of the day, students from Zweledinga High end up being driven back home at sunset without being assisted.
After two days in Whittlesea, nearly 1 200 pupils from 36 schools have arrived. Nine schools were turned away. Nearly 700 learners have been screened for eye conditions, with 88 eligible for specs and four referred to an ophthalmologist.
The doctors look exhausted. Dr Anda Gxolo says over the past two days numerous children presented with ear problems. There were also long lines for dental care this time.
Despite the long hours, Dr Phumelele Sambumbu, who manages five of the eight Keready mobile clinics in the Eastern Cape, says she loves her work. “I come from these parts – from a village between Cofimvaba and Tsomo. My old grandmother is bedridden. I know first-hand how difficult it is to have access to care when you’re from a village like that and when you suffer from ailments like that. The idea of bringing health services to people who would otherwise struggle to access them is what drives me,” she says.
Mapping the need
Based on its relationship with the department of health, Keready has ambitious plans to expand its grassroots outreach programmes to help narrow the gaps in healthcare nationally.
A map on the wall of Keready’s office shows the number of government clinics in the Eastern Cape relative to schools. There are around 700 clinics in the province, but over 5000 schools (which works out to more than seven schools per clinic). Nationally, the ratio is similar with around 3 400 clinics and 25 000 schools.
It’s no surprise then that, according to Harris, staff on Keready’s 46 mobile clinics in the four provinces where it operates cannot keep up with demand for their services.
“Based on our mapping of the national population, we know there are 2 500 communities that don’t have reasonable access to a clinic. Just to deal with the gaps, we need 2 500 mobile clinics. We can tell you exactly where in the country to put them,” says Harris.
To reach ill people who are ill but don’t know it, Keready aims for nurse-supervised ambassadors to do door to door visits in communities to check who has TB, HIV and hypertension. “We have digitised every street and every house by satellite. Each house would be marked off; if TB’s picked up, it is mapped,” says Harris.
Plans for the door to door programme are well under way, he says. “In the Eastern Cape, Keready has partnered with the Small Projects Foundation to train 80 young people [as nurse-supervised ambassadors] from the Industrial Development Corporation’s Social Employment Fund to do health testing house to house.”
Eventually, says Harris, there could be 80 people linked to each of the 46 mobile clinics, meaning that a total of 3 680 trained people could be going from door to door.
“Going forward we’d want to find the disease before the disease finds us – TB, HIV, hypertension, diabetes and general growth issues [in children] are the core areas we will address in this programme,” he says.
But the extent to which Keready can deliver on its ambitious expansion plans will depend on funding and to what extent government continues to implement services using mobile clinic outreach programmes. The German financial contribution to the Keready project comes to an end in September. “We are working day and night to get more funding,” says Harris. He says they will soon be meeting with potential donors.
Is complementing in-person care with virtual care (hybrid care) a key part of the answer to South Africa’s NHI aspirations, asks Deon Bührs, Managing Director of Genie Health SA, who suggests that technology is the ‘unreasonable man’ in complementing decent universal healthcare and that self-empowerment is the only solution to sustainable wellness.
“The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
George Bernard Shaw
There is a school of thought that a young democracy can benefit from a well-considered blend of socialism and capitalism, particularly when it comes to healthcare and education. I would second that, to a degree. That South Africa requires a more equitable health system goes without saying though, as the apparent disparity and divisions between the haves and have nots is ever widening.
The status of our public healthcare system and the spiralling costs of the private offering need to find parity. A sad situation indeed, because at one stage, South Africa had one of the best public health sectors in the world, where groundbreaking heart transplants, for example, were done.
To the question of universal healthcare then. If it means that universal healthcare is a fundamental human right that everyone should aspire to, then it’s a yes, the NHI is essential. It should not be a matter of political affiliation, and let’s be clear, there is already healthcare for all in South Africa, through the public health system, free at the point of care for those who cannot afford care. But it is the quality of this care, and the effective management of these services that lie in stark contrast to that of the private healthcare system.
Signed in literally at the 11th hour before the country went to general elections, the National Health Insurance (NHI) bill is a polarising topic for many. The massive cost of providing a functioning NHI as per the bill, has been estimated conservatively at more than R200 billion a year, while some estimate closer to R1 trillion. With an already strained tax base, we must adopt new thinking as to how to deliver healthcare in a cost sensitive and effective way.
To my mind, one of the most effective ways of ensuring there is universal care that works, is recognising and supporting the role the patient plays in empowering their own health, recovery and wellness journey. They appear, however, to have been forgotten in the conversation that is the NHI bill to date.
For me, in its current guise, the NHI will unfortunately not bridge the quality divide. In fact, if we are not careful and if we do not find common ground, and hold government and the private sector to account, our entire healthcare system could well be in danger of failing – completely.
The unreasonable man test – laying the groundwork for new ways of healthcare delivery
Although expediently signed into law with little regard to comments or concerns raised from many sectors including health and business, the NHI does lay the groundwork for new ways of delivering healthcare and sets the scene for changing the mindset from the current sick-care system mentality to one of a patient-empowered HEALTHcare system.
Change must happen, but the extent of that change often depends on what Irish playwright and political activist, George Bernard Shaw, once stated as: “The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
At present, Prof Nicholas Crisp who has been tasked with helming the delivery of the NHI, could be seen as Shaw’s “unreasonable man” in his efforts to equalise and deliver universal healthcare. Ensuring that the lever of technology is utilised in an effective way is critical though, to ensure that we don’t try and replicate previous perceived successes, and not move forwards.
With a challenged healthcare system, both public and private, we are called to not give up hope, but to lean into the solution, and at the same time, avoid a defensive posture of that which only served the few. I believe that these circumstances force us to innovate, and to seriously consider new ways of providing healthcare for all. It should be seen as an exciting time of just where we can push the future of healthcare.
For instance, we already know that a traditional healthcare delivery system, with its associated costs and accessibility challenges for those living in remote parts of our country just won’t cut it. But unlocking technology as the new delivery channel of healthcare complimented by affordable and fast internet, could well be the solution to cracking the code of healthcare for all.
Through technology we can drive the patient-centric approach to health and open the door for patients to more easily access the multi-disciplinary team of healthcare professionals they need.
The best of both worlds – prevention, and when required, recovery
An example of doing things differently, is a new approach to musculoskeletal health that has been facilitated by digital transformation, and which is finding growing adoption in South Africa. With objective improvements in patient outcomes, satisfaction scores and recovery times, virtual care teams can support patients through their recovery programmes, ensuring improved compliance and ownership of their health journey. And empowering patients to embrace exercise and activity over surgery and pharmaceuticals where appropriate, has a dramatic impact on the overall healthcare spend.
Imagine patients having the choice to access a multi-disciplinary team of experts anywhere in the country – from the comfort and convenience of their own home or workplace, all at the tips of their fingers. No need to be transported to a clinic or hospital every time they need healthcare services. This is entirely possible, with platforms like Genie Health, that provide a hybrid approach in complimenting in-person care with virtual care.
NHI needs a strong front loader like these hybrid platforms that provide the full range of allied healthcare services, to reduce the burden of care and cost on an already strained system, by reducing unnecessary hospital admissions, surgeries, medication and travel costs and allowing for the existing framework to be brought up to date and even surpass expectations.
With ICASA reporting over 75% of the population having Internet access in South Africa and more than 90% smartphone penetration, pressure on Mobile Network Operators to provide zero rated data for healthcare applications (as they have done in education and other areas) mounts.
If measures like this can be implemented, they will have a tremendous impact on reducing the burden on the existing healthcare system through a self-health-empowered approach, with the backing of a full clinical team on the ready to assist the patient.
The ultimate question is how do we make healthcare more affordable and accessible to all South Africans, which is the core aim of the NHI?
The answer – we need to renew our focus on the key stakeholder, our patients – and empower them to drive their own health, by using technology as the backbone for sustainable wellness. It could well be, that with a renewed mindset and health-empowered citizens, the NHI is the true gamechanger for progress in HEALTHcare that we all need.
Despite the promise of Universal Health Coverage (UHC) for all, the recent signing of the NHI Bill has brought with it several misconceptions around medical schemes that undermine the very foundation of our healthcare system, writes Dr Katlego Mothudi, Managing Director at the Board of Healthcare Funders (BHF).
In a historic move aimed at transforming the South African healthcare landscape, President Cyril Ramaphosa signed the National Health Insurance (NHI) Bill into law. This landmark decision promises to move South Africa towards Universal Health Coverage (UHC) for all citizens, regardless of socio-economic status.
While the goal of UHC is commendable, the rhetoric leading up to the NHI Act’s announcement has created misconceptions about the role of medical schemes.
With many believing that they should cancel their memberships immediately to enjoy free health services for the foreseeable future. However, Dr Katlego Mothudi clarifies that the implementation of NHI will take several years, dispelling this misconception.
The NHI Act introduces a single-payer system, central to the idea is that healthcare is a ‘public good’, suggesting all healthcare funding should exclude medical schemes, and should be government-funded. Dr Mothudi counters that healthcare is more accurately described as a social good. A public good, like military services, is one that the government must provide and from which no one can be excluded, regardless of payment. While healthcare is essential, it is not feasible to provide it as a public good.
The Board of Healthcare Funders (BHF), concerned about the numerous misconceptions propagated by government representatives since 2009, commissioned Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at Wits Health Consortium, to investigate these claims. Despite their hyperbolic nature and lack of systematic research, these statements have significant weight due to their endorsement by influential individuals. Prof van den Heever’s report identified frequently repeated assertions that he concluded were unsubstantiated and untrue.
Key Findings from the Report:
1. Medical Schemes are Unsustainable – False
In 2009, claims suggested that many medical schemes were headed for collapse due to unsustainable financing models, with 18 schemes reportedly nearing insolvency. Prof van den Heever’s report refutes this, showing stability in medical schemes from 2005 to 2022. The number of beneficiaries increased by over one million from 2009 to 2022, with consolidated reserves of R114 billion in 2022, far exceeding the required 25% reserve ratio. Broker costs have not been a systemic concern, and total non-health costs per average beneficiary per month for all medical schemes decreased by 34.7% in real terms from 2005 to 2020.
2. Health Services are a Public Good – False
In 2011, Health Minister Aaron Motsoaledi claimed that private healthcare was a “brutal system” due to commercialisation. However, Prof. van den Heever clarified that healthcare is not a public good in the economic sense, as it does not meet the criteria of being jointly consumed without exclusion. Healthcare is a crucial service but providing it as a public good is not feasible.
3. Most Medical Scheme Beneficiaries are White – False
Last year, Prof Olive Shisana, an honorary professor at the University of Cape Town and special advisor to President Ramaphosa, stated that the private sector predominantly serves the privileged white population. However, Statistics South Africa’s 2021 research indicates that of the total population utilising private healthcare services, 50.2% are Black African, 32.3% are White, 9.8% are Coloured, and 7.6% are Indian/Asian.
Need for Balanced Perspectives
While the BHF supports healthcare reform, it raises concerns about the NHI Act’s constitutionality and calls for a factual review of claims about medical schemes. It is crucial to present both sides of the debate to understand the implications fully. Including government perspectives and addressing how the NHI will affect individual citizens would provide a more comprehensive view.
Medical schemes remain a valuable national asset that plays a crucial role in ensuring the long-term viability of South Africa’s healthcare ecosystem. BHF advocates for a balanced approach to healthcare reform that considers both public and private sectors’ strengths and weaknesses.
Dr Kenneth Jacobs entered Parliament as an ANC MP in 2019, and two years later was elected chairperson of the Portfolio Committee on Health. (Photo: Parliament)
By Biénne Huisman
The chairperson of the National Assembly’s Portfolio Committee on Health Dr Kenneth Jacobs played a pivotal role in deliberations on the National Health Insurance Bill. Spotlight’s Biénne Huisman asked Jacobs about some criticisms of NHI and about his plans for life after Parliament.
Back in Cape Town, Jacobs tells Spotlight the NHI signing was the culmination of his own work dating back fifteen years. He says he started working on public health projects relating to universal health coverage and the NHI in 2009, as a consultant to the National Department of Health.
For him, at the heart of the bill lies fairness.
“We should be able to provide all of the people of South Africa the opportunity to access quality healthcare,” he says.
Jacobs entered Parliament as an ANC MP in 2019, and two years later was elected chairperson of the Portfolio Committee on Health after his predecessor, Dr Sibongiseni Dhlomo, became the Deputy Minister of Health. Committee chairpersons are elected by and from among the members of each committee, meaning the majority party in Parliament has the most influence in selecting chairpersons.
As chairperson, a large part of Jacobs’ job was to hold the country’s executive and the National Department of Health to account on behalf of South Africa’s citizens.
Amongst other tasks, he played a pivotal role in overseeing public deliberations around the NHI Bill, which included 338 891 written submission and presentations by 133 organisations. These included political parties, trade unions, medical aid schemes, health technology organisations, the South African Medical Association, and university departments.
“It is never in the history that the committee had such an engagement by the public,” says Jacobs. “So I’ve been very blessed and fortunate to go to Parliament in the final process of the NHI Bill.”
‘Disheartening’ criticism
Both before and after its signing into law, NHI has been deeply divisive, with several political parties and other role players threatening litigation. One line of criticism is that, while many people and organisations made submissions to the committee chaired by Jacobs, the final bill did not changed substantially from what it was prior to the public hearings.
Interviewed on the topic, Business Leadership South Africa CEO Busi Mavuso, said government rushed populist policy through Parliament – an electioneering ploy – as the significant public input into the Bill and its socioeconomic ramifications had not been considered.
Jacobs voices his frustration at such criticism of the NHI public participation process, saying it is “disheartening”, adding that criticism are doled out by South Africans who are “in better financial positions”.
He explains the process of collating so much information: “Well, firstly it’s driven by the chairperson [him]… We appointed a team through Parliamentary processes, who looked at the submissions, and interpreted the submissions using computerised systems. It’s thematic – what are the themes, really? These are developed into reports; the reports on all the public hearings, those reports are all available.”
He adds: “So people who want to write and say all these negative things, they really should go and access these documents and see what the submissions were.”
‘It’s attractive to make people insecure’
Another aspect of NHI over which many have expressed concern is the potential for corruption, particularly in light of massive healthcare corruption during the height of the COVID-19 pandemic and more recent alleged corruption at Tembisa Hospital in Gauteng. Here criticism ranges from a simple distrust in government to run such funds, to more nuanced criticisms of aspects of the bill that critics say increases the risk of corruption – such as the Minister of Health’s expansive powers and accountability to cabinet rather than to Parliament.
In an interview following the signing of the bill, DA Chief Whip who was also a health portfolio committee member, Siviwe Gwarube, said: “The NHI will not address the underlying issues in our healthcare system; it is financially unfeasible, an election gimmick, and will burden South Africans with increased taxes.” She added: “The potential for corruption is staggering, and the flawed parliamentary process further erodes public trust…”
When asked about fears that money might disappear from centralised NHI coffers – to be governed by a board appointed by the minister of health – and accountability to prevent such, Jacobs says: “I think that people are putting the cart before the horse. You must remember this will be an entity [with tender procedures], and then who is supposed to appoint them [board members] in any case? Somebody has to have the responsibility. Why can that not be the minister, for example. But remember that it will be a transparent process, the same as the appointment, I think, as what we do with the appointment of judges.”
The NHI fund will be a schedule 3A entity, similar to, among others, the Road Accident Fund, the National Lotteries Commission, the National Laboratory Service, the Office of Health Standards Compliance, the Competition Commission, and the Council for Medical Schemes.
Jacobs says checks will be provided by the country’s forensic investigation agency, the Special Investigating Unit (SIU). “And there are many ways to put checks and balances into place,” he says, “we talk [in the bill] about the interventions which can be made, or the investigations which can be made by the SIU and other law enforcement agencies”.
Shortly after taking over as health committee chairperson, Jacobs told Spotlight that rooting out corruption in the health sector was a priority. At the time, he stressed the importance of safety nets for whistle-blowers, and of establishing systems to enforce accountability. Around the time of his appointment in 2021, whistle-blower Babita Deokaran was murdered for exposing R1 billion worth of allegedly irregular tenders issued at the Tembisa Hospital in Gauteng.
Asked about these particular earlier priorities, Jacobs responds: “I have no answer on that, I don’t think I want to talk about corruption now…” Upon reflection, he adds: “Of course corruption is important. Losses to the fiscal is important; people doing wrong is important. People need to be brought to book, be held accountable for doing wrong…”
Later on in the interview, when the issue of corruption comes up again, he says that corruption has decreased in South Africa: “I think we’ve advanced quite a bit from the time when corruption was more rife. I think nowadays you hardly hear about these things and it’s because unprecedented intensive programmes were put in place to address these issues of corruption and fraud. I really think what they [critics] are doing is fear-mongering, telling people that you need to be frightened, and I’m going to say again, those who are telling others to feel frightened, are in a better financial position. So it’s attractive to make people insecure.”
Money for NHI?
Another common argument against implementing NHI is that it is not affordable. Government’s spending on health has declined in real terms for much of the last decade and the South African economy is struggling by most measures.
Asked about crippling budget cuts in the health sector as it stands, and questions around the NHI’s affordability, Jacobs says South Africa has insufficient central funds because of unemployment, and that South Africa needs more jobs and more workers to increase its tax-base.
“My personal view is that we need to understand why there’s a budget problem,” he says. “So where is government supposed to get money? Who are supposed to contribute? Those who are employed. And look at our employment rate – is it government’s responsibility? No, the emphasis is wrong. It is businesses’ responsibility.
“When people have employment they can contribute to the coffer… and I’m going to keep on saying, the narrative is in the wrong place. We need to say to South Africans: ‘don’t all of us have a responsibility?’ Those who have the economy in their hands and those who don’t have the economy in their hands, all of the responsibility to drive our country forward.”
How to drive South African healthcare forward, remains contested. Several organisations representing healthcare workers, such as the South African Medical Association, do not support the NHI Act in its current form. Others, including the South African Medical Association Trade Union, welcome it.
Meanwhile, Jacobs expresses empathy for his clinician colleagues: “As a medical doctor, I have absolute respect for all of my colleagues. I would like you to write it; I understand the conditions under which our medical and or health personnel have to function. And I don’t think that National Health Insurance be a negative thing for healthcare professionals.”
‘Why should there be people who profit from the ill health of other people?’
Another concern in some quarters is that NHI will over time squeeze out medical aid schemes and leave people with no alternative to health services provided through NHI. This because, according to Section 33 of the NHI Act, medical schemes will not be allowed to cover services that are already covered by the NHI fund.
Asked about the future of medical aid schemes in South Africa, Jacobs says: “What is the medical aid system? It’s a profit driven system by people who are in business. Is it correct that there are people who make profit off the lives of people, and the health of people? I don’t think that is correct.” (Note: Medical schemes are non-profit entities while medical scheme administrators are for-profit.)
He adds: “What is wrong with having one single system, in which everybody has access to the same healthcare? Why do we need to keep exclusionary rights for some people, based on them having a better income than others? I think that’s the bottom-line on the answer of the medical aid. Whether medical aid will stop functioning or not. I think that’s not the question to ask. The question is why should there be people who profit from the ill health of other people?”
‘From policy to practice’
Going forward, given that he won’t be returning to Parliament, Jacobs hopes to resume doing public health consulting work for the National Department of Health.
“I have a project which is very dear to me,” he says. “I want to start an institute for health governance, and it’s called, ‘from policy to practice’. It’s on health governance, universal health coverage… and will be instrumental in influencing dialogue. So, I can’t wait to stay active in the health sector, but not being restricted in that I’m no longer a member of Parliament, not feeling that there’s some sort of conflict.”
Jacobs will now move from the Acacia Park Parliamentary Village on Cape Town’s northern fringes back to his family home in Wellington.
Jacobs says that they will soon have seven public health doctors in his family – that is, when his son completes medical school at Stellenbosch University. His daughter recently finished medical school and is contracted as a doctor at a clinic in Khayelitsha.
Originally from Gqeberha, Jacobs holds a Bachelor of Medicine and Bachelor of Surgery degree from Stellenbosch University where he also obtained a Master of Medicine degree in family medicine. He went on to get a Master of Science degree in sports medicine from the University of Pretoria. In earlier years, he served as a physician to the Stormers and Springbok rugby teams.
In the previous interview with Spotlight, Jacobs relayed how his formative years were tough. His family were forcibly evicted from sea-facing South End, in what was then Port Elizabeth, and moved to Gelvandale, in the city’s northern suburbs. His father worked in a shoe factory, but lost his job when Jacobs was in grade 10.
“South End was like Port Elizabeth’s District Six,” said Jacobs, in the earlier interview. “So yes, honestly, that was something that had a huge impact on me. I decided then that I would not allow somebody to suppress or oppress me and I think it is probably why I just kept on studying and improving.”
At 65 years old, Jacobs exudes ambition and enthusiasm. Wrapping up, he quotes an Afrikaans aphorism: “Die mens wik maar God beskik” (Humanity proposes, God disposes).
Professor Susan Cleary delivering her inaugural lecture as part of a lecture series by the University of Cape Town. (Photo: Supplied)
President Cyril Ramaphosa recently signed the NHI Bill into law. The question is whether this will bring South Africa closer towards Universal Health Coverage. Professor Susan Cleary argues that the NHI is a wide ranging reform with both positive and controversial aspects. The key will be to find a middle ground in order to continue on the journey to UHC.
President Cyril Ramaphosa signing the National Health Insurance (NHI) Act on the eve of the elections is a smart move from the perspective of a political party seeking to shore up its base. The concern though to those of us working to strengthen the health system is whether the NHI will enable the country to move closer towards Universal Health Coverage.
For the NHI naysayers, perhaps it would be important to alleviate some fears and concerns. The NHI is a long-term project. In the 2024 budget, National Treasury reduced the conditional grant allocations to the NHI in comparison to what was allocated in the 2023 budget. While signing the NHI Bill into law is a step forward, the reduction in resources towards NHI implementation reminds us that this is a long term project. In addition, it is likely that there will be legal challenges which will lead to considerable delays for the scheme to be fully implemented.
The NHI is a wide-ranging reform, with many positive aspects sitting alongside some key controversial aspects. Positive aspects include the opportunity to enable greater use of evidence and transparency in priority setting through the further institutionalisation of Health Technology Assessment processes (akin to ‘NICE’ in the UK), as well as the opportunity to use national-level purchasing power to drive down the prices of commodities such as medicines. The role of private multidisciplinary practices (GPs, nurses, health and rehabilitation professionals, etc) in the future NHI also holds some promise to improve access to healthcare particularly to parts of the country with limited access to public clinics.
On the other hand, there are two key controversial aspects. The first is related to what may or may not happen to medical schemes and medical scheme administrators once the NHI is fully implemented. My sense is that there is no short-term concern in this regard. A bigger concern is whether a single pot of money in the NHI fund will present a larger or a smaller corruption risk than the current situation of multiple pots spread across provincial treasuries and medical aid schemes.
Another concern is that the NHI reform might disrupt our ongoing progress towards Universal Health Coverage within our existing public sector. Our public sector is not perfect, but it is a system that has equity at its heart. The common definition of Universal Health Coverage is to provide all individuals and communities with access to needed promotive, preventive, resuscitative, curative, rehabilitative and palliative health services of sufficient quality to be effective, while ensuring that the utilisation of these services does not expose users to financial hardship.
The two main goals of Universal Health Coverage are: (1) the provision of quality health care services to those in need and (2) the avoidance of financial catastrophe in this process. Clearly healthcare is far from free – indeed it is very expensive – and so the goal of avoiding financial catastrophe is about implementing prepayment and risk pooling mechanisms, whether these are tax or insurance based.
Let’s first look at how we are doing on the provision of quality services. The below figure plots countries according to their achievements on the Universal Health Coverage Service Coverage Index. In this context, coverage of essential health services is measured based on indicators that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged populations.
On this index, South Africa’s achievement is at just over 70%, similar to many other middle-income countries. While there would be room for improvement, our performance is in line with our global peers.
Global comparison of countries in terms of service coverage and quality
Source: World Health Organization – Global Health Observatory (2024) processed by Our World in Data. Accessed May 2024.
The second indicator is financial risk protection. The below figure plots countries against the percent of total health expenditure that is paid out of pocket at the point of use. On this indicator, we score 5.7%, indicating extremely high levels of financial risk protection.
Global comparison of countries in terms of the percent of total health expenditure that is paid out of pocket
Source: World Health Organization (via World Bank) processed by Our World in Data. Accessed May 2024.
While this does not mean that there are no instances of financial catastrophe, undoubtedly there would be, particularly for those seeking treatment for certain types of cancers. That said, over the past two decades I have studied this issue extensively. Across a wide range of conditions in diverse settings, we have interviewed tens of thousands of people to understand the costs that they face in using health services, including everything from transport costs, to costs of food, shelter or accommodation, costs of child care, lost income, under the counter payments to public sector providers (which we never found), fees paid to private providers or money spent at pharmacies. This research consistently showed that the level of catastrophic spending was very low. Our performance on financial risk protection is outstanding. I celebrate the work of those colleagues that shepherded in the removal of user fees in our national health system during the dawning of our democracy. We should all be thanking them.
Despite these successes on Universal Health Coverage, there are areas of concern for the South African health system. We do not achieve health outcomes commensurate with our level of investment. My sense is that this is driven by our relatively high burden of disease; for example we continue to have the world’s largest HIV treatment programme. While our average life expectancy steadily increased with the introduction of antiretroviral therapy (although note the downturn from 2020 which coincides with the Covid-19 pandemic – see the below figure), the HIV epidemic has been a cruel setback that needs to be considered when we seek to make global comparisons on life expectancy and avertable mortality.
Global comparisons of life expectancy: 1970 – 2020
Source: United Nations World Population Prospects (2022) processed by Our World in Data. Accessed May 2024.
Now that the NHI Bill has become the NHI Act, it is time to move on from debates about whether we need NHI or not, and rather focus on how we can make the NHI work for us.
Our public sector will be the backbone of our future NHI and so we should seek to continue to strengthen this system. It would also be wise to put in place measures to strengthen our private system given that private providers are intended to play a key role in the NHI. We should be pragmatic.
The NHI includes many exciting opportunities for leveraging big data and artificial intelligence in health systems strengthening, but at this stage we hardly have any electronic health data. A clear step forward would be the further implementation of the National Digital Health Strategy (2019-2024) which includes the establishment of a patient electronic health record, amongst other needed developments.
In addition, the NHI places emphasis on the achievement of a purchaser provider split via establishing ‘Contracting Units for Primary Health Care’ (CUPS). These new entities will contract with both public and private providers within a defined geographic area, on behalf of a particular population. The establishment of CUP ‘proof of concept’ sites is therefore a priority, but must be done in a way that generates learning and enables adaptation to different contexts.
Let’s continue to push forward on many of these complex undertakings. It is going to take time, but it is needed, irrespective of the name that we choose to give to our health system.
*Cleary is professor of health economics and the head of the School of Public Health at the University of Cape Town.
Note: The views expressed in this opinion piece are not necessarily shared by the Spotlight editors. Spotlight is committed to publishing a variety of views and facilitating informed discussion that deepens public understanding of health issues.
President Cyril Ramaphosa at signing ceremony of the NHI Bill at the Union Buildings in Pretoria.
Speech by Cyril Ramaphosa, article from Spotlight
President Cyril Ramaphosa yesterday signed into law the National Health Insurance (NHI) Bill, which is the ANC-led government’s plan for universal health coverage, just 14 days before the country heads to the polls.
The NHI aims to unify the country’s fragmented health system, Ramaphosa said at the signing ceremony at the Union Buildings in Pretoria on Wednesday.
However, he also noted that processes are yet to be established and that the Act’s implementation will be incremental rather than a massive overnight overhaul.
Here are 8 noteworthy quotes from the President’s speech:
“[T]he NHI is a commitment to eradicating the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect”.
“[T]he NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention”.
“The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.”
“The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.”
“The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.”
“The NHI is an important instrument to tackle poverty. The rising cost of health care makes families poorer. By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.”
“Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.”
“The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.”
Here is Ramaphosa’s full prepared speech:
REMARKS BY PRESIDENT CYRIL RAMAPOSA ON THE SIGNING OF THE NATIONAL HEALTH INSURANCE (NHI) BILL, UNION BUILDINGS, TSHWANE, 15 MAY 2024
Minister of Health, Dr Joe Phaahla, MECs of Health, Senior Officials, Representatives of the health fraternity, Representatives of civil society, Representatives of labour, Members of Parliament’s Portfolio and Select Committees, Public representatives, Members of the media, Distinguished Guests, Ladies and Gentlemen,
We are gathered here today to witness the signing into law of the National Health Insurance Bill, a pivotal moment in the transformation of our country.
It is a milestone in South Africa’s ongoing quest for a more just society.
This transformational health care initiative gives further effect to our constitutional commitment to progressively realise access to health care services for all its citizens.
At its essence, the NHI is a commitment to eradicate the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect.
By putting in place a system that ensures equal access to health care regardless of a person’s social and economic circumstances, the NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention.
This vision is not just about social justice. It is also about efficiency and quality.
The provision of health care in this country is currently fragmented, unsustainable and unacceptable.
The public sector serves a large majority of the population, but faces budget constraints. The private sector serves a fraction of society at a far higher cost without a proportional improvement in health outcomes.
Addressing this imbalance requires a radical reimagining of resource allocation and a steadfast commitment to universal healthcare, a commitment we made to the United Nations.
The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.
The NHI Bill presents an innovative approach to funding universal healthcare based on social solidarity.
It proposes a comprehensive strategy that combines various financial resources, including both additional funding and reallocating funds already in the health system.
This approach ensures contributions from a broader spectrum of society, emphasising the shared responsibility and mutual benefits envisioned by the NHI.
The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.
The NHI carries the potential to transform the healthcare landscape, making the dream of quality, accessible care a reality for all its citizens.
The NHI Fund will procure services from public and private service providers to ensure all South Africans have access to quality health care.
The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.
Through more effective collaboration between the public and private sectors, we can ensure that the whole is greater than the sum of its parts.
The effective implementation of the NHI depends on the collective will of the South African people.
We all need to embrace a future where healthcare is a shared national treasure, reflective of the dignity and value we accord to every South African life.
Preparations for the implementation of NHI necessarily require a focused drive to improve the quality of health care.
We have already begun implementing a national quality improvement plan in public and private health care facilities, and are now seeing vast improvement.
In signing this Bill, we are signalling our determination to advance the constitutional right to access health care as articulated in Section 27 of the Constitution.
The passage of the Bill sets the foundation for ending a parallel inequitable health system where those without means are relegated to poor health care.
Under the NHI, access to quality care will be determined by need not by ability to pay. This will produce better health outcomes and prevent avoidable deaths.
The NHI is an important instrument to tackle poverty.
The rising cost of health care makes families poorer.
By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.
The NHI will make health care in the country as a whole more affordable.
The way health care services will be paid for is meant to contain comprehensive health care costs and to ensure the available resources are more efficiently used.
Through the NHI, we plan to improve the effectiveness of health care provision by requiring all health facilities to achieve minimum quality health standards and be accredited.
Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.
The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.
There has been much debate about this Bill. Some people have expressed concern. Many others have expressed support.
What we need to remember is that South Africa is a constitutional democracy.
The Parliament that adopted this legislation was democratically-elected and its Members carried an electoral mandate to establish a National Health Insurance.
South Africa is also a country governed by the rule of law in which no person may be unduly deprived of their rights.
We are a country that has been built on dialogue and partnership, on working together to overcome differences in pursuit of a better life for all its people.
The NHI is an opportunity to make a break with the inequality and inefficiency that has long characterised our approach to the health of the South African people.
Let us work together, in a spirit of cooperation and solidarity, to make the NHI work.
Disappointment as President prepares to sign flawed bill
The announcement that President Cyril Ramaphosa will sign the National Health Insurance (NHI) Bill into law this week without seeking much-needed revisions is disappointing, although not unexpected, according to the Health Funders Association (HFA).
“The HFA has been preparing for this day, despite our strong belief that a more collaborative approach between the public and private sectors is essential for achieving Universal Health Coverage [UHC] in a timely and effective manner,” says Craig Comrie, HFA Chairperson.
“We are deeply disappointed that the opportunity to review certain flawed sections of the NHI Bill has been missed, as the HFA sees enormous potential for leveraging the strengths of both public and private healthcare to expand access to quality care for all South Africans.
“Throughout the NHI Bill’s development process, the association submitted recommendations centred on collaboration and maximising the sustainability of healthcare provision through the use of a multi-funding model to build the South African healthcare system,” he says.
“Even with the President signing the NHI Bill into law on Wednesday, there will be no immediate impact on medical scheme benefits and contributions, nor any tax changes. The HFA is well prepared to defend the rights of medical scheme members and all South Africans to choose privately funded healthcare, where necessary.
“Our focus, as always, is on protecting and expanding access to quality healthcare for all South Africans. As we await the finer details of the President’s signing, we wish to assure all South Africans that we are ready for this next step,” Comrie says.
“The HFA will continue monitoring developments closely and share updates as necessary. Our goal remains the same: a healthcare system that works for all South Africans, and we will take all necessary actions to support that goal.”
President Cyril Ramaphosa has finished “looking for a pen” to sign the National Health Insurance (NHI) bill into law, and is set to approve the legislation on Wednesday, May 15.
While this “electioneering” move comes as a surprise to many, some experts anticipated this timing. With its signing, the legal battles over it will now begin. An array of medical and professional associations are readying their court papers, armed with numerous expert objections and petitions finding fault with the bill, widely criticised as unaffordable, demoralising and disastrous. But what will it look like in the end? Is it in fact an opportunity to fix public and private healthcare for the better?
To understand the NHI bill’s consequences and possible remedies better, Quicknews asked medico-legal specialist Martin Versfeld of Webber Wentzel & Associates about the legal aspects of the NHI bill, what it means for doctors in private practice, what can be done to ensure it fixes SA healthcare instead of damaging it further, and what its likely outcomes will be.
“The inequality of South Africa’s healthcare situation is not lost on anyone, least of all those in healthcare,” Martin says. “I think every healthcare professional, every hospital group, every healthcare provider recognises a need to assist South Africans more generally and to ensure there is better access to healthcare.”
Examination of the NHI bill has shown that it will simply exacerbate the problem, with possible wider consequences for the country’s economy (If Eskom’s load shedding is anything to go by – Ed). Viable alternatives towards repairing the beleaguered public healthcare system have been suggested, but political pressures have seen the bill signed into law. At this point, it is a certainty that it will face a barrage of litigation.
NHI, the mirage on the horizon
While the NHI is now set to be signed into law, there were efforts to persuade President Ramaphosa to not sign it. Recently, a South African Health Care Practitioners (SAHCP) petition was presented that contains a number of points and precedent to other laws that were rejected due to serious concerns. This petition had gathered 23 000 signatures from healthcare professionals.
Martin believes that it is a very effective petition, and it may have ‘resonated’ except for its timing. “The challenge that we face here is that it is an election year,” he points out. So while this petition and other appeals to the President to reject the legislation might have merit, and may have otherwise succeeded, it is extremely unlikely that Ramaphosa could go against his party’s goals.
“The NHI is a centrepiece, arguably, of the ANC’s election manifesto and they will be very reluctant to signal a climb-down at this point. So I think Cyril, as much as he might personally take a view that, under different circumstances, would be appropriate – I think he’d be under enormous pressure simply to sign the legislation into law.”
The time to act, with the most impact, will be after the elections.
As soon as NHI is signed into law, there will be a tidal wave of litigation, predicts Martin. This will be the next best time to challenge it. There are two avenues; whether the entire legislation is struck down as unconstitutional, or when it comes to the nitty gritty of implementation, when “the plethora of regulations are introduced.”
Even absent the court battles that will be waged, it will take years to fully implement NHI. Martin points out the length of the process, “The NHI is not going to be implemented to the full extent of what the legislation provides from the get go,” he says – it simply can’t be.
“It will be introduced incrementally by way of the introduction of regulations. So what I would expect as a first step would be to introduce the infrastructure required in order to create this collective pooling of funds.
“They will also be regulations which empower Nicholas Crisp and others to employ the essential staffing required to start to implement NHI.
“So it’s envisaged that there will be a very long process.”
‘Decades of litigation’
“Once the legislation takes effect, of course, the doctors and other stakeholders, including the medical schemes, will have an opportunity to carefully review the legislation and take a view as to whether or not they wish to, at this juncture, challenge certain aspects of that legislation on the basis of the – amongst other things – lack of constitutionality thereof.”
Martin stresses that the objections that have been lodged and engagements made to-date are not wasted effort. “It’s very important that the court sees and appreciates all the efforts that the industry has made in order to engage practically and meaningfully with the government. If nothing else, it puts the government on the back foot and the healthcare providers on the front foot.”
“This is not a matter which anyone is going to take lying down,” he says.
Speaking at a media briefing, SAMA’s chairperson, Dr Mvuyisi Mzukwa, said that the NHI bill will impact not only health professionals, but the country as a whole.
“SAMA has, on various platforms, made its position known that, as doctors, we swore an oath of service to those who seek healthcare from us. We do not believe this Bill will achieve what it purports to do,” he said.
The notion of how physicians resist unjust situations is a relatively new one, since the patient takes priority. Unlike worker resistance, which makes use of strikes and disobedience, the resistance of physicians must work within power structure and never compromise patient care. According to a study by Wyatt et al., “physician resistance includes a refusal to comply with professional expectations of limiting their concerns to the bodily care of patients.” Their review found that physicians have often engaged in resistance when their personal and professional interests were threatened, particularly around issues of autonomy.
Keep calm and carry on?
Despite its name, NHI would not actually provide healthcare insurance – instead Section 33 introduces a financing and single-supplier mechanism reminiscent of Eskom’s doomed model.
For most in the healthcare industry, section 33 is the greatest source of uncertainty and concern. It essentially eliminates medical schemes – but those reallocated funds only account for a fraction of the NHI’s true cost. However, this provision only comes into play once NHI is fully implemented – which could take decades, or just never happen, because of its sheer cost. The real threat, Martin says, is the perception and fear around NHI.
Martin has heard of “very negative consequences,” such as on the “decision on the part of students to study medicine; on professionals to stay committed to being in South Africa, leading to significant emigration on the part of healthcare professionals.
“For me, the real concern is less about whether or not NHI will ultimately be implemented in its current form, because I don’t believe it will be simply because we can’t afford it.”
Even if it is implemented, Martin suspects that many doctors will simple opt to operate on a cash basis, and wealthy individuals would be able to pay for specialists, expensive chronic medications and extended hospital stays. Though with the average age of specialists now at around 61, up from 53 in 1996, they may be in short supply in coming years.
There is also the question over what impact the mere threat of NHI will have on those with money and the ability to invest in the economy. Martin is “very anxious about the push factor associated with the perception that we can no longer get the required healthcare services.”
At some point it becomes a question of whether high net worth individuals can afford to pay for private healthcare, like they currently do for solar panels and generators to deal with the loadshedding crisis, and if that becomes a push factor to make them emigrate, taking their wealth, skills and economic contribution with them.
Implementation is still an open question
The devil is in the details, and in this case it is the thousands of specific regulations which will have to be rolled out in order to turn NHI from a law on paper into an actual functioning system.
Martin believes that it is quite likely that the NHI will end up only being partially implemented, if at all. Many of the requirements are quite steep.
All health users will need to have an electronic health record, for example – it will be a colossal undertaking to link South Africa’s 60 million plus, heavily rural, population, not far off of the UK’s 67 million. Just to get such a system running will take years. Still, a nationwide database would be extremely valuable for healthcare.
Even so, the NHI pilot projects failed to deliver on their promise of patient-centric care; the final report on the NHI Phase 1 interventions found that success was driven by factors which included “strong political will, adequate human and financial resources for implementation, good coordination and communication and good monitoring systems in place at the time of implementation.” Factors which worked against the interventions included “inadequate planning, lack of resources, inconsistent communication a lack of coordination where necessary and insufficient mechanisms to monitor progress to ensure course correction.”
(Of the two groups of factors, government initiatives have almost always landed squarely in the latter category – Ed)
In the end, where is the money?
There also is simply no money for the NHI, which is estimated by the Freedom Foundation to cost up to R1 trillion (more, even, than the much decried public wage bill) for full implementation.
Doctors in many provinces are unemployed as their health departments struggle under budget cuts. The Western Cape for example, has a hiring freeze, creating additional workload as positions go unfilled. The strain is being felt by doctors and nurses in hospitals. Already a petition of 1200 HCPs has been sent to the WC government’s offices. Centralised support from the National Department of Health has, in fact, been going backwards, with a number of wage-related issues being dropped squarely on the, already beleaguered, Provincial departments.
The NHI is also without historical precedent, as Martin says “no country that has introduced a form of National Health Insurance has sought to exclude the ability of the private sector to, in parallel, offer an insured medical service.” Ghana trialled a form of national health insurance, only for it to quietly fade away. The system involved capitation, in which a predetermined flat payment is paid to a provider to cover a defined benefit package of services for a patient. In theory, this forces cost containment onto providers.
It is important to note that schemes on the scale of NHI have only been achieved in a mere handful of countries, a list which consists almost entirely of very wealthy countries, with strong tax bases. South Africa’s situation is very different.
“We have a tiny tax base with a massive disease burden,” Martin points out.
Big in Japan
The country that successfully implemented such an initiative the fastest was probably Japan: “it took them 40 years or so,” Martin noted.
Japan, a country noted for the longevity of its people, has a massive tax base and a tiny disease burden, Martin points out. Indeed, for decades it was the world’s second largest economy. Hardly an act that a developing country like South Africa can try and follow in a matter of years, especially when a wealthy country, like the UK, has been struggling to maintain its own NHS.
The economic consequences of attempting it would be a huge tax increase, with high net worth individuals leaving.
Meanwhile, South Africa is a healthcare tourism destination for residents of wealthy countries that have national healthcare, because it has a world-class private health care industry. That source of international income would also fade away, under NHI.
Stick and carrot: building the NHI that South Africa needs
Nevertheless, there is a way forward to Universal Health Care, through successful public-private partnerships.
SAMA’s position also reflects this. “We believe that any form of health reform must be based on a health system that is built on adequate human resources for health, access to essential drugs, medicines and vaccines, suitably utilising evidence-based policies, ethical leadership and governance, as well as being built on digital and technologically integrated systems,” Mzukwa said.
Once the dust from the election settles, then the time will come for healthcare professionals and associations to properly engage with the government on NHI, as it is faced with the reality of implementation.
In that case, Martin says, once government has “considered the cost more carefully and agreed that they need to be more receptive to offers of collaboration with the private healthcare space,” then it can “accept that medical schemes as we know and understand them today can continue to exist and provide a parallel support to those who can afford to pay for medical schemes.”
What can doctors do? Martin advises that they carry on working through their associations. The various healthcare groupings are collaborating to both benefit the government and also to litigate and challenge the legislation and regulations. But these two aims should not be separated into two separate efforts, he says.
“I think there should continue to be an effort to collaborate collectively, to come up with positive solutions for the benefit of all South Africans. I think equally they will obviously have to, in parallel, to the extent necessary, litigate – I believe litigation is entirely inevitable, but they’ll need to collaborate around that.”
