Disappointment, concern and court after Ramaphosa decides to sign NHI Bill

Disappointment, concern and dismay that the president will sign the NHI Bill at the Union Buildings in Pretoria on Wednesday were evident in comments from medical and civic organisations on Tuesday. Legal proceedings are also starting.

Everybody knew that the president said in his State of the Nation Address that he is just looking for a pen to sign the National Health Insurance (NHI) Bill into law. Some of us held on to the hope that he would, as custodian of the Constitution, refer it back to the National Assembly because it is clearly unconstitutional.

But politics won.

As part of the electioneering drive of the ruing party, he decided to sign it. Not in his office like any other piece of legislation, but at a public ceremony at the Union Buildings.

Dr Katlego Mothudi, managing director at the Board of Healthcare Funders (BHF), says the signing of the NHI Bill represents a significant milestone in South Africa’s collective efforts to progress towards universal health coverage (UHC) for all South Africans.

Although the BHF recognises the policy’s intent to progress towards universal health coverage through the NHI as a vehicle, its core aim is to ensure the sustainability of the healthcare sector and in this respect, Mothudi says, the BHF will immediately institute legal proceedings to challenge section 33 of the Bill because it is unconstitutional and unlawful to ensure the longevity of the industry.

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Challenge to section 33 of NHI Bill that reduces role f medical schemes

“We want section 33 removed as it reduces the role of medical schemes that are a national asset. BHF will continue to actively monitor developments, engage with relevant authorities and provide guidance and support to its members to navigate the changes ahead. We urge medical scheme beneficiaries not to panic, as the NHI is still far from implementation,” Mothudi says.

The South African Health Professionals Collaboration (SAHPC) is also preparing a legal challenge. It is a national group of nine medical, dental and allied healthcare practitioners’ associations representing more than 25 000 dedicated private and public sector healthcare workers.

Dr. Simon Strachan, a spokesperson for the SAHPC, says in addition to its many submissions and engagement in the NHI parliamentary process the SAHPC made a submission to the president in December, urging him to refer the NHI Bill back to Parliament because it is unconstitutional and not in the best interest of patients and citizens. 

“Their input and insights were ignored. SAPHC also believes its members’ concerns and recommendations throughout the parliamentary process were systematically ignored, raising serious questions about the fairness and effectiveness of the democratic process.”  

SAHPC members’ disappointment stems not only from the disregard for their expertise but also from the potential consequences the unworkable bill may inflict on the healthcare landscape, he says. “Where we are now is unprecedented and we believe that the NHI, in its current form, will reverse rather than progress, equitable, quality healthcare in South Africa.”

He says as healthcare practitioners, their members’ primary concern is the wellbeing of their patients. “As experts in our field, we believe the president has an obligation to ensure that the NHI improves, rather than limits overall healthcare for every citizen.  He has failed to do this.”

The South African Private Practitioners Forum (SAPPF), South African Medical Association (SAMA), Federation of South African Surgeons (FoSAS), South African Dental Association (SADA), South African Society of Anaesthesiologists (SASA), Unity Forum of Family Practitioners (UFFP), South African Orthopaedic Association (SAOA), South African Society of Obstetricians and Gynaecologists (SASOG) and the Radiological Society of South Africa (RSSA) are members of the SAHPC.

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Signing of NHI Bill disappointing, but not surprising

Craig Comrie, chairperson of the Health Funders Association (HFA), also says the signing of the NHI Bill without seeking much-needed revisions is disappointing, although not unexpected. “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.”

He says the HFA is deeply disappointed that the opportunity to review certain flawed sections of the NHI Bill was 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.

“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.”

Cas Coovadia, CEO of Business Unity South Africa (Busa), says it is deeply concerned that Ramaphosa will sign the NHI Bill into law, given its many substantive and procedural constitutional flaws. Busa believes that the legislation in its current form is unimplementable and damaging to the country’s healthcare sector, to the economy more broadly and to investor confidence.  

“Although we fully support the objective of universal health coverage, the NHI Bill in its current form is unworkable, unaffordable and not in line with the Constitution. What is especially troubling is that the president is proceeding with the Bill despite extensive constructive inputs made by a wide range of stakeholders, including doctors and healthcare professionals, civil society, public sector unions, academics and business.” 

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Concern that significant public comment not included

Business Leadership South Africa (BLSA) CEO, Busisiwe Mavuso, expresses the concern of the BLSA and says in signing the NHI Bill the president will discount the significant public comment on the proposed Bill which has found it to be unworkable, economically damaging and contrary to the precepts of the South African Constitution.

“Public consultation cannot just be a matter of procedure, but must include proper consideration of the input received, as spelled out in the Promotion of Administrative Justice Act. It is hard to believe that there has been proper consideration when draft legislation is finalised without change after a comment period.”

She says in this time of heightened electioneering, political campaigns are a distraction to the business of running the country, particularly at a crucial time for us to make progress on the major challenges facing our economy.

“Government is rushing populist policy through parliament, which can only be seen to be an electioneering ploy, as the significant and meaningful public input into the Bill and its socioeconomic ramifications have not been considered.”

Damian McHugh, CMO at Momentum Metropolitan Health, says the implementation of the NHI Bill in its current format is not sustainable and the already documented challenges made by numerous stakeholders will become more vocal, particularly around the constitutionality of the Bill.

“Another key consideration is that the South African economy does not have the required funds to support the implementation. Critically, although the president is expected to sign the bill, the current status quo remains in effect, as the implementation of the bill will take some time. Therefore, our message to our members and the wider South African community is to continue with your current healthcare arrangements.”

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Lengthy court battle will prolong implementation essential health care reforms

Gary Feldman, executive head of healthcare consulting at NMG Benefits, also says the NHI Bill in its current format is not achievable it will face many legal challenges. “The risk of lengthy court battles is real and this will inadvertently prolong the uncertainty and affect the timely implementation of essential healthcare reforms.”

He emphasised that members of medical schemes or a medical insurance products must not cancel their membership as this would put them at risk of having no cover and having to either self-fund or rely on state facilities for any medical need.