NHI Act: unanswered questions call for transparency

The demand for transparency around the National Health Insurance (NHI) Act is intensifying as there are still many unanswered questions, such as how it will be funded and where the health professionals to render the healthcare services will come from.

The passage of the NHI Bill into an Act of law set the stage for one of the most significant overhauls of South Africa’s healthcare system, Craig Comrie, chairperson of the Health Funders Association (HFA), says.

“As government embarks on this ambitious plan, the stakes have never been higher. The NHI Act is more than a mere piece of legislation. It is a test of constitutional rights and the nation’s commitment to fostering a more inclusive and equitable society.”

Comrie says the HFA welcomes the meeting between President Cyril Ramaphosa and Business Unity South Africa (Busa) leadership to discuss the NHI last week as a positive step.

“As a member of Busa, we find it encouraging that the minister and deputy minister of health, along with other senior officials, were part of this constructive and forward-looking discussion. We can only hope that these recent discussions will mark the start of a series of engagements with key stakeholders, as the South African government must engage in open dialogue with all stakeholders, including private healthcare providers, medical schemes and the general public.”

He says the HFA will provide industry input for Busa’s presentation to the President to help propose workable solutions to set South Africa’s healthcare train on the right track with inclusive mechanisms that will benefit all.

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Many unanswered questions about NHI

However, he says there are still many unanswered questions. “The critical questions about the NHI Act’s constitutional validity, economic feasibility and potential impact on the public and private healthcare sectors, specifically the role of medical schemes, remain unanswered.”

Comrie points out that the president reaffirmed his belief that the Act is constitutionally sound during a recent question and answer session, but he declined to share specifics on how this conclusion was reached.

In response, Comrie says, the HFA will test various aspects of the NHI’s constitutionality, which is crucial for establishing a stable healthcare framework that delivers quality health services for all South Africans.

“This is a critical juncture for politicians, policymakers and every South African who relies on the nation’s healthcare services in the private as well as the public sector. Against this background, the HFA is seeking to strike a balance between much-needed healthcare reforms and the hard-hitting risks of the NHI Act that demand amendments.”

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Government adamant about NHI’s constitutionality

Government has been adamant about the NHI’s transformative potential to address inequalities in healthcare access, contending that the NHI is aligned with Section 27(1) of the Constitution, which guarantees the right to access healthcare services, including reproductive healthcare.

On the other hand, Comrie says, this part of the NHI Act cannot be read without the consideration of Section 36, which indicates that existing rights should not be compromised if there are alternative ways to achieve, in this case, universal health coverage.

“This is a key part of responding to the president’s invitation for alternative proposals that stand a more realistic chance of achieving a partnership with the private sector for improving healthcare for consumers,” he says.

“Any alternative proposals from the private sector will come with the need to amend the current NHI Act. If it is left unchallenged in its current form, it can be likened to letting the healthcare train run on a single track of public sector inefficiency.

“By adding the private sector as a parallel track with both heading in the same direction towards universal healthcare coverage, we can stabilise and accelerate the journey.”

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What will be the future of medical schemes?

Comrie points out that the medical scheme sector effectively provides funding for the majority of services in the private sector with less than 10% of health consumers paying for services out of their own pocket in the private sector.

He says this population group serves a significant portion of the taxpaying population, yet its role in the new system remains ambiguous. “Will private healthcare consumers be forced to rely solely on centrally procured services, or will there be room for a coexistence that stands a better chance of laying the track towards a successful healthcare future that can benefit all South Africans?”

Comrie says transparency and collaboration are essential in addressing the questions surrounding the NHI’s financial viability, human resource capacity and broader economic impact. “The future of South Africa’s healthcare system hinges on finding a balanced approach that ensures quality, accessibility and economic sustainability for all citizens.”

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How will government fund NHI and where will the staff come from?

Although government proposes funding the NHI through general taxes and mandatory payroll contributions, Comrie says this plan has been met with scepticism as it raises considerable questions about the economic burden on taxpayers, particularly given the country’s high unemployment rate of 33.5% and sluggish economic growth rates of around 0.4% in the second quarter of this year.

“Critics argue that increasing tax rates to fund the NHI could backfire, reducing overall tax revenue, as highlighted by the Laffer Curve, which suggests that higher taxes can lead to lower revenue if they exceed an optimal rate.”

Another question is where will the healthcare professionals come from. Reports indicate that the quality of care in public health facilities is often subpar, with systemic inefficiencies and resource constraints leading to poor health outcomes.

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High vacancy rates in public sector a concern

The sector is grappling with high vacancy rates for healthcare professionals, exacerbating the strain on an already overburdened system. As it is, Comire points out, South Africa is already facing a severe shortage of medical personnel, with the vacancy rate for doctors ranging from 22.4% in the Free State to 5.5% in the Western Cape, while the national average vacancy rate for nurses stands at 14.7%.

The current system is struggling to fill thousands of vacancies for doctors, nurses and allied healthcare professionals, with over 2 000 unfunded vacant posts for medical doctors across nine provinces requiring an estimated R2.4 billion to fill them.

Many provinces report alarming doctor vacancy rates with a rate of 18.5% in Mpumalanga, 17.6% in Limpopo and 11.3% in KwaZulu-Natal. Comrie says the shortage is not just a numbers game either. “It affects the quality of healthcare that can be delivered.

“These figures raise serious concerns about the system’s capacity to deliver reliable and accessible healthcare services hampered by corruption and lack of proper leadership and management.”

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NHI not only way to achieve universal health coverage

Comrie emphasises that the NHI is not the only solution to South Africa’s healthcare challenges and is certainly not a panacea in its current form. Government must take a more collaborative approach, engaging with all stakeholders, including the private healthcare sector, medical schemes and the general public.

“Open dialogue is crucial to finding sustainable solutions that work for everyone. Critical decisions must be made and these should not be taken behind closed doors. The nation’s healthcare needs are too important to be dictated by a select few without broader consultation.”