Over the years, the National Health Insurance Bill has proved to be a point of debate for many South Africans. While many argue that government can’t and shouldn’t be trusted with the billions needed to fund the NHI there are millions who need such a system.

The National Health Insurance bill was passed by the National Assembly and sent to the National Council of Provinces last month after initially being tabled in 2019. Since then, there has been significant discourse surrounding this bill and rightly so. While it’s described as revolutionary by the ANC, it also seeks to indirectly smother the existing medical aid schemes millions of South Africans and health care providers have come to rely on.

As explained by SA News, “The business models of private funders and their administrators will change over time. Once the NHI Fund covers a benefit, the medical schemes may not cover the same benefits. This means that their membership fees must be reduced, and some will be too small to survive so they will consolidate with others to maintain a viable risk pool for the benefits that they may still cover. Administrators of medical schemes will no longer manage over 250 options, meaning the complexity of their services will be greatly reduced.”

Effectively, as government covers more and more treatments through the NHI, the less viable medical aid schemes as we know them will become obsolete and make no mistake, government intends to treat as much as it can. While the bill says that medical aid schemes will continue to exist, it’s not clear what they will exist for if the NHI is constantly grabbing benefits a medical aid may previously cover.

In opposition to the bill, outlined in 50 points by the Democratic Alliance it highlights the view that South Africa is not able to financially sustain a national health insurance system.

“The DA has already previously stated that should the ANC push this Bill through Parliament with their majority, the DA will consider taking legal action and challenge the validity of this Bill in court in order to protect the millions of South Africans and their right to access to adequate health care, as is enshrined in the Constitution,” the DA wrote in May.

The root of the problem with the NHI is that government cannot be trusted with large sums of money.

During the COVID-19 pandemic, corruption was as infectious as the disease itself with R2.1 billion in possible fraudulent and corrupt contracts discovered by January 2022. Worse still, the State Capture debacle has led to very few arrests and even fewer convictions.

One can understand why South Africans are so hesitant to welcome a so-called free health care system that government promises to foot the bill for. This is also why there are fears that health care professionals will leave the country. If government officials are eating into the funds earmarked for treatment and care and those institutions don’t get paid, those institutions will close up shop.

Aside from the funding, there are also concerns about the impact on health care facilities as they are inundated with more citizens than they can handle. Government would also need to oversee the conditions of these facilities constantly. Facilities would also have to undergo an accreditation process to get access to payment from the fund. Government already struggles with these processes and it simply can’t struggle here when lives are potentially on the line.

Worse still, the NHI dictates what fees are charged by health care providers and while there will be committees that debate these fees, there’s no telling how adequately or inadequately the fees set would cover the expenses incurred for treatment.

Can it work though?

Free health care isn’t a unicorn, many countries offer their citizens the service including China which only introduced basic medical insurance in 2018. As of September 2020, 1.35 billion people in China were covered by a basic medical insurance system.

According to an overview published in 2021, the Chinese system has reduced medical burden by as much as R860 billion and importantly is “sustainable and growing”.

By the DA’s count, nine million people in South Africa are covered by a medical aid of some form which leaves over 50 million who aren’t. The fact that 84 percent of the nation has to pay out of pocket for any medical issues they may have is alarming given the cost of health care.

There is also very little talk of an alternative to NHI aside from leaving things as is, but as above, the existing system doesn’t work for the majority of citizens.

Thankfully, the NHI won’t appear overnight with government earmarking a three-year transitional period.

During this time the following is expected:

• Continuing with the health system strengthening initiatives including human resource planning.
• Development of NHI legislation and amendments to other legislation.
• Establishing institutions that must be the foundation for a fully functional Fund.
• Purchasing of personal health care services for vulnerable groups such as children, women, people with disabilities and the elderly.
• Establishment of the Fund as a Schedule 3A entity as contemplated.

Of consolation are promises that the NHI will be transparent. The Department of Health is also working with the Health Sector Anti-Corruption Forum and the Special Investigating Unit to identify risk as well as analysing and mitigating all fraud and corruption risks that may affect the fund.

How this transparency will take shape is not clear but we would love to see data regarding the fund made freely accessible so that it can be monitored openly. After all, one way the NHI will be funded is through employee and employer taxation so that data should be accessible to all South Africans given the vested interest we have.

How medical aid schemes will evolve or disappear is an unknown quantity at this stage but should the NHI bill get signed into an act by the president, we don’t expect to have to wait too long for push back from the sector, political parties and citizens.

We would like to see free health care for all, and while we’re hopeful, we also have years of experience with corruption, and it’s up to government to surprise us all.

[Image – Marcelo Leal on Unsplash]