ANC gets its 'revolutionary' NHI legislation adopted despite opposition criticism and likely litigation

That the National Health Insurance (NHI) is a step closer to implementation comes at a crucial point ahead of the 2024 elections, allowing the governing ANC on the hustings to show it delivered on its 2019 universal healthcare election promise.

As far back as the 2007 Polokwane ANC national conference, and the 2010 ANC General National Council, NHI has been a key policy instrument supported across the tripartite alliance with labour federation Cosatu and the South African Communist Party (SACP).

“South Africa cannot transform and upgrade its public healthcare sector without eliminating the imbalances between the private and public health sectors which are skewed in favour of the minority-servicing private health sector,” the SACP said in a statement four-and-a-half hours before the parliamentary proceedings.

“It (NHI Bill) is a milestone in what should be a continuing struggle for quality healthcare for all, against the background of the overall agenda by the reactionary opposition to NHI.”

It will still take some time for the legislative processes to run their course in the National Council of Provinces (NCOP) before it goes to the president’s in-tray for signing.

Cosatu called on the NCOP to now “move with speed” to also pass this legislation.

“It is critical government allocates sufficient resources to ensure the NHI Bill becomes a reality for all South Africans…

“South Africa cannot continue on a path where public healthcare is buckling due to under-resourcing, unfilled posts and long queues, whilst the private healthcare sector charges exorbitant rates and caters for the few who can afford it,” said Cosatu parliamentary liaison, Matthew Parks.

The political significance of the NHI Bill adoption in the National Assembly was signalled not only by the alliance statements of support, but also the attendance of both Health Minister Joe Phaahla and his deputy Sibongiseni Dhlomo in the House for the debate.

“We do understand some of the concerns about poor management, but we want to say even in the overburdened public services there are jewels. I can give you examples…” said the minister after, again, outlining the imbalances in South Africa's healthcare where 84% of people rely on public healthcare.

“This has led to a situation where the public health system is under tremendous pressure, while the private healthcare is over-servicing its clients leading to ever-rising costs to the members of medical schemes while the investors are enjoying huge dividends including from the JSE.”

By pooling private and public health funding, the health minister said, “We can achieve access, equity and quality, but also drive down costs.”

Having described the NHI Bill that establishes the fund for universal health as “historic” and the “most revolutionary piece of legislation” since South Africa’s 1994 transition to democracy, Phaahla dismissed opposition criticism and concerns.

It was “untrue” to say the estimated nine million South Africans on private medical aid would now migrate to only the public health service, as DA MP Michele Clarke pointed out in her debate contribution.

“We all contribute to one pool (of resources) under one fund so we can access services both in the public health services but also in private health... The cost will be negotiated.”

However, the Bill forecasts medical schemes only offering services not available on the NHI, and is firm on set referral pathways. 

And while the health minister appoints the fund’s board, no parliamentary role is envisioned in that process, heightening concerns over the lack of accountability also among medical associations like Sama, which called for parliamentary supervision.

Exactly how the NHI would be funded remains unclear, although payroll taxes and personal income levies have been raised, even as value-added tax (VAT) hikes are understood to have been ruled out by National Treasury.

In Tuesday’s debate, Clarke also pointed out that government had yet to identify exactly what the NHI would cover.

“Will the department pay for hip replacements, dental care, appendix removals, dialysis, chemotherapy, TB and HIV treatments, or mental healthcare? We don’t know because you have refused to inform us. Possibly because you do not know.”

While the EFF called for the nationalisation of private hospitals and health facilities, opposition parties raised most of the public health facilities’ failure to meet the minimum standards necessary for accreditation for the NHI.

The 2022 fire at Johannesburg’s Charlotte Maxeke Hospital has deeply affected health services in South Africa’s richest province, while in May 2022, Rahima Moosa Mother and Child Hospital paediatrician Tim de Maayer penned an open letter describing horrendous conditions.

Read more in Daily Maverick: A wake-up call for Health Department heads: Children are dying because of horrendous state of our public hospitals

The former health ombud, Malegapuru Makgoba, was recently scathing about the state of public health in Gauteng, also describing the Eastern Cape as a shambles.

Read more in Daily Maverick: ‘They change CEOs like panties’: outgoing ombud lashes ailing Gauteng, Eastern Cape health departments

Freedom Front Plus MP Philip van Staden called the NHI a “political gimmick” and called on President Cyril Ramaphosa to withdraw it rather than imposing it on the “mess” that is public healthcare.

“It is not able to deliver healthcare to people,” he said, adding: “The NHI will not pass a constitutionality muster... This law will stall in the courts if it is passed…”

But ANC MP S’dumo Dlamini, a one-time deputy minister, former Cosatu president and nurse by profession, said the NHI, once implemented, would supply “more resources for staffing, infrastructure, equipment and medicines and supplies... Healthcare will never be a marked commodity, it is a public good”.

And the speech of the last ANC lawmaker, Annah Gela, dressed in ANC colours and an NHI T-shirt, was met with applause and cries of “Phambili (forward) NHI, phambili!” from the governing party’s benches – and silence elsewhere in the Good Hope Chamber.

And that illustrated the divisions in the House and South Africa’s body politic – even as everyone agreed on the need for accessible quality healthcare. DM