NCOP passes NHI Bill in face of widespread condemnation by health professionals, business and opposition

6 Dec 2023

Now that the National Health Insurance Bill has been passed in the National Council of Provinces on the back of support from eight provinces, the controversial legislation will land in the in-tray of President Cyril Ramaphosa, who must decide what to do next.

The options are limited, but not without significance. According to the Constitution, a President can return a law to Parliament over procedural issues and concerns that it may not meet constitutional muster. Or he can refer the legislation directly to the Constitutional Court for a decision on its compatibility with South Africa’s supreme law.

At a media briefing on Wednesday immediately after the National Council of Provinces (NCOP) passed the National Health Insurance (NHI) Bill, Health Minister Joe Phaahla said the legislation would be implemented in stages once it got the presidential nod.

“The passage of the Bill does not close the door on consultations. This is just the beginning... In terms of implementation, all these stakeholders are key. The detail will emerge in regulations, directives and further policy and implementation plans,” Phaahla said.

“The implementation of the NHI, the fact that this will be disruptive, I can’t deny it, [but] the current situation is not sustainable.”

Shortly after Wednesday’s NCOP vote, the South African Health Professionals Collaboration called on President Cyril Ramaphosa to refer the NHI Bill back to Parliament for reconsideration. The collaboration represents more than 25,000 private and public healthcare workers from nine medical, dental, and allied associations.

The Hospital Association of South Africa expressed disappointment. “We urge the Presidency to recognise the compelling inputs into the National Health Insurance Bill made by us and many others in healthcare and to address the issues raised by the private sector,” it said in a statement.

Last week, the DA said it would petition Ramaphosa not to sign the Bill into law, failing which it would try to mobilise a third of the 400 MPs to support legislators going to the Constitutional Court for a decision on the Bill’s validity.

Petitions to Ramaphosa will also come from organised business groupings Business Unity South Africa (Busa) and Business for South Africa (B4SA), given their lobbying.

“The business groups believe that the Bill, in its current format, is not only unworkable, unimplementable and unaffordable, but also unconstitutional, both on substantive and procedural grounds,” Busa and B4SA said in a joint statement shortly after the NCOP’s approval.

Last week, the business groups called for a delay in the vote in letters to Parliament’s presiding officers and Deputy President Paul Mashatile in his capacity as leader of government business, or the liaison between Cabinet and the national legislature.

In the wake of these letters, with just 30 minutes to go, the NCOP did defer the NHI Bill vote for a week at the request of the council’s chairperson, Amos Masondo. This effectively opened the door for conversations, as at this stage of the lawmaking further consultations and changes to the legislation are not possible.

Read more in Daily Maverick: NHI Bill vote delayed amid backroom political twists and last-minute business lobbying

In Wednesday’s NCOP vote, all provinces but the Western Cape were in favour of the Bill. This was expected — the provincial mandates that determine votes were put on public record in the NCOP health and social services committee on 21 November.

Having a debate was unusual for the NCOP, but this NHI Bill is a key political moment for the governing ANC as it marked the fulfilment of a policy principle that dates to the ANC’s 2007 Polokwane national conference and 2010 national general council.

The three-hour debate that gave the majority of speaking time to the ANC provided a PR platform for the party ahead of what’s expected to be a tough 2024 election campaign. That was signalled when Masondo told the NCOP, “We will now listen to the minister address the country.”

Applause from Cosatu

The political import so close to the 2024 elections was underscored in the applauded support from the ANC’s alliance partner Cosatu shortly after the vote.

“Government needs to move with speed to resource and build a quality NHI that will guarantee quality, accessible and affordable universal health coverage for all South Africans,” the trade union federation said in its statement. “Cosatu and the overwhelming majority of workers are in support of an NHI.”

During the NCOP debate, ANC speakers described the NHI Bill as “revolutionary”, “historic” and “a victory for the poor” that would eliminate inequality and the discriminatory two-tier (private/public) healthcare.

Health MECs from Eastern Cape, KwaZulu-Natal, Limpopo and Mpumalanga talked up their ability to deliver the NHI and emphasised how increasingly more public health facilities were attaining the required “ideal clinic standard”. Quality services were being delivered at newly built facilities like the Dr Pixley Ka Isaka Seme Memorial Hospital in KwaMashu, KwaZulu-Natal, which Ramaphosa recently officially opened.

It was a point directly contradicted by opposition speakers from the DA, IFP, Freedom Front Plus and the EFF, who for different reasons rejected the NHI Bill. However, all pointed to corruption, maladministration and dilapidated public health facilities, particularly in rural areas and townships.

Read more in Daily Maverick: National Health Insurance roll-out one step closer, but private healthcare has burning questions

EFF Delegate Mmabatho Mokause rejected the Bill because it effectively outsourced healthcare to the privately owned health industry, which would be enriched. “Today we are being misled by the ANC that this Bill will deal with the collapsed healthcare [system],” Mokause said.

In an illustration of the NHI’s divisiveness, for the KwaZulu-Natal IFP delegate Nhlanhla Hadebe, the debate was an opportunity to publicly reject the NHI, even as the ANC-run province supported it.

For the FF+, delegate Fanie du Toit cautioned of the corruption already present in the health system and misadministration-related shortages that saw babies at hospitals sleeping in cardboard boxes. “Everyone in South Africa will be at the mercy of the nightmare to which South African state hospitals have declined.”

DA delegate Delmaine Christians asked, “How do we trust this government that has failed to deliver service, allowed infrastructure to crumble and corruption?” Her fellow DA delegate Dennis Ryder bluntly said the NHI Bill’s “implementation will result in a half-baked mess”.

‘A very historic day’

Phaahla, however, told the NCOP, “NHI is about ubuntu”, or social solidarity.

“This is indeed a very historic day and historic achievement because here we are putting into statute a framework, we can create the health insurance fund. The perpetual divisions, at least in the area of health, can come to an end.”

The legislation the NCOP adopted is the same that the National Assembly adopted in June in a close vote, with the ANC carrying the law only with the support of some one- and two-seat political parties.

Read more in Daily Maverick: ANC gets its ‘revolutionary’ NHI legislation adopted despite opposition criticism and likely litigation

Opposition parties, organised business, private sector healthcare institutions, doctors’ unions, medical associations and civil society are agreed on the need for universal healthcare — just not how this NHI Bill foresees it.

Concerns include the referral system that binds patients and GPs, the lack of costings for the NHI — some estimates run up to R500-billion a year — and the paltry state of public health facilities, most of which fail the government’s own standards.

However, the NCOP’s adoption of the NHI Bill is a crucial realisation of the ANC’s longstanding universal public health policy, supported by its alliance partners, Cosatu and the South African Communist Party (SACP).

Once the Bill lands on the presidential desk, it’s up to Ramaphosa to juggle this party political election appeal with widespread concerns over the Bill’s unimplementability. It’s squarely up to him to decide whether to return the legislation to Parliament for another go.

It’s a political pickle — a clash between party and state, so to speak, with just months before the 2024 elections. DM

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South Africa

Applause from Cosatu

‘A very historic day’