What is the NHI?
The most important thing to note is that it is not a health system (as per Britain’s National Health Service), but a fund – which the government will use to buy healthcare services for people from both the public and private sectors.
Who will run the NHI fund?
A board which will report to the minister of health. It will consist of no more than 11 people, the bill specifies, appointed by the minister. Board members may not be government employees, and cannot serve for longer than five years. A CEO will be appointed by the board, subject to the approval of the minister.
When the NHI kicks in, how much will I pay for healthcare?
Nothing. This is the idea, anyway. You will be able to walk into the nearest hospital, clinic or GP’s office that has a contract with the NHI fund and get treated for free. The first time you do so, you will have to register using your ID book or passport and have your fingerprints taken.
What about foreigners?
This has been one of the points of contention for civil society. All South African citizens, permanent residents and refugees will be covered, as will all children. But asylum seekers and illegal foreigners will only be covered for certain conditions and emergency care.
Where will the money for the NHI come from?
“Our taxes”, says a fact sheet from the Government Communication and Information System (GCIS). Many have pointed out that the South African tax base is very small.
The country has 7.1 million registered taxpayers, but just three million pay 90% of personal income tax. Personal income tax is the “primary revenue source in South Africa’s fiscal system”, according to economist Andrew Donaldson.
The NHI means taxes will rise: GCIS says there will be a “surcharge” on income tax and a “payroll tax payable by employers and employees”.
What kind of health services will I be able to access?
“Comprehensive”, including palliative care and mental health services.
So is this the end of private healthcare in South Africa?
No, insists GCIS: “Contrary to some public narrative[s], the NHI is not going to abolish or do away with private health providers”. In fact, government maintains that the NHI will actually benefit private healthcare providers – because entering into contracts with the NHI Fund will give them a much larger pool of patients, and “they will be able to provide services to patients throughout the year, not worried about depletion of funds of patients at any stage”. That’s because the NHI Fund will settle the bill.
One thing that will be different, however, is that private healthcare providers will no longer be able to set their own fees in terms of the NHI contract. The NHI Fund will decide the fees – a prospect which doubtless strikes fear into the heart of many practice owners.
What about medical aid schemes?
They would seem to be in a world of trouble, which is why so many have immediately threatened court action. This is because medical aids will no longer be able to cover you for any service covered by the NHI Fund – which, government keeps maintaining, will cover almost everything. (This aspect of the legislation, Discovery has said, is globally unprecedented.)
You will still be able to be a member of a medical aid scheme, but the prospect does not seem very appealing. Medical aid schemes will be decimated financially since the fees they would be able to charge would presumably only be a fraction of the king’s ransom they can command now.
GCIS acknowledges that “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”.
Can I opt out of the NHI, or opt out of making contributions to the NHI?
Nope.
How long will this all take to implement?
The smart money is on “literally decades” – if indeed it ever comes to fruition. Ferial Haffajee quotes one expert here as estimating 30 years.
In theory, there are supposed to be two phases, with the first unrolling between 2023 and 2026 and the second ending in 2028.
The Department of Health’s NHI head Nicholas Crisp told Bhekisisa in 2023: “You won’t feel anything in the first year, nothing. [The system] won’t change in a short time; it will take a couple of years before we see the first steps.”
Health Minister Joe Phaahla said on Thursday that come 2028, anyone will be able to walk into any private health facility and be treated free of charge. This will almost certainly not be the case by then.
How do doctors feel about the NHI?
A number of industry bodies representing healthcare workers have indicated that they will litigate the matter. Some private-sector doctors interviewed by News24 said that they refused to work for the state and would emigrate if forced to do so.
Is anyone very positively disposed towards the NHI?
The ANC, obviously, and its allies in the trade union movement. The GOOD party released a statement supporting the signing of the bill but urging government to “iron out identified wrinkles”.
Pretty much all other political parties have condemned it, with even the EFF terming it “misguided, disingenuous and opportunistic”.
Then again, it is peak election season – and the signing of this bill is a gift to the opposition as well as to the ANC.
Does nationalised healthcare ever work?
Yes. Please see Tim Cohen’s excellent (very NHI-sceptical) piece which includes a table laying out the comparative costs and outcomes for various national health systems across the world.
But can it work in South Africa? There is abundant reason to be doubtful – and not just because of the potential for corruption and mismanagement or the parlous existing state of the public health service.
Public buy-in to the idea also requires a kind of social compact, in terms of the wealthier cross-subsidising the poorer, to which the deeply polarised atmosphere of the moment in South Africa seems distinctly unsuited. DM