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Private healthcare leaders flag poverty, quality of care, litigation and graft among many NHI challenges

Private healthcare leaders flag poverty, quality of care, litigation and graft among many NHI challenges
President Cyril Ramaphosa signed the National Health Insurance (NHI) Bill into law on 15 May 2024. A high court judgment has dealt a ‘major blow to NHI idea’, according to trade union Solidarity. (Photo: Mmutle / GCIS)
Takudzwa Pongweni
By Takudzwa Pongweni
20 Jun 2024
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The Health Funders’ Association recently hosted a symposium addressing the National Health Insurance Bill’s impact on private healthcare in South Africa. Amid concerns over funding and healthcare system sustainability, stakeholders explored potential reforms and challenges facing medical scheme members and practitioners.

The nonprofit Health Funders Association (HFA), representing stakeholders involved in the funding of private healthcare in South Africa, recently held a symposium on the National Health Insurance (NHI) Bill.

The NHI, membership of which will be compulsory, aims to address healthcare inequity in South Africa by providing equitable access to quality healthcare services. Ramaphosa signed the NHI Bill into law in May despite widespread concerns about the financial viability and impact on the healthcare system it would have. 

At its symposium on 19 June the HFA discussed changes that those working in the private health industry could face in the coming years, and how these changes might affect the country, the health sector and medical scheme members.

Addressing South Africa’s healthcare inequality


Dr Paula Armstrong, senior director at FTI Consulting, who focuses on policy and regulatory framework with a special interest in healthcare policy, spoke about South Africa’s social gradient in health. 

“I don’t think it’s news to anybody in this room, the correlation between socioeconomic status and healthcare outcomes. But I think it’s always useful just to look at some of the data in South Africa to see how high that correlation is, and how bad health outcomes are for the majority of South Africans,” she said.

South Africans have poor healthcare outcomes compared with other countries with relatively similar socioeconomic status and economic development, such as Lebanon, Tunisia, Egypt and Columbia, said Armstrong. 

Higher levels of disability-adjusted life years (DALYs) point to worse healthcare outcomes. 

NHI Dr Paula Armstrong. (Photo: Supplied)



Armstrong cited a DALY graph from 2016 that included countries with highly developed economies, including Canada, the UK, US and Germany, the BRICS countries and middle-income countries. 

“It is somewhat dated from 2016, but it is likely to be the same, it was certainly similar in 2019 [...] relative to all of those countries, South Africans DALYs are higher. South Africans as a population are sicker than anybody on this chart. This is what we are dealing with, this is what we have to solve and this is what the NHI seeks to solve,” she said.

Armstrong also noted the National Income Dynamics Study, conducted every two years by the University of Cape Town, which showed the proportion of households that are either in chronic poverty (more than two years), transient poverty (temporary, measured below the poverty line), or were vulnerable, middle class or elite.

“What we can see is that over a period of about nine years, chronic poverty and transient poverty increased in 2010, which seems to be the impact of the financial crisis around that time. What we don’t have is any data post-Covid on this. What I can tell you is that it’s going to be a terrible picture post-Covid,” she said.

“Even though it is improving, you can see that still more than 50% of households are measured to be below the poverty line in South Africa. So, given the correlation between poverty and poor healthcare outcomes, this is a problem that we have to solve, and this is the objective of universal health coverage in South Africa”.

Navigating challenges and opportunities in South African healthcare


Dr Simon Strachan, chairperson of the South African Private Practitioners Forum (SAPPF), spoke about the challenges and opportunities facing South African healthcare, with a focus on the need for a comprehensive approach to reform, engaging healthcare professionals in the process, and addressing the social determinants of health.

“The inequalities that exist in South African healthcare are clearly known to us. We came through the public sector, it taught us what we know. We understand that it has to move and we want to be part of that process,” he said. 

“The one thing that is very clear about healthcare professions is [that] no matter the circumstance, we’re still going to be there. We’re still going to look after you. We still have a duty to our patients. So we don’t want to feel like we have to persuade or manipulate it to work in an environment that is not conducive to our livelihoods or offering the best quality and access to our patients,” he said.

President Cyril Ramaphosa after signing the National Health Insurance Bill into law on 15 May 2024. (Photo: Mmutle / GCIS)


Concerns raised regarding Bill’s effects on patients and practitioners


SAPPF’s main concerns about the NHI Bill were quality of healthcare, access to healthcare, contracting with healthcare practitioners, treatment protocols, governance, medico-legal litigation and corruption.

“It is very likely going to be a primary healthcare service that is affordable to the country. But surely, if you improve primary healthcare services across the country, you are going to uncover more patients who need secondary and tertiary care,” Strachan said. 

“Therefore, you’re going to need more hospital services. If that logic is true, what this creates is the hospicentric system because what’s not included in the Bill is any contracting for ambulatory specialist services. It’s all supposed to happen in the hospital. That’s a huge problem we have with the Bill.”

The Bill also makes no mention of physiotherapists, occupational therapists and other rehabilitative facilities. 

“Where do they fit in all of this? There is a problem about the quality of care that patients will receive,” he said.

An accredited primary healthcare provider or health establishment providing primary healthcare services must be reimbursed by the fund in accordance with the prescribed capitation strategy, according to the Bill. 

Read more in Daily Maverick: Everything you ever wanted to know about the NHI but were afraid to ask

“At the GP level it will be by risk-adjusted capitation. It’s not necessarily the best way to fund healthcare, especially at community level, where you will be looking for continuity of care and quality,” he said.

Strachan raised concerns about the “Powers of Fund” section of the Bill. It states that the fund may enter into a contact for the procurement and supply of specific healthcare services, medicines, health goods and health-related products with an accredited health service provider, health establishment or supplier, and must negotiate the lowest possible price for goods and healthcare services without compromising the interests of users or violating the provisions of the Act or any other applicable law.

“We obviously want to deliver healthcare as economically as we can, […] we have no problem that there should be treatment protocols and guidelines, but cost is but a part of the decision-making process when determining benefits and treatment guidelines,” he said.

“If you’re saying it’s at the lowest cost, can I ensure then that the patient I am seeing in front of me is going to get the best medical care that I can offer? If I’ve made a diagnosis and look at the formula list and there is only that available when I know there is far better available.”

There were also concerns around medico-legal litigation, and Strachan noted that mistakes occur when practitioners are hungry, angry, late or tired.

Read more in Daily Maverick: Consolidated legal challenges to NHI Act will have more clout

“I had a meeting with someone who said: ‘You are going to have a lot more patients, the rooms are going to be packed with patients.’ You are going to have a workforce that is going to be overworked and we know the situation in the country already so we need to guard against this,” he said.

Strachan also added that the public and private sectors must collaborate effectively, with strong governance, adequate funding and efficient administration, to achieve successful universal healthcare.

“We believe that we are one national health asset, and the way we approach this from now is with the absolute belief that there will be a well-governed, well-funded, well-administered private sector in this country going forward, and it has to work in parallel with the state for universal healthcare to work in this country,” he said. DM

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