50 Reasons why the NHI will never work

By Michele Clarke MP – DA Shadow Minister of Health

Today the parliamentary portfolio committee on health concluded its clause-by-clause deliberations on the National Health Insurance (NHI) Bill.

It should come as no surprise that the ANC members in committee refused to effectively engage with the content of the Bill, as well as the concerns and contributions of opposition party members in the committee and opposing legal opinion provided by the independent Parliamentary Legal Services.

The DA voted against the Bill with an overwhelming number of objections, with the Bill so poorly formulated that there was only one course of action to take – object to the entire Bill in its totality.

Read more: Crisp boasts a centralised SA health data system as part of proposed NHI

With that in mind, the DA has compiled 50 reasons why the NHI will never work:

  1. South Africa is physically and financially not able to finance the NHI in its current model.
  2. By increasing taxes on the already shrinking tax base, we will see a large emigration of fed-up taxpayers, leading to even less funding.
  3. The South African Medical Association (SAMA) has confirmed that the implementation of NHI will see hundreds of doctors emigrating overseas to avoid the NHI.
  4. The Office of Health Standards Compliance (OHSC) is struggling to inspect and accredit health facilities in a timely manner as is and will not be able to accredit every healthcare provider for the purposes of the NHI.
  5. The OHSC has confirmed that only the Western Cape and Gauteng have scored sufficiently to become accredited service providers should the NHI come into operation.
  6. The NHI would give the Minister far too many powers and duties – he would essentially run the day-to-day business of the Fund rather than have oversight responsibilities.
  7. The Bill also allows the Health Minister unvetted powers to make far-reaching health regulations without necessary oversight.
  8. Certificates of Need (CONs) have been provisionally declared unconstitutional, yet the NHI Bill heavily relies on these for the placement of service providers.
  9. Lack of transparency on addressing skills and personnel shortages in less desirable or more remote areas in the country.
  10. The NHI Bill requires every citizen to register for the NHI online but fails to take into account the millions of people who do not have access to electricity and water, let alone the internet.
  11. People living in rural areas will not have access to the necessary equipment to capture their biometrics necessary to access the NHI. South Africa’s administrative systems are all in chaos – the NHI biometric system will hardly be the exception.
  12. No recent feasibility studies have been done regarding the financial impact of the NHI post-Covid-19.
  13. The NHI further centralizes the powers of the Health Department which will inevitably cause disconnect between the three spheres of government. This will lead to even greater shortages in supplies and personnel.
  14. The removal of all day-to-day administration and running of hospitals to a national centralised control violates the constitutional framework as powers are taken away from provincial level.
  15. The District Health Management Offices are structures that effectively strip away the powers of provinces to finance and plan district health services and allocate them to the Minister of Health. This is unconstitutional with zero feasibility studies having been done.
  16. In its annual report presentation to Parliament, the OHSC indicated that centralization is impeding its ability to reach its target and the Office is in fact moving towards decentralization.
  17. The majority of hospitals in South Africa are so underfunded in terms of infrastructure maintenance and development, as well as buying new equipment, and understocked that the NHI will further exacerbate these shortages.
  18. Hospitals are completely understaffed in the current regime and NHI does nothing to combat or correct this – South Africa has a critical skills shortage of 27 000 and placement of community service personnel is chaotic at best.
  19. The fixed dates provided in the NHI Bill for the timeline are also completely inaccurate and were determined when the Bill was first drafted. These dates have come and gone and are defunct clauses.
  20. Referral pathways as described in the NHI will put unnecessary strain on the system and impede quick access to specific healthcare interventions. This in turn could lead to a refusal to fund certain procedures if preferred pathways weren’t followed.
  21. Treatment protocols might impede the treatment of certain conditions and patients.
  22. Medico-legal claims will skyrocket even further due to maladministration of the NHI Fund, which will collapse the health industry.
  23. The NHI Bill assumes that poor individuals have the ability to travel hours to a certain service provider in the hopes of being able to register as a patient, all whilst the cost of living has dramatically risen. The NHI will dissuade people from seeking medical attention.
  24. The NHI fails to take into account the shortages of emergency medical services (EMS) equipment like ambulances. Often the nearest ambulance to transport patients are hours away – sometimes the nearest ambulance is in a different province to the patient.
  25. Public healthcare standards are already abysmal and the NHI will abuse patients’ rights to quality healthcare.
  26. No separation of powers within the Fund – the NHI can deny service and also determines the success of appeals.
  27. The framework of the Bill seeks to eventually remove medical aids, which denies individuals the right to access to adequate healthcare of their choosing and rights of association.
  28. The erosion of the private health sector, as well as the few well-functioning public health facilities, particularly in the Western Cape. The current public health system will not be able to cope with influx of new patients once medical aids are removed.
  29. Doctors and other health practitioners’ inability to work privately, as well as medical aids being removed as primary medical funding, will violate their constitutional right to employment.
  30. The NHI Bill excludes asylum seekers despite Constitutional provision.
  31. The NHI Bill fails to properly define emergencies, as well as the level of care to be provided during emergencies.
  32. No information on whether a person will not be treated if no medical necessity exists. No information on what a medical necessity means.
  33. There is no list that has yet to be provided of what healthcare products and procedures will be available. No information on which procedures are not covered so we know from the outset where the issues are going to be.
  34. Lack of information on whether a person that failed to follow referral pathways due to an emergency or unavailability of other service providers nearby would be required to pay their medical costs in full.
  35. The Fund is not autonomous as alleged.
  36. The functions of the Fund will never be achieved from the outset thereby invalidating the Bill from the start.
  37. The pooling of funds will make the NHI vulnerable to theft and corruption.
  38. Current supply-chain mismanagement would be amplified.
  39. Amplification of lack of consequence management
  40. Only entities and governments in the Western Cape have been able to pay their suppliers within 30 days. The NHI will be no different and delays in payment of more than 90 days will destroy small businesses.
  41. There is no information as to what the rates of payment to medical services providers will be nor if they will accept these rates.
  42. There is no external audit and risk procedures or assessments to prevent corruption and looting.
  43. No confirmation that the NHI’s sharing of information won’t lead to Protection of Personal Information (POPI) Act breaches.
  44. There is no guarantee that the quality of health care will be the same as what citizens are receiving from private healthcare through medical aids.
  45. No information has been provided on how the capped case-base fee is calculated.
  46. The NHI fails to take into account the reality that many public health facilities will be unable to comply with the NHI as they don’t have access to the internet, phones or working computers.
  47. There is no information as to why the Minister is a part of the complaints procedure.
  48. Appeals Tribunals are appointed by the Minister, which strips them of any independence, they should be appointed by a transparent process.
  49. There is no uniformity in time periods between complaints procedures and appeals. It should be uniform to provide certainty.
  50. The redistribution of the medical savings tax credit would result in citizens paying more tax each year.

And just in case 50 reasons are not enough,

  1. the NHI Bill also attempts to regulate how Treasury disperses funds. This is not possible through the Bill and can only be done through a Money (section 77) Bill.

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It is unfathomable how the ANC is prepared to push through a Bill that has so many issues and concerns without considering any of the points validly raised by opposition parties. Notwithstanding the glaring constitutional issues that the Bill has, it also has a number of legislative shortfalls and clauses that are impractical and impossible to implement. 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 healthcare, as is enshrined in the Constitution.

The DA also calls on all its moonshot pact partners to join us and reject the fatally flawed NHI Bill when it comes before the National Assembly for a vote.