Why SA’s controversial NHI bill has stirred up opposition
South Africa's public health care system faces critical challenges with 85% of its population lacking medical insurance, relying on an overstretched public sector. The government's proposed National Health Insurance (NHI) aims to provide universal coverage but faces scepticism over viability and affordability, sparking legal challenges and concerns about eroding constitutional rights and potential corruption.
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By Mike Cohen and Janice Kew
The South African Constitution promises everyone the right to health care. Yet nearly 85% of the nation's 62 million people have no medical insurance and rely on a decrepit public system with too few doctors, resulting in delayed or inadequate treatment. In 2007, the ruling party agreed to enact universal national health insurance, but its implementation stalled while details were being ironed out. Just two weeks before May 29 elections, President Cyril Ramaphosa signed off on enabling legislation for the program, which is meant to be phased in over several years. The ruling party's opponents accuse it of trying to win over voters with false promises of better treatment. Health-care professionals and business groups have expressed doubts about whether the plan is viable and affordable, and plan to challenge it in court.
1. What's South Africa's public health care system like?
The country's poorest people have access to free treatment at 3,888 public clinics, community health centers and hospitals, but these facilities are often plagued by broken equipment and shortages of medicine and beds. In its most recent report, covering 781 primary health facilities, the Office of Health Standards Compliance found that only 65% of them met the required service delivery standards. There's also a shortage of medical personnel. In the public sector, the ratio of practitioners to population is 0.3 per 1,000, whereas in the private sector, it's 1.75 per 1,000. Poor working conditions are the most common reason given by doctors for leaving the public sector. While voters are frustrated by sub-standard treatment, their biggest concerns, according to a Social Research Foundation poll, are high unemployment, the presence of undocumented migrants and high levels of crime and corruption.
2. What's the plan to fix the problems?
The aim is to provide universal access to health care through a centrally managed government fund that buys services from public and private providers. All South Africans will have to contribute upfront to the fund, with the wealthy subsidizing the poor. In exchange, citizens will receive free treatment for a range of conditions determined by the state. Estimates of the cost of the program — called National Health Insurance (NHI) — vary widely, with some pegging it as high as 500 billion rand ($27 billion) annually. Additional funding is supposed to come from new taxes and existing state budgets, including money reallocated from provincial health departments, although the specifics are still a work in progress.
3. Who's for and against the plan?
Besides the ruling party, the African National Congress, the plan's supporters include the Congress of South African Trade Unions, the country's biggest labor group. Both argue that NHI will fix a dysfunctional system and make access to treatment more equitable. While Discovery Ltd., the country's largest medical-insurance provider, and hospital companies such as Life Healthcare Group Ltd. and Mediclinic International Plc have voiced backing for an overhaul of the health-care system, they say NHI isn't workable in its current form. Several organizations have said they are preparing legal challenges to the legislation, which could delay or derail its implementation.
4. What are the concerns?
Those contemplating lawsuits argue that the law erodes the constitutional rights of both patients and health-care professionals and that input from interested groups was ignored. Among the specific worries raised:
- Once NHI has been fully rolled out, the role of insurers will be reduced to offering coverage for treatment that's not offered by the state. And if the NHI ends up being administered by the government or just a handful of companies, many private administrators will be left out in the cold.
- The government intends to set the rates it pays private companies and practitioners for services, which likely would erode their profit margins. The South African Health Professionals Collaboration, a group of nine organizations that represents more than 25,000 practitioners, has warned of a looming exodus of health-care professionals if they are forced to accept government terms of employment and fees.
- The main opposition political party, the Democratic Alliance, says NHI will effectively nationalize health care, and funds allocated to it will be vulnerable to corruption.
- Lobby group Business Unity South Africa says that the NHI legislation can't be implemented in its current form and that pushing ahead with it is damaging the health-care sector, the broader economy and investor confidence.
- Taxpayers won't be able to opt out of NHI, which will limit their treatment options, and they likely will see their personal income taxes increase. The government has also said it intends to scrap tax credits for private medical insurance.
5. Can the government pull this off?
It's a tall order. Pilot projects have provided no evidence that NHI will deliver improved health care. The program's critics say the government should focus on making the existing health care system work effectively rather than embarking on a massive overhaul. The government's managerial record raises doubts about its ability to accomplish such a major undertaking. Other state entities, including the national power utility and logistics company, have been crippled by losses and rocked by corruption allegations and management upheaval, while the state education system has left many without the skills needed to get a job, contributing to a 33% unemployment rate. Opinion polls show the ANC risks losing its parliamentary majority in the election, meaning it may have to enlist the support of smaller rivals — some of whom don't back NHI in its current form — to retain power.
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