The continuing availability of decent health care could be a decisive factor for many of those, of all races, who are considering their future in South Africa, particularly the young, the well-qualified and the entrepreneurial with the means to move.

Yet these would in all likelihood be the unintended consequences of the NHI.  Under the  scheme:

The very rich could continue to buy private medical services – but would have to pay three times for their health care – first through their normal taxes, secondly through the NHI tax surcharge and finally out of their pockets.

All this would be phased in over a seven-year period to be completed in 2026.  Existing medical insurance schemes would continue to operate until then.  However, after 2026 they would be able to offer only supplementary cover for services not reimbursable by the NHI.

The NHI would be managed by a vast new bureaucracy which, we are assured, would be run on a cost-effective and corruption-free basis.  In the UK, which has a long tradition of corruption-free administrative efficiency, the National Health Service employs 1.7 million people – a million of whom are involved in administration.

Where would the NHI find the skilled manpower to administer the scheme – and who would pay for it?  Government has shown that it cannot run existing SOEs effectively – what would make the NHI different?

There is no clarity at all on what the NHI would cost.  The White Paper talks of R256 billion by 2026 – in 2010 rands. However, this is already R420 billion in 2019 rands. Given the government’s proclivity to underestimate and mismanage costs – the final figure would probably be at least R450 – R500 billion (in 2019 rands).  (By comparison, the British NHS costs R2.3 trillion rand for a population of 65 million).

This would be funded from:

The payroll tax and surcharge would have to yield R200 – 250 billion – compared with 2019 receipts of R553 billion from personal income tax and R230 billion from corporate income tax.

It is accordingly not surprising that the Report of the Davis Tax Committee on the Financing of the NHI has stated that:“…given the current costing parameters outlined in the White Paper, the proposed NHI, in its current format, is unlikely to be sustainable unless there is sustained economic growth.”

Why is the ANC so intent on pressing ahead with so potentially ruinous an initiative at a time when:

The ANC’s first motivation is its ideological commitment – confirmed by its Nasrec resolutions – to impose equality through wealth redistribution – rather than by evolving equality through decent education, sustained economic growth and job creation.

The ANC is right about the inequality of health care delivery. Public health expenditure for 2019-20 is +/- R230 billion – which is only 4.1% of GDP compared with a global average of 6.3%.  However, 4.5% of GDP (52% of the total health spend) is spent on private health care for only the 16% of South Africans who are covered by medical insurance and the 8% -10% who pay for private medical care from their own pockets.  (It is important to note that this is not a black/white thing: only one-third of those with access to private medical care are white).

What the ANC forgets is that the 4.5% of GDP that citizens and companies pay for private medical care is discretionary spending from their after-tax incomes.

The ANC is desperate to proceed at any cost.  It seems to believe that complex problems can be solved by convening summits, publishing reports and establishing bureaucracies, instead of allowing individuals, companies and markets to make their own choices.  As Chris Hart puts it: the ANC sees all the problems as solutions and all the solutions as problems.

There is a strong argument for the reform of health care delivery.  However, this can best be achieved by:

There are, however, a number of reasons why the NHI might not be implemented as envisaged:

The NHI is full of good intentions.  However, the road to health care perdition is paved with such intentions and terminates in potentially disastrous unintended consequences.  All those who are concerned about the extension of more equitable health care to all the people of South Africa should say “No!” to the NHI.   They should unite to work for a fair and practical system that will significantly improve public health care delivery – and that will not, at the same time, erode South Africa’s existing private health care system.

By Dave Steward: Chairman, FW de Klerk Foundation
23 August 2019