Issued by the FW de Klerk Foundation on 15/06/2023

On Tuesday 13 June 2023, the first house of Parliament, the National Assembly, passed the controversial National Health Insurance (NHI) Bill, which it believes will “achieve universal access to quality health care services” in South Africa. The NHI Bill will do nothing more than ensure all South Africans receive an equal share of a failed public health care system.

COVID-19 highlighted South Africa’s deeply divided health system – characterised by an increasingly dysfunctional public sector that cares for between 65% – 80% of the population and a private sector that caters to the 16% of the population covered by private medical insurance and the 10% – 15% who pay for private medical care from their own resources. 

The national health budget for 2022 – 2023 was R259 billion – representing little more than 4% of GDP, which is low by international standards. By contrast, the private sector spent slightly more – 4.2% of GDP – on the approximately 25% – 30% of the population to which it provides medical service. The level of care in the private medical sector is world-class, while that in the public sector – despite some islands of excellence – is beset by poor management, inadequate maintenance, understaffing, corruption and theft.

The Government’s response to this situation is the NHI Bill, which would grant every South African the right to “receive necessary quality health care services free…” by pooling funding for private and public health care providers.

Under the Bill:

• The NHI would be the core purchaser and provider of medical services and medicines to people living in South Africa.
• Registered health care users would be entitled to free medical care and medicine from accredited service providers.
• Health service providers would decide on treatment and referrals to specialists and would be reimbursed by the NHI.
• The NHI would decide annually what payment rates would be applicable to health care service providers.

Numerous submissions made to Parliament on this Bill expressed grave concern over the feasibility of the NHI system – a concern shared by Treasury, with annual cost estimates exceeding R450 billion – and over Government’s inability to provide quality health care given the inadequacy of current public health care delivery.

In a 2019 poll conducted by Solidarity, 41.6% of health care practitioners had responded that they would consider emigration if the scheme were adopted – threatening the viability of existing medical insurance schemes, private hospitals and medical practitioners. “Only 15% of the respondents were of the opinion that the NHI could be implemented successfully, and 84.5% believed that the NHI had the potential to destabilise the health care system in South Africa.”  

The Bill would also have far-reaching implications for the freedom of people involved in medical insurance schemes, private hospitals and medical practices to pursue their occupations and professions in a sustainable manner. Each year, countless young and qualified doctors and nurses struggle to secure residencies at private health care facilities or go abroad to avoid placement at public medical institutions. 

Although any effective initiative to improve health care for all South Africans should be welcomed, it is ludicrous to imagine that a government currently unable to provide basic – let alone quality – public health care and whose debt sits at 64.7% of the country’s GDP (2022), could effectively implement the system needed to sustain this type of “universal” health service. 

The NHI Bill, like the Employment Equity Amendment Act and Expropriation Bill, is born from the ANC’s National Democratic Revolution ideal: “The central task in the current period is the eradication of the socio-economic legacy of apartheid; and this will remain so for many years to come.” For it, the NHI Bill is a crucial step in the redistribution of wealth and services according to demographic representivity. But what good is dooming all South Africans to a future of preventable sickness and death caused by maladministration and negligence? 

Surely, the solution to inequality in health care would be to expand the rights of those who don’t have access to quality health care, rather than to hinder those who do? Unfortunately, the NHI Bill and the intended system it creates will fail to deliver effectively and will affect the ability of the provinces (which bear the primary responsibility for providing medical service delivery, including hospitals and clinics) to intervene. 

The NHI Bill is now before the National Council of Provinces, which will involve an opportunity for public participation. Now is the time for the public, including private health care providers, to heed the warning against this system.