Issued by Shaun Kinnes and Siyakudumisa Zcina, Interns at the Foundation, on 11/04/2024

Introduction:

This is the second in a series of articles on the National Health Insurance Bill [B11B-2019] (“the NHI”). The Bill, passed by both houses of Parliament and currently awaiting the President’s signature to become into law, has been years in the making.

The first article in the series looked at the problems surrounding the NHI Bill and how it is not the silver bullet to the problems facing the public healthcare system. This article will aim to examine other solutions to fulfil the right to access to healthcare (guaranteed in section 27 of the Constitution). South Africa needs a sustainable public healthcare model that allows everyone equal access to it, irrespective of their financial situation.

Healthcare internationally – single-payer v multi-payer systems:

The United Kingdom’s National Health Service (“NHS”) and Brazil’s healthcare system are both predominantly single-payer systems. A single-payer system is where a single public actor is responsible for covering the fiscal costs of providing healthcare to the citizenry of a nation.

The Australian or Canadian-style systems on the other hand, involve multiple stakeholders – including provinces, private insurance groups, and national governments – contributing to financing and accessibility.

While single-payer systems, like the NHS, have faced challenges (such as delayed access and workforce shortages), multi-payer systems, like Australia’s, have offered citizens tax rebates to access private facilities, thereby reducing waiting times in public hospitals.

Within the multi-payer system there is also differentiation: Australia’s multi-payer system combines public and private hospitals, providing tax rebates for private healthcare. In contrast, Canada has a decentralised healthcare system managed by 13 provincial governments, called “Canadian Medicare”. Canadians can choose private plans for uncovered services, with tax rebates offered. Public coverage is 100%, while private coverage is 67%, emphasising healthcare for all with not-for-profit operations and aligning with prioritising people over profit.

These comparative healthcare systems underscore the complexity of healthcare financing and delivery. While single-payer systems like the NHS face challenges, multi-payer systems in Australia and Canada demonstrate diverse funding mechanisms involving various stakeholders.

The way forward:

The NHI is a single-payer system and is often likened to the NHS. However, a single-payer approach may not suit South Africa’s healthcare reality. This is primarily due to the country’s fiscal position and the fact that it would undermine the role of provinces in providing healthcare.

Considering South Africa’s current healthcare landscape, involving provincial health departments, medical aids and public hospitals, as well as the historical complexity of funding healthcare, a multi-payer system seems most  suitable. A multi-payer system would also ease the burden on the public fiscus (and thus the taxpayer).

South Africa’s pursuit of a sustainable and accessible healthcare system necessitates careful consideration of these models, balancing universal coverage with financial sustainability and equitable access.

Moreover, South Africa must invest in competent hospital administrative staff, especially CEOs. Groote Schuur and Tygerberg hospitals in Cape Town showcase successful public sector outcomes. Groote Schuur is a global level 1 trauma centre, which means that it is a tertiary hospital capable of providing treatment to the most severe injury. It also offers tertiary training and specialist services.

State hospitals could consider partnerships with university health sciences faculties, as proposed by former Wits University Vice-Chancellor Professor Adam Habib. Implementing these models nationwide would enhance healthcare access and quality.

Access to healthcare services is a fundamental human right, requiring sustainable financing and careful planning to ensure continued accessibility and quality. As it stands, the NHI Bill’s exorbitant cost and unclear implementation strategies render it financially unsustainable and potentially destructive to South Africa’s health sector.

The Foundation urges President Cyril Ramaphosa to exercise the powers the Constitution gives him to send this law back to Parliament for reconsideration, lest we face insurmountable financial, human resources and managerial deficiencies challenges that will cripple everyone’s right to access healthcare. The Foundation urges the State to rather consider a combination of a multi-payer system and a partnership with university health sciences faculties to address the current problems in the public healthcare system.