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

Introduction:

This is the first 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. Section 27 of the Constitution mandates that everyone has the right to access healthcare services, including reproductive health care, as well as sufficient food and water and social security. This section asserts that the state must take reasonable legislative and other measures, within its available resources, to progressively realise these rights.

In addition, universal access to healthcare is a key priority of South Africa’s National Development Plan (“NDP”). It is also a key UN Sustainable Development Goal (“SDG”).

SA’s public healthcare system:

While notable hospitals exist in South Africa’s public healthcare sector, the sector overall faces multifaceted challenges – one of which, that has recently made headlines, is the severe shortage of doctors. This is exacerbated by funding constraints which has left over 800 qualified medical professionals unemployed and prompted some skilled practitioners to emigrate. The persistent budget limitations hinder recruitment efforts, compounding the crisis in public healthcare facilities which are already plagued by equipment shortages and medication deficits.

The NHI & universal healthcare access:

The NHI intends to achieve “Universal Health Coverage”. It seeks to ensure that no one is deprived of access to quality healthcare due to a lack of money by creating one public health fund with adequate resources to plan for (and effectively meet) the health needs of the entire South African population.

Despite this, the NHI has been fraught with criticism and unfeasibility studies: Solidarity, a prominent trade union, has vowed to escalate its opposition to the NHI, holding key Government figures personally accountable for its consequences. Legal experts from Webber Wentzel highlight the lack of clarity regarding the NHI’s impact on South Africa’s extensive private medical scheme and insurance industry. They emphasise potential constitutional challenges concerning healthcare access (section 27), property rights (section 25) and freedom of trade (section 22).

NHI – the problems:

It is important to note that the argument was never about whether or not South Africans should have access to quality medical care, but instead, about the following problems regarding the NHI Bill:

Government’s ability to manage:

The alarming unemployment figures within the medical profession raise profound questions about the Government’s ability to manage its healthcare workforce:

A recent Medical Protection Society (MPS) survey (that allowed healthcare practitioners from state healthcare facilities to comment anonymously), saw 91% of doctors say staff shortages are a “significant threat” to patient safety. Furthermore, 66% said that medication shortages impact patient safety and 45% said that equipment shortages impact patient safety.

It is not that South Africa does not have doctors. In fact, it has over 800 unemployed doctors. The mismatch between a surplus of qualified medical practitioners seeking employment and understaffed hospitals hints at a systemic failure in the State’s management of the public health sector.

Private medical aids:

The present framework of the NHI prohibits medical aids from funding health procedures offered by the NHI Bill – making the State, under the Ministry of Health, the sole purchaser of healthcare. The NHI Bill also diminishes the current role of provincial health departments in providing healthcare.

Rare diseases:

Of particular concern is how the NHI Bill will affect individuals suffering from rare diseases (estimated at 3,7 million people in South Africa). These conditions often necessitate specialised care, including access to specific doctors, equipment, medications and diagnostic tools. However, because the NHI emphasises primary healthcare services, it overlooks this community’s complex needs. By prioritising primary care and centralising healthcare provision, the NHI risks neglecting those with rare diseases, leaving them without adequate support or access to essential treatments. This approach not only fails to address their unique healthcare requirements, but also undermines the private sector without ensuring sufficient enhancements to the public healthcare system.

Sustainability

The NHI’s framework, positioning the State as the sole purchaser of healthcare, exacerbates concerns surrounding sustainability and unaffordability, as acknowledged by Finance Minister Enoch Godongwana. This shift also diminishes the role of medical aids, which are vital employers in the country, further undermining the fiscal tax base. While the NHI aims to address healthcare disparities, doubts persist regarding its efficacy.

The staggering cost:

Perhaps the biggest concern is the cost of the proposed NHI, estimated at R460 billion annually. Government estimates are that the NHI would require (at least) an additional R200 billion in tax revenue. This can only be obtained by raising taxes or lessening tax credits, or a combination of both.

The Treasury, the Davis Commission and the Minister of Finance have all stated that the scheme is unaffordable. (Finance Minister Enoch Godongwana admits it is unaffordable and that the proposed financing sources are unsustainable.)

The State simply does not have the money.

Health practitioners’ exodus:

The South Africa Medical Association has indicated that doctors will leave the country should the NHI become law. This is a loss in skills the country can ill afford, as well as one that will further contract the shrinking tax base.

NHI & inequalities in healthcare access:

The vast disparity between South Africa’s private and public healthcare sectors highlights a critical issue. Unfortunately, the current framework proposed by the NHI Bill threatens to exacerbate this gap rather than bridge it. As the problems listed above illustrate, it is not the silver bullet to the problems in the public healthcare system. Other solutions to fulfil the right to access to healthcare will be examined in the next article in this series.