South Africa


NHI in times of collapsing public healthcare, rampant corruption and deep mistrust in government?

NHI in times of collapsing public healthcare, rampant corruption and deep mistrust in government?
Insulating the National Health Insurance from influence-peddling officialdom and the politically connected is vital but may be a near-impossible task. (Photo: Rosetta Msimango/Spotlight)

There are questions about whether a mega state-owned enterprise like the National Health Insurance can really deliver quality health while State Capture, corruption and political nepotism networks remain in place.

Universal quality health is a principled goal. The National Health Insurance is South Africa’s vehicle to achieve that in line with Section 27 of the Bill of Rights in the Constitution.

It’s been done elsewhere. 

In the United Kingdom, despite recent funding cuts and other shortages and delays, a sense of pride exists in that institution established for everyone following World War 2. 

Across the European Union and Nordic countries, quality public health means that even while private medical care exists, it’s not really a thing; not even for the chattering classes there.

South Africa’s NHI has its roots in the 2007 Polokwane ANC conference that resolved to “reaffirm the implementation of the National Health Insurance System by further strengthening the public healthcare system and ensuring adequate provision of funding…” 

A reliable single health information system, free health cover for Struggle veterans and a “reliable single health information system” were also part of the NHI. 

Definite details emerged at the 2010 ANC National General Council in Durban. Then ANC National Executive Committee health subcommittee chairperson and KwaZulu-Natal premier, Zweli Mkhize, outlined what was needed. 

“Membership to NHI would be compulsory for the whole population, but the public can choose whether to continue with voluntary medical scheme cover,” he told the Sowetan at the time (Party wants National Health Insurance in place). 

“The main source of revenue for the NHI fund will be allocations from general taxation.”

The 2012 Mangaung ANC conference resolved that “the NHI fund be set up urgently using state revenue by 2014”. 

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The 2017 Nasrec ANC conference resolved, “The ANC should ensure that the implementation of the NHI remains a priority of government” and that medical aid tax credits should be used to fund what was increasingly called universal healthcare, perhaps in recognition of how NHI polarised public debate.

But by then it was clear that the 11 NHI pilot projects started in 2014 were showing serious shortcomings in even the basics, and the Office of the Health Standards Compliance established in 2013 highlighted that the public health sector struggled to maintain basics like cleanliness.

Still, the NHI is a key demand from Cosatu, the ANC’s alliance partner. And it’s been an election promise in every ANC election manifesto since 2009. 

On the 2019 campaign trail, the governing ANC promised to “Achieve free, quality healthcare for all at the point of service by 2025 with a National Health Insurance”.

After a 12-year practice run, and with the implementation date in 2026, where is the NHI?

This week, MPs start clause-by-clause deliberations of the Bill that, in late 2019, landed in Parliament. It’s one of the last legislative steps before the health committee agrees to the Bill, and takes it to the House.  

This law will establish the NHI Fund — and set out matters like its funding, various committees for determining benefits, health product procurement alongside an internal appeals process and an internal investigation unit for claims of malfeasance. 

Registration is compulsory, with biometrics. Patient referral pathways are set — the family GP may no longer be an option — with financial penalties for straying off referral pathways.

While in 2010 private medical cover was still a voluntary option, the NHI Bill allows private healthcare to only provide top-ups, or “complementary services”. That’s cosmetic surgery, “fashionable spectacle frames” and “expensive dental procedures” for aesthetics, according to a Health NHI info brochure.

Private healthcare providers, among others, are not necessarily pleased, even if the draft law elsewhere clearly talks of the NHI Fund contracting accredited health service providers. 

Word on the grapevine was that Discovery had been looking to be a main NHI partner to government.

Recently, Discovery CEO Adrian Gore was less coy in public. 

“Discovery is supportive of the NHI and will use its capabilities and resources to assist,” he’s quoted by Business Day (NHI is morally correct but handle with care, says Discovery’s Adrian Gore). 

NHI was a “moral imperative”, said Gore, while also proposing the continuation of private medical aid cover once NHI contributions are paid. 

Such a posture would dovetail with President Cyril Ramaphosa’s administration’s social compacting — even when the NHI has been steeped in often polarising debates in South Africa’s political economy.

But the public healthcare system is now beyond stretched — it’s at breaking point. 

Electricity and water outages, stock-outs and the lack of medical equipment as officialdom leaves bills unpaid and theft spoils operations. 

Political nepotism and a care-devoid officialdom fails to assist, more focused on pandering to political bosses even amid wrongs, as the public hearings into the 2016 deaths of 144 Life Esidimeni patients showed.

Hospitals are in dire straits. Whether that’s Johannesburg’s fire devastated Charlotte Maxeke Hospital, which is still not fully operational over a year after the April 2021 fire, or the rat-infested, bloody medical waste-strewn Livingston Hospital, Gqeberha, in mid-2021. Right now, orthopaedic surgeons at that hospital are unable to operate on patients through a lack of equipment due to millions in outstanding payments to suppliers, Johnson & Johnson.

Accounts of having to queue from 4am at clinics are the rule, not the exception, with no guarantee of seeing a doctor or making it to the pharmacy before it closes — if there’s even more than a headache pill available.  

This is the lived reality for the around 50 million South Africans who do not have private medical aid cover. The nine million South Africans with private medical cover pay R212-billion for this. 

Summary of views on the proposed health funding model presented to Parliament

A decade into NHI pilots and support measures like the standards compliance office, the Health Budget for 2022 stands at R64.5-billion. 

The Covid-19 personal protective equipment tender saga showed the preponderance of corruption and how the politically connected are benefitting. Even with vanity projects of putting up Covid hospital beds — without nurses, doctors or even oxygen. 

Mkhize, who’s denied wrongdoing as health minister in the Digital Vibes communications scandal, remains under investigation by the Hawks. 

Yet the NHI Fund will be the sole provider and contractor of healthcare services, with enormous powers to the minister for “governance and stewardship” — and appointing everyone on the NHI Fund board.

The State Capture commission reports, like the ones on Eskom, set out in painful detail how ministers ensured pliant board members for the Guptas and their business associates to, bluntly put, loot state-owned entities. 

Let’s be clear, centres of public health excellence exist across South Africa. Academic hospitals like Groote Schuur do groundbreaking medical treatment and research, as does the Walter Sisulu University hospital and the Red Cross Children’s Hospital.

But often that’s against the odds. And in spite of everything. 

On 10 May Health Minister Joe Phaahla in his Budget vote called on “all members of Parliament to support the NHI Bill… as an instrument for Universal Health Coverage. In the meantime, we are laying the foundation for a strong public health system…”

ANC lawmakers, who have the numbers in the House, have already indicated they will support the NHI Bill pretty much as is. The IFP is in support. The DA, EFF and Freedom Front Plus are not. And so the party political ratcheting rhetoric unfolds from all sides — clause by clause.

What’s needed instead are measures to limit wide-ranging ministerial powers; to allow parliamentary oversight in appointments as happens with the SABC, the Auditor-General and the Public Service Commission (and elsewhere), and fund decision-making. 

Also crucial are greater independent checks and balances on the board and its benefit and procurement committees through established health sector organisations.  

Excluding asylum seekers and so-called illegal foreigners from healthcare, except for emergencies, could well be unconstitutional. The lack of civil society and labour representation anywhere seems downright odd given the NHI’s character.

Insulating the NHI from influence-peddling officialdom and the politically connected is crucial.

Health must be for health’s sake — patient-focused, supportive of healthcare professionals, responsive and dignified. Only an NHI that does that will deliver universal quality healthcare. DM


Comments - Please in order to comment.

  • Andrew B says:

    Dear me, DM. What is that stench? Ah, yes – hypocrisy. While none of your informed reservations about the NHI are ones I disagree with, your approach has also been to spend the past two and a half years allowing for another, equally ruinous, obtuse and downright unscientific public health agenda. At devastating cost. Despite family doctors and ICU intensivists saving countless of our citizens at every stage of infection, in their practices from Mitchell’s Plein to George Mukhari Hospital and everywhere between, the only journalist on your staff who ventured outside the ‘safe-thought’ bubble to interview these doctors was your citizen editor. Once. Had you followed up on his reasonable, objective line of interest you could have confirmed for yourselves and your readers, why serious doctors were finding that from their own clinical experience, the treatment option with a dirt-cheap, generic, multi-drug protocol worked. That it did so in early or late stage infection. One which cost cents on the Rand compared to the government’s ineffective policy of lock downs, waiting for vaccs and being told to stay home if testing positive or symptomatic because there was no early treatment option. Only for our people to arrive at hospitals by the time they couldn’t breathe, hundreds of thousands dying en route, in hospital or too terrified to risk a run in with our state health system. Where was your public health policy scepticism then, DM? And still you allow the anti-treaters free reign.

    • Tom Boyles says:

      It never ceases to amaze me how naive Maverick Insiders are. Andrew, you don’t have a clue about how medical advances have brought about profound improvements in healthcare of the last century. I’ll give you a clue- it isn’t listening to annecdotes from GPs about multi drug regimens probably using worm tablets. It’s rigorous scientific method which, in the case of Covid has been remarkably rapid and successful giving us a raft of vaccine and medication that are shown to work. It’s pure naivety, the way you think you can make advances by listening to a few annecdotes fro GP.

      • Andrew B says:

        Dear Dr. Boyles, the argument above betrays its own lack of any evidence basis; insofar as its comment on treatment is concerned. My case was not anti vaccine but pro early treatment. Which is not reflexively anti-vax but is made out to be by the vaccine lobby, to discredit it. Two things can be true at the same time – namely effective early outpatient or in hospital multi-drug treatment protocols – co-existing with the vaccine approach. But the argument of insufficiency used against early treatment was precisely the one used from May 2020 to win Emergency Use Authorization for the vaccs under the FDA rules; namely that no new drug can be granted EUA if there exists a safe, available, effective alternative. The early outpatient and in-hospital treatment options had to be discredited or the EUA would not be granted. Enter the insufficiency canard [or ‘anecdotal’ if you like]. So effective because it is not a precise value and the goal posts are forever subject to what the eminences of public health need them to be. e.g. when the FDA made their first finding of insufficiency against worm tablets [your term], they qualified their 5 March 2021 statement as follows: ‘The FDA has not reviewed data to support use of Ivermectin in COVID-19 patients to treat or to prevent COVID-19’. They hadn’t even looked at the data! And SAHPRA cite the FDA as the basis for their own findings. Is this the rigorous scientific method of which you speak?

  • Nic SA says:

    We often compare SA to the UK, Germany etc. and say well it is stupid to try something like NHI, we are not a developed country. But we should look at our peers. Thailand has an excellent national health insurance system in a country with similar size population, government budget, economic development and corruption to SA. They also still have a large private healthcare and medical tourism sector. We should see what we can learn from our “developmental peers” rather than getting stuck an ideological camps that are either completely against or completely in support of the system.

    • Robert Mitchell says:

      I think that nobody would argue your point. Only for the fact that the ANC has stolen the country and now are looking for another thing to steal! NHI under the current government simply wont work!

    • Paddy Ross says:

      As an expat who spent thirty plus years working as a surgeon in the NHS, the last of which as a consultant with private patients also, I am 100% in favour of the SA government providing high quality health care in the public sector. But essentially banning private health care will contribute nothing towards achieving high quality care in the public sector. Stopping people from spending their own money on private health care is authoritative government in the extreme.
      It is barn door obvious that people who subscribe to private health care reduce the demand on the public health system. Those who are trying to abolish private health care access in SA must be motivated to do so only by envy.

  • Unfortunately all our best doctors will emigrate. Medical aid members will drop down to hospital plans to cover dread diseases and accidents and self insure the rest. The poorer medical aid members will be thrown onto the tender mercies of the public health services. Medical tourism to Russia by ANC ministers will increase. It’s not going to end well.

    • Tom Boyles says:

      Except the best doctors won’t leave. Currently, most reside in the public service and already push through despite terrible conditions. They will stay and continue to provide the best care that they can under NHI #imstaying

      • Karl Sittlinger says:

        There are quite a few reports that seem to suggest different:
        Business tech “South Africa faces exodus of doctors and other professionals because of the NHI”

  • Riette Fern says:

    If the NHI is such a great idea for South Africa, then why is it purported that only Russian doctors could cure Zuma and Mabuza from poisoning?

  • Wilhelm van Rooyen says:

    Universal Health Coverage is such a wonderful idea, but the people who are to implement are:
    have shown themselves to be bunch of crooks
    have no relevant experience in running such a system

    So, how can we trust hem with the billions of ZAR involved?

  • Gillian Dusterwald says:

    In reality, we have a healthcare system that can serve our whole country, including the very poorest of the poor, very well. If it was properly staffed and if allocated money was spent where it should be. The hospitals in the Western Cape are proof of that!

    • Robert Mitchell says:

      yes they cant even get their ow hospitals right now they want the private ones. they will destroy those too! Fact.

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