The approval of the National Health Insurance (NHI) Bill by the National Assembly this week seemed to catch some by surprise, as the industry expected further amendments following widespread concerns.

The Bill still has to be approved by the National Council of Provinces before being signed off formally by Parliament and promulgated by the President. South Africa’s healthcare system remains unequal, with 84% of the population dependent on a heavily burdened — and in some cases under-resourced — public health system, with 16% on medical schemes.  

The NHI seeks to solve this disparity by redistributing resources to provide equitable access to healthcare.

However, implementation will require significant investment in the health system as well as a phased approach to ensure that it is rolled out in a sustainable and effective manner. 

“While the Bill ensures that medical schemes will still exist, they will be required to provide complementary cover to beneficiaries of the NHS,” said Dr Katlego Mothudi, the managing director of the Board of Healthcare Funders (BHF), at the recent release of the Sanlam Benchmark Survey. 

“Employers may be mandated to contribute to the NHI fund on behalf of their employees. This is of course subject to finalisation of the funding mechanisms.”   

The BHF, an industry body representing medical schemes (with the exception of Discovery Health medical scheme), has identified several anomalies in the Bill that require further attention and alignment with constitutional mastery. 

One of the first points the BHF raises is the fact that the NHI is not universal health coverage, but a funding mechanism. 

“Medical schemes, managed care organisations and administrators as well as other funders of health are an asset to the ecosystem and are geared to move our country to achieve universal health coverage,’’ said Mothudi. He added that although initial plans are for full implementation of NHI by 2026, this is looking increasingly unlikely. 

“It will probably be another 10 to 15 years before it is fully implemented, according to the Department of Health,” he said.

Material concerns

Dr Ryan Noach, the chief executive officer of Discovery Health, says he is surprised the Bill was passed despite “material concerns raised by almost all the opposition parties at the committee, and further to this, the significant constitutional concerns which were raised by the parliamentary legal adviser which seem to have been ignored”.

Noach says it is particularly concerning that the inputs of healthcare professionals, who are essential to the delivery of healthcare, were not given the appropriate weight and attention in the amendments to the Bill. 

“As a result, it appears highly likely that this Bill will be challenged through various legal avenues, including probably being contested on various constitutional grounds, based on multiple stakeholders’ stated intent during the PPC hearings premised on key issues which have not been amended.”  

How will it be funded?

The billion-rand question of how the NHI will be funded has not been addressed. 

“This is particularly concerning, given the minister of finance’s recent comments relating to the financing challenges and nascent stage of the Treasury’s work on NHI funding,” Noach says.

“It is absolutely critical to understand the affordability and economic strategy for supporting the Bill’s proposals, as well as the financial systems and controls required to ensure effective oversight of the monies in the fund. 

“Sans substantial financial support, the necessary health system improvements and the sustainability of this approach will be impossible. It is in fact a clear and present risk that the resources to support this proposed structure do not exist within our fiscus.”  

Sandra Sampson, director at Allmed Healthcare Professionals, says estimates for funding the NHI range from R165-billion to R450-billion. DM