‘We want to build a Rolls-Royce healthcare system for all,’ says Ramaphosa on signing NHI Bill into law

Despite widespread concerns about the financial viability and impact on the healthcare system of National Health Insurance (NHI), President Cyril Ramaphosa said it would eradicate South Africa’s stark healthcare inequalities.

“This transformational healthcare initiative in many ways gives further impetus and effect to our constitutional commitment to progressively realise access to healthcare services for all citizens,” Ramaphosa said on Wednesday as he signed the NHI Bill into law at the Union Buildings in Pretoria.

The NHI, for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa by providing equitable access to quality healthcare services.

“In this essence, the National Health Insurance is a commitment to eradicate the stark inequalities that have long determined who in our country receives adequate healthcare, and who suffers from neglect, by putting in place a system that ensures equal access to healthcare regardless of a person’s social and economic standing and circumstances.” 

The vision that no individual should bear an untenable financial burden while seeking medical attention is not just about social justice nor is it a new one. Ramaphosa referred to a document adopted by the ANC in 1943 and noted a paragraph saying the state must provide adequate medical and healthcare facilities for the entire population.

“We are achieving that dream 81 years later and that is why I am going to sign this Bill,” he said.

Rectifying a fragmented system

“The provision of healthcare in this country is currently fragmented. It is unsuitable and it is wholly unacceptable. The public sector serves a large majority of the population but faces budget constraints. The private sector serves a fraction of society at a far higher cost without a proportional improvement in health outcomes,” Ramaphosa said. 

Addressing this imbalance required a radical reimagining of resource allocation and a steadfast commitment to universal healthcare, which was a commitment South Africa had made to the United Nations, Ramaphosa said. 

“So, those who are trying to hold us back to a fragmented system are completely out of line with the global vision … which we are a part of… We are not outliers. We are very much in line with what is happening in the global community.” 

Don’t listen to doomsayers, says health minister 

Health Minister Joe Phaahla said the day marked a “historic milestone” in South Africa. “The inequities and inequalities that characterise our health systems are unjustified and require a fundamental overhaul to ensure equity and sustainability,” he said.

The NHI presented a comprehensive, transformative approach to healthcare and was founded on the principles of equity, sustainability and social solidarity and ensured that every South African regardless of socioeconomic status had access to comprehensive healthcare, he said.

Phaahla said the implementation was not only about the policy but “about the wellbeing of South Africans” and the Act was not electioneering but a promise to provide a better future for all South Africans. 

“To healthcare workers and professionals: don’t listen to the doomsayers. Don’t listen to the doomsayers and scaremongers who are telling them, ‘Things are going to collapse, you must leave now that the President has found the pen, be on the next flight.’ Stay here, things are going to be better,” Phaahla said. 

The real challenge in implementing the NHI was not a lack of funds, but the best allocation of resources that currently favoured the private health sector at the expense of public health needs, Ramaphosa said. 

“We cannot have a situation where there is a portion of the South African population that continues to live under an unequal system, while the others continue to live in another privileged type of system — this is completely against what the ethos of our democracy is,” he said.

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Addressing criticism of the NHI

Ramaphosa said he was aware of the fears that had been expressed about the NHI. 

“Those who are fearful, those who are afraid, I say, just think about the commitment that the governing party has always had to building South Africa as a sustainable growing nation. National healthcare on a universal basis is going to build our nation in a very practical way.” 

He likened the current anxiety to fears expressed ahead of the transition to democracy and the introduction of the right to strike, and argued that those fears had proved to be unfounded.

Numerous bodies have indicated they are prepared to approach the courts to challenge the Act. 

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Ramaphosa said it was important to remember that South Africa was a constitutional democracy and the Parliament that adopted this legislation was democratically elected.  

“We have a clear Bill of Rights, we have a robust Constitution, so those who fear that this Bill or this Act is going to erode their rights just rest assured that there is a Constitution and a Bill of Rights that protects all of us,” he said.

The NHI had the potential to transform the healthcare landscape, making the dream of quality, accessible care a reality for all, Ramaphosa said.

The NHI fund would procure services from public and private providers to ensure all South Africans had access to quality healthcare and it recognised the respective strengths and capabilities of the public and private health systems, he added.

The private healthcare system was often referred to as the real backbone of health while the public health system was spoken about in insulting ways, Ramaphosa said.

“What we’re trying to build is the Rolls-Royce system of healthcare for all South Africans, and it aims to ensure that we complement the systems and reinforce them with each other. Through more effective collaboration between the public and private sector, we can ensure that the overall is greater than the sum of its parts,” he said.

“If you are afraid of the NHI, take heart and courage from the fact that we are going to implement NHI in a phased manner, so as to ensure that every sub-milestone becomes an important one to make the NHI much more effective.”  

Phaahla said the fundamental structure necessary for implementing the NHI would be established within six to 12 months and that the yet-to-be-established NHI Fund, which would procure services from public and private service providers, would be governed by a board made up of “people of good standing”.

Quality and affordable healthcare, tackling poverty 

The signing of the Act signalled the determination to advance the constitutional right to access healthcare as articulated in section 27 of the Constitution, Ramaphosa said. “Remember, section 27 of our Constitution is what we all as South Africans said we wanted … and this is what we are signing today.”  

The Act set the foundation for ending a parallel inequitable health system where those without means received poor healthcare. Under the NHI, access to quality care would be determined by need, not by the ability to pay and this would produce better health outcomes and prevent avoidable deaths, he said.

The NHI was an important instrument to tackle poverty, Ramaphosa said.

“The rising cost of healthcare makes families poor. Healthcare provided through the NHI will free up resources to poorer families for other essential needs, and through this we will be able to reduce poverty, we will be able to reduce inequality and this is an essential step on our journey as a nation to make the lives of people better,” Ramaphosa said.

“The NHI is an opportunity to make a break with inequality, inequity and inefficiency that has long characterised our approach to health. The NHI is here, l have found my pen.” DM