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The NHI and its aspirations for universal healthcare: Points of contention


Dr Kaymarlin Govender is research director at HEARD, University of KwaZulu-Natal. He is a member of faculty at the College of Law and Management Sciences. He leads an NRF-STINT partnership with the University of Gothenburg, Sweden, on research and postgraduate education on social determinants of HIV in East and southern Africa.

While South Africa’s ambitions to offer more inclusive healthcare sounds laudable and pays homage to notions of inclusiveness and solidarity, the rapid and unfolding reality of this proposed healthcare reform leave us with a palpable sense of unease.

The recently published National Health Insurance (NHI) Bill is seen by the government as South Africa’s pathway to achieving healthcare for all.

The bill has ambitious expectations to reduce South Africa’s current disparities in access to healthcare. Yet experience from other low-and middle-income countries has shown us that the pathway to achieving universal health coverage is not straightforward.

Yet, there is an imperative for South Africa to align with World Health Organisation and United Nations declarations on universal health coverage which is seen as the pillar of sustainable development and global security.

It is worth noting the WHO definition on universal health coverage is that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

While South Africa’s ambitions to offer more inclusive healthcare sounds laudable and pays homage to notions of inclusiveness and solidarity, the rapid and unfolding reality of this proposed healthcare reform leave us with a palpable sense of unease. Our path to universal health coverage is complicated by not only the country’s history of inequities in healthcare, but also its present political complexion and diverse sector interests, irrespective of widespread aspirations towards solidarity and inclusive healthcare for all.

Other countries that have sought to achieve universal health coverage have shown that a capable state, through its government, is central to implementation in areas of financing, regulation and sometimes direct provision of healthcare services. In our case, questions have been raised on how the NHI will be financed, what services will be covered and what additional costs South Africans have to bear in a climate of a stalling economy and high cost of living, mismanagement of public funds and systemic levels of corruption.

Nonetheless, much the same can be said of our private healthcare sector: South Africans fortunate enough to be on medical aid are faced with escalating medical costs, risk profiling to limit access and overpricing medical insurance abuse (overpayment for medical procedures and medicinal prescriptions).

As a starting point, most of us will agree that innovation is necessary for our outmoded and dual systems of healthcare. More than 85% of the country is reliant on public health. We have a large private healthcare sector, which accounts for more than half of all health expenditure but serves only 16%-18% of the population. A common interpretation of the bill is that the two-tiered system will be replaced by a single and inclusive system with centralised government management.

The recent introduction of the bill has produced much debate on the government’s approach to universal health coverage. Some pointers for consideration as we rapidly move to 2026 target of the NHI roll-out:

  • There is an obvious fear in setting up a multi-billion fund. We have heard terms such as creating an “autonomous public entity” to manage the NHI and “pooling of allocated resources” from public and private sector healthcare to procure healthcare services and medicines. However, there is a lack of clarity in key issues: Where will the billions of rand come from amid other competing priorities of the state? It is not an understatement to say that a growing national economy has to be the substrate to make for health inclusion and re-distribution of resources. Equally worrying, the creation of a monolithic entity with convoluted systems, poor administrative capacity and multiple bottlenecks affecting procurement and delivery of services. The recent stock-outs of HIV medication in public sector clinics is an apt example.

  • A related question is how we make this entity corruption-proof in the aftermath of State Capture? The recent Health Market Inquiry also talks about massive corruption in the private health sector, with some recommendations going forward for structural reform. More deliberation is needed on how the management structure for the NHI will be configured and how this will be policed. We need to determine the functions, roles and responsibilities of this new entity to manage the NHI. This includes defining roles and responsibilities between the purchaser (NHI Fund) and the provider (National Department Of Health and private sector entities) in terms of who is responsible for areas ranging from fund administration to provider management, as well as for re-insurance and risk mitigation. We also need to closely watch whether commitments to reform private healthcare will occur (as indicated in the Health Market Inquiry report). Success here will be foundational to NHI roll out in 2026.

  • The benefits plan described in the White Paper prioritises coverage of vulnerable groups defined as children, orphans, the aged, adolescents and people with disabilities, women and rural communities. It commits to building on current primary healthcare to be free of charge, and for children under six, pregnant women, the disabled and the indigent not to pay user fees for higher levels of care. It also specifies key services to be covered under NHI, including reproductive health services, maternal health services and paediatric and child health services. The Office of Health Standards Report shows that more than 80% of public health clinics were non-compliant for the requirements of NHI implementation. There is an urgent need to assess national treatment guidelines and treatment protocols to map what should be available in relation to what is available to determine service delivery gaps and bottlenecks from primary to higher-order services. As part of this exercise, services need to be costed and then organised for prioritisation based on estimates of need, the burden of disease, utilisation, availability and equity. Experience shows there are few, if any countries that can provide completely comprehensive quality services, whether preventative, curative or palliative. South Africa even less so. There are convincing arguments for a form of “progressive universalism”, as advocated by the Lancet commission on “Investing in Health”; that is, start up with a minimum package of services for complete coverage and expand this offering incrementally over time as health finances improve. More discussion on the nature and form of health benefit packages is needed. The success of NHI depends on the selection of a cost-effective and affordable benefits package that prioritises the delivery of basic, quality services to the entire population, particularly those currently underserved.

  • Would we be able to cover all people with the same level of quality services? In the NHI pilot districts, we have seen disparities across districts in relation to health demographics, lack of delivery of health services, lack of compliance with quality standards for services, lack of district management capacity (lack of commitment, staff and resources) – all exacerbated by systemic corruption. These issues are compounded by multiple epidemics with underserviced populations most affected. In the light of finite resources, there is an argument for “positive discrimination”, privileging the poor at the expense of the rich — prioritisation of health services in districts where poorer people reside. Is that feasible and sustainable? To what extent does this go against values of inclusion and solidarity? Proposals on these issues have to be based on sound moral arguments and, therefore, there must be more public debate about how we take on a more holistic pro-poor approach in our policy framework.

If we are to adopt a universal and inclusive system of healthcare, we are setting ourselves up with the almost impossible task of trying to fix a broken public healthcare system, while simultaneously working to re-engineer a new one. The district health system is the basic unit of analysis in healthcare reform. NHI deliberations aside, the most urgent task is to fix health service delivery at local level.

Universal health coverage will remain an empty promise unless local health systems are strengthened to improve quality essential services to everyone. The irony is that without an equitable and inclusive healthcare system, the long-term cost control to both the public fiscus and current private sector users would be impossible to contain.

The dual model system in South Africa is neither desirable nor sustainable. Ultimately, South Africans must decide on the type of fiscal commitments and structural changes required to eliminate disparities in access to healthcare. The government needs to set up a process of engagement with diverse stakeholders on details contained in the bill. We require transparency, accountability and decisions based on sound evidence. DM


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