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Why South Africans need National Health Insurance


Lebogang Mulaisi (Cosatu’s National Social Development Policy Co-ordinator) and Khwezi Mabasa (Senior Researcher, Mistra) are contributors to the Mapungubwe Institute for Strategic Reflection’s (Mistra) research on the socio-economic impact of BEE legislation and the experiences of black entrepreneurs in post-apartheid South Africa.

The government recently published an updated National Health Insurance Bill for public scrutiny and commentary, inciting support and opposition, informed by three primary considerations: economic interests, ideological prisms and lived experiences within the nation’s health system. This article combines all these dimensions and demonstrates how NHI benefits transcend the current narrow focus on fiscal or revenue issues.

We present four compelling reasons, based on documented research and extensive health worker policy dialogues, which justify why South Africans need the NHI.

The first relates to the unequal structure of the nation’s health system. It is characterised by stark inequalities based on race, class and gender. For example, data from the StatsSA General Household Survey (2018) reveals that only 16% of South Africans have access to medical aids. This membership is dominated by white citizens (72%) while only 10% of Africans have access to medical schemes.

Furthermore, South Africa’s health finance is very skewed when contrasted with other countries. An impressive 8.5% of GDP is spent on overall health services, but this is largely consumed by private health sector users and providers. How does a country justify a “two-tiered” health system in which half of the overall health expenditure is spent on 16 per cent of its population?

These figures also debunk the myth of limited resources within the system. South Africa’s health expenditure exceeds the World Health Organisations (WHO) recommended health expenditure of 5%. The NHI seeks to address this structural inequality within the system by providing an alternative Universal Health Coverage (UHC) model.

President Cyril Ramaphosa recently received an international award for his government’s choice on introducing UHC.

Second, South Africans need NHI for accessing primary healthcare. Various health studies prove that South Africa’s health system is overly curative. This has significant implications for health service costs and the nation’s disease profile. A clear example is the continued rise of noncommunicable or lifestyle diseases.

South Africa requires a preventative health paradigm and system, which is not over-dependent on curative health technologies and interventions. The NHI provides the building blocks for such a system through prioritising and institutionalising a primary healthcare model. It focuses on health service decentralisation through community healthcare workers, school health teams, and district health structures. These institutional arrangements are more suitable for achieving primary healthcare within communities.

This shift towards primary health supports a syndemic health model, which is advanced in the Mapungubwe Institute for Strategic Reflection (Mistra) publication entitled Epidemics and the Health of African Nations. This model connects disease burdens to social, economic, environmental and cultural factors. The current public discourse on NHI overlooks this crucial pillar because of the reductionist debate on fiscal implications and revenue generation.

Third, NHI is crucial for increasing employment and improving working conditions in the health sector. Human resources are at the centre of the health system. Evidence shows that adequate numbers of well-distributed healthcare workers with the right skills mix results in improved coverage of essential health services and an overall improvement in key health outcomes.

Although human resources for health is the biggest single component of the health system, on which more than 50% of health funding is spent, it is often not well planned due to numerous complex and interwoven issues. This reality informs the NHI’s emphasis on the primary healthcare model, which requires additional community health care workers and nurses.

These healthcare workers will be at the coalface in the proposed implementation of the NHI. The pooling of resources, through the NHI Fund, will also improve working conditions in the public health system by providing the equipment and other health supplies required for decent working conditions.

Fourth, the NHI is crucial for addressing challenges that persist in the private sector, as healthcare costs limit access and erode private healthcare users’ benefits.

The Competition Commission’s Private Health Market Inquiry found that three hospital groups (Netcare, LifeHealthcare and Mediclinic) account for 90% of the private hospital market. This concentration of power in the sector makes it vulnerable to collusion. Without much competition, the three major hospital groups dictate price increases for medical aids and benefit from the over-utilisation and over-treatment at private health facilities.

Section 39 of the NHI Bill curbs the private sector supplier-induced demand by setting requirements for service providers and facilities to comply with in order to fulfil NHI fund accreditation requirements. These include treatment protocols and guidelines, which cover medicine prescriptions, health product procurement, and health referral pathways. DM


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