Business Maverick


The full implementation of NHI will cost the nation R1-trillion


Leon Louw is the CEO of the Freedom Foundation. He is the former CEO and Founder of the Free Market Foundation.

If genuine insurance were decriminalised, this would be a far better framework to provide quality healthcare for all, a goal on which all decent people would agree.

President Cyril Ramaphosa has been asked by Parliament to impose an unaffordable R1-trillion National Health Insurance (NHI) bill on the nation. This is the conclusion of Freedom Foundation research. 

This frightening prospect is now sitting on the President’s desk awaiting his signature. The nightmare scenario for citizens and Treasury developed after the National Council of Provinces passed the NHI Bill on 6 December, ignoring amendments and warnings proposed by thousands of stakeholders.  

This NHI cost analysis shows conclusively that NHI, as proposed, would be too costly to implement. At best, there might be a slow, half-hearted and partial implementation. 

Statistician Garth Zietsman, lead researcher and co-author of the report, said, “Until this study, there has been no published attempt at a comprehensive costing. Many estimates have been suggested, but there has been no detailed calculation. This is partly because no one knows what would constitute full, partial or incremental implementation. 

“Since no one knows what NHI implies, my research is modelled on plausible scenarios and the conclusion is that ‘full’ implementation, taking into account all possible elements of NHI, could cost R1-trillion.” 

The Bill does not propose healthcare “insurance”, but a financing and single-supplier mechanism resembling the failed Eskom model, to implement profoundly flawed and doomed healthcare policy. 

If genuine insurance were decriminalised, this would be a far better framework to provide quality healthcare for all, a goal on which all decent people would agree. 

Paradoxically, it proposes the prohibition of insurance. Real insurance would be achieved if unambiguous private healthcare insurance were fully decriminalised. That would make healthcare more realistically affordable for government, better quality healthcare for all, especially the poor, and more expeditiously achieved. 

Under properly defined healthcare insurance, the government would require all people who can afford it to insure themselves, and subsidise private cover for those who cannot (on a means test) afford it.

A payroll tax has been proposed. 

Zietsman says, “That amounts to saying that there will never be NHI. Such taxes could raise no more than enough for minor improvements to the already existing universal healthcare system as opposed to anything remotely resembling what has been promised. 

“No systematic study has been done on the substantial damage of such a tax, especially for the poor.”

One of the substantial, yet unmentioned, NHI costs will be lost taxes from those parts of private healthcare that are replaced, banned, curtailed, nationalised or government-funded. 

This additional cost, which must be added to every estimate, is estimated at R57-billion.

The report’s conclusions show that there is no plausible scenario under which NHI could happen. It would consume nearly half the annual Budget or a quarter of the entire economy (GDP). Lower figures that have been published are optimistic underestimates.

South Africa already has universal healthcare in that everyone is entitled to a limited range of government-funded care. What is proposed is unclear, undefined and unknowable, including to the current policymakers. 

What is done in practice under NHI as proposed will be determined arbitrarily by the present and future unknown ministers.

Zietsman agrees, “This analysis addresses these and other core concerns. Real-world ‘healthcare’ includes everything that ordinary people regard as caring for their health. The cost of comprehensively defined excellent healthcare as understood by civilians would substantially exceed the highest estimates so far.”

Louw said, “The NHI Bill is not substantive law since what is to be done is not in it. That will, as stated in the report, be decided arbitrarily to unspecified and unpredictable extents on unknowable dates, if ever. It is not possible to know from the Bill what would constitute partial, incremental, or full implementation, nor even what constitutes ‘healthcare’; what it includes and excludes.” 

Therefore, this in-depth analysis considers everything that ordinary people regard as caring for their health.

When it suits them, government officials will tell us what is in and what is out, how and by whom it will be delivered, and thus how hundreds of billions, if not a trillion, might be raised or avoided. BM


Comments - Please in order to comment.

  • Brett Redelinghuys says:

    This is plainly an election ploy.
    1/ as stated we have NHI already
    2/ but ANC has broken it
    3/ So they trying to sell a dream and say “we did this”.
    Starve their argument (and bill) of oxygen. Vote “YES” for the bill and then ask these idiots to implement it… Let them fail yet again. To vote against just gives the moral strength as they can BS the voters.
    Like the second coming of Christ (as predicted by Zuma), NHI can never actually be implemented because these clowns don’t know how (see lack of any detail in Bill) AND their only experience is to break what’s already working (see existing healthcare deterioration since 1994.
    Vote YES for the bill, then kill it when ANC is kicked out in next or 2028 elections.

    • J vN says:

      You’re right about it being an election ploy. Even the dimmest ANC cadre – the galactically dumb and obtuse Cde Nicholas Crisp springs to mind – must know that the NHI is an unachievable communist wet dream. Treasury is clearly not interested in this folly and has kept silent about funding this idiocy.

      This doesn’t mean that the NHI’s failure won’t benefit the ANC. It is a racing certainty that, when it inevitably fails, imaginary racists and especially the private sector will be blamed, and this will in turn be offered up as a weak excuse not to privatize Eskom or SAA.

  • Confused Citizen says:

    How is it government’s business what products/services I buy with my AFTER TAX money? Why is government crying about what people spent their money on in the private health sector? They should stop calling each other comrades and start implementing policies that will grow the economy. That will raise tax collections which can be used to expand training hospitals’ budgets so that more doctors and nurses can be trained. They should stop corruption in the public health sector. Lastly, provide all females over 15 with free birth control at any pharmacy, not only at state clinics. We do not have enough water and health services to support the growing population

    • William Kelly says:

      So sweet. You naively think your after tax money is yours? Bwaa haa haa! Not any more it isn’t. Hasn’t been for a long time. By the Tim you snuff it, 95%of every thing you have ever earned ends up in the hands of the State. All they’re doing now is stealing more from you whilst you are still alive, safe in the knowledge that the soon to be dead, i.e. you, cannot fight back from beyond the early grave NHI is dooming you to.

  • Beyond Fedup says:

    There is nothing more destructive on earth than an African liberation movement when it comes to power, as history has so clearly demonstrated many times over. Instead of maintaining standards and raising the bar for all, or aka, not throwing the baby out with the bathwater, they break, steal and destroy the country. The vile anc has taken this to new depths of depravity as they are intrinsically, criminal, corrupt, parasitic, hypocritical and predatory. Everything they lay their grubby and rapacious hands on becomes an instant failure, leaving poverty, misery and a wasteland behind. This NHI is nothing different – just a cheap election ploy, much like the thief-in-chief Zuma did with free education and is doomed to fail. Civil society, the private sector etc. must rise up and contest every inch of this mirage.

  • Willem Boshoff says:

    It’s time for a proper stand-off between the private sector and the government. We cannot pretend we’re on some kind of middle road anymore; the government is progressively taking the low road. The writing’s been on the wall for Eskom, Transnet, SAPO, SAA etc. for some time but instead of doing the right thing and privatizing they forge ahead to bring more critical services under their NDR philosophy.

  • Rosemary Blazeby says:

    Before Ramaphosa signs he should be subject to Q and A from specialists. He is paid for educated signatures not factional biased. The contributing public should have a vote . We already pay sick benefits for the needy. We are a lot more giving until pushed around by fools and suffer costs by medical aid contributing thieves. Medical aid already are taking advantage and way behind on medical costs snd inflation.

  • Rosemary Blazeby says:

    Ramaphosa and cohorts will will go to uk and America for medical treatment. This should be banned entirely. And if caught using western world medical they must be fired and jailed

  • Jo Van says:

    No medical practitioner will be paid for services by the NHI which will compel them to up and leave to make a living somewhere else. Health services in the country will implode completely and the corrupt cadres will channel the money to themselves leaving nothing for us, the people. If Cyril signs this bill he will prove himself to be the idiot we have started suspecting him to be. We’ll have to stop this nonsense in the constitutional court.

    • Michael Thomlinson says:

      A quick discussion with my GP revealed his thoughts: Dozens of young doctors will leave along with specialists if this idiotic NHI is implemented as there are better prospects overseas. At the moment, contrary to popular belief, we do have very competent doctors in the public health system but they are over worked and not not given the support that is due to them. The NHI will only exacerbate this and they will ultimately up and leave. Where will this leave us SA folk? Up the creek without a paddle while the ANC comrades fly themselves off to Russia or Europe for medical treatment.

  • Kenneth FAKUDE says:

    If only this government was reliable it will be a good move, we pay taxes for them to administer and offer sound health services, the medical aids exploited this gap and they charge us more than what we need to put food on our tables forgetting medicine will not work on empty stomachs, same like education the government failed private schools are ripping us off, education should be a free necessity to build the economy, we buy import things we should be building and china is laughing all the way to the bank

    • Ben Harper says:


    • Matthew Quinton says:

      Even if the government was SUPER reliable… the NHI would fail dismally.


      Because it is a mathematical impossibility to deliver services in a country where only 10% of the country pay tax

      No matter how cleverly you budget, there not enough tax being paid by that small fraction of people to cover the services.

      Here’s the bad news Kenneth.

      For the NHI to work, we have to dial back to 1992 and focus on education…

      then by around 2002, when we have a batch of educated matriculants, we can start to grow employment levels.

      Fast forward to around 2005, and that new batch of educated matriculants will be earning and paying tax.

      So… maybe 2006 or 2007 there would be enough tax flowing into the system to think about NHI.

      But… it’s not 1992, and the ANC has screwed the pooch so hard that in order to even get our country BACK to where it was in 1992 when the evil Nats and all their horrible working infrastructure were removed will take around 10 years of construction and several Trillion rand.

      So, conservatively, and based on the assumption that the masses are willing to take a short break from breaking shit, we need a MASSIVE interest free loan from somewhere else, then we need 10 years of hard building, during which the masses need to fight the whole steal/burn/break urge… THEN we can start again with education and finally income and finally NHI..

      BEST case scenario we should have the finances in place to afford the NHI around 2045

      • Kenneth FAKUDE says:

        unfortunately very soon we will not even have a country or organisation that will trust us even with a high interest loan, imagine stealing money on the eve of a pandemic that was threatening the whole country and that was a loan from the IMF if my memory serves me right, i was shocked when the finance minister suggested some form of tax for more money knowing all forms of taxation have been exhausted, drive to Limpopo you pay a toll gate after a few kilometres you pay another on the same route without even a town in between, vat went to 15% during the Guptagate even a new party taking power is set to fail but with our patience for abuse i think we can manage until such committed people get things right, although to get the number of votes will be an uphill, history shows that the more you push people to poverty the more they appreciate the mere grants and keep voting for you

  • Tom Boyles says:

    Kind of hilarious reading how the Right wing tie themselves in knots over NHI forgetting that they are a tiny minority. The 80% of people who don’t have private medical insurance will only benefit from NHI even if it is imperfect. So from a democratic point of view it will always be a winner. The opinion of the rich Right wing is so irrelevant.

    • Garth Kruger says:

      the 80% are in the public system anyway so nothing will change there, Tom. The rest who currently pay will be forced into the public system which makes no sense. Why destroy the private system? Plus: I’m not sure this has to do with right wing or left wing. The NHI will become a feeding trough for corruption.

  • Hello There says:

    It’s comical every time a thoughtful analysis published regarding this or the other ANC policy, proposing a rational argument based on evidence and some inherent logic.
    You are trying to beat the ANC in a game they are not playing. The private sector is in cahoots with a kleptocratic government because it implements every rule and regulation dutifully, because that is the game they play and they assume the government does too, irrespective of how moronic it actually is.
    It’s much better to assume that everything the government does is to enrich itself and a few connected cronies – and start behaving accordingly…

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