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Why the NHI is clearly a dream that never was nor is likely ever to be

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Professor Alex van den Heever holds the Chair in the field of Social Security Systems Administration and Management Studies at the Wits School of Governance.

Signing the NHI Bill into law will not change the fact that the health plan is doomed.

The world of practical policymaking has five basic prerequisites for success – that is, of course, if you care about the public interest.

First, work from the world as it is and not as you would like it to be. Second, understand your context by doing your homework through research and productive engagements with society. Third, diagnose what is not working with the systematic use of evidence and reasoning.

Fourth, prioritise what to address from the myriad possible issues. And fifth, identify appropriate interventions – again using evidence and reason – that match your capabilities, are aligned with your objectives and are not harmful to the public interest.

The larger and riskier the area of policy intervention, the greater the need for these five prerequisites to be adhered to fully.

It is, therefore, a matter of considerable concern that not one of these five prerequisites has been complied with in the National Health Insurance (NHI) policy process. Instead, it has been characterised by a disregard for submissions and evidence, and an overemphasis on rubber-stamping.

Since 2007, when the NHI proposal first emerged at the ANC’s national conference in Polokwane, to the present, no systematic research has addressed any of the five prerequisites. This is despite convening ministerial advisory committees and spending several billion rands on 11 failed “NHI pilot projects”. The diagnostic is simply a retort: South Africa has a two-tier health system and it should be a single-tier health system.

False assertions

As an alternative to evidence, various ministers, deputy ministers and the Department of Health have sought to motivate this simplistic remark by resorting to false assertions about the performance, sustainability and outcomes of the medical schemes system, in an attempt to bolster the case for an otherwise nonexistent motivation for the drastic NHI proposals.

Such assertions included that medical schemes are on the verge of collapse; that their members run out of benefits halfway through the year and are dumped on public hospitals; that 77% of medical scheme beneficiaries are white; that private health systems are always harmful to the achievement of universal health coverage; that medical schemes are causing the movement of health professionals from the public to the private sector; and that many members face unacceptable out-of-pocket expenses. 

Each of these assertions is false and cannot reasonably be regarded as evidence worthy of consideration. First, medical schemes are solvent, providing coverage to nine million beneficiaries (nearly two million more than in 2005) and showing no signs of collapse. Note, the status of medical schemes is published each year based on audited financial statements, and these reports are provided to the minister of health.

Second, there is no evidence of medical scheme beneficiaries running out of benefits and needing to be “dumped” on public hospitals. It is somewhat surprising that no systematic report exists showing that this is a problem. Contrary to this assertion, major medical expenses are mostly covered as prescribed minimum benefits, which schemes must cover in full. It is therefore impossible for members to run out of benefits. 

Third, the assertion that 77% of medical scheme membership is made up of “whites” is false. Evidence from Statistics South Africa shows that most beneficiaries are in fact “black” and that “whites” make up only about 30%.

Fourth, private arrangements, whether funders or providers, form part of every universal coverage framework around the world. In countries such as the Netherlands, Germany and Belgium, regulated private mutual funds, akin to South Africa’s not-for-profit medical schemes, are responsible for all coverage. Most countries have hybrid arrangements mixing public sector provision with social insurance funds and private funders.

Fifth, there is no official research-based report that demonstrates that the private health system removes any health professionals from public employment. In fact, the only official reports produced indicate that they don’t have adequate data on health professionals in South Africa, whether in the public or private health sectors.

Read more in Daily Maverick: NHI fund will take decades to roll out — we answer your burning questions

Read more in Daily Maverick: Everything you ever wanted to know about the NHI but were afraid to ask

Sixth, according to the World Health Organization, South Africa has the 11th-lowest levels of out-of-pocket expenditure in the world. This outcome is entirely a result of the two large systems of coverage: one offering healthcare free at point-of-service for the majority of the population, and the other the system of medical schemes, where care is mostly prepaid or funded from a pool.

When signing the NHI Bill, the President continued this polarising tradition by arguing irrationally that medical scheme members are somehow privileged and spoilt.

Medical scheme members, however, pay for their own healthcare from their disposable incomes, while at the same time funding about 75% of the public health system. This double payment is logical and it is why South Africa can provide a big public health system together with a sustainable medical scheme system.

Unlike the political elite in South Africa, most medical scheme members are teachers, police officers, civil servants and secretaries. In contrast to the insulting picture painted by the President, this group of law-abiding, tax-paying citizens have to pay more and more for education, healthcare, electricity, property rates and taxes, security and water because of the public sector failures directly attributable to the predatory political elite.

Scant chance of implementation

The NHI proposals and the legislative framework are largely unimplementable, which is why the public is advised that very little will change over the medium term.

In fact, of all the NHI puffery, this inability to implement is the only aspect that is plainly true. Not because the groundwork needs to be carefully laid with millions of well-thought-through milestones and “sub-milestones”, but because the policy framework is unimplementable.

The NHI proposals are premised on the government being able to raise an additional R300-billion in tax revenue, which, even if phased, is impossible. The money is needed as the proposals seek expressly to deny income earners the right to cover their own healthcare, regardless of the ability of the state to ensure adequate access to it.

By kicking the can down the road, therefore, the President plainly seeks to avoid accountability for a stillborn reform that has no prospects of success.

More importantly, if everyone is sufficiently distracted by his newfound pen, he clearly hopes no one will notice the absence of genuine health reforms in both the public and private health systems.

What South Africans really need to know is who the obstacle is to genuine health reform. Powerless medical scheme members? I think not. DM

Professor Alex van den Heever holds the chair of social security system administration and management studies at the Wits School of Governance.

This story first appeared in our weekly Daily Maverick 168 newspaper, which is available countrywide for R35.

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Comments - Please in order to comment.

  • Pet Bug says:

    Really interesting read. Thank you.

  • Gretha Erasmus says:

    Thank you for a very good opinion piece setting out the repeated lies. The biggest lie of the ANC is that any opposition to this particular NHI bill is opposition to universal health care.

    • Andre Fourie says:

      I think the biggest lie of the ANC is that all its manifold failures and catastrophes are a product of “apartheid”, but yes, the NHI obfuscation is not far behind in its vulgar depravity.

  • Wilhelm Boshoff says:

    Excellent! Now that our president found his pen, we should help him look for his reading glasses and his thinking cap.

  • Jeff Pillay says:

    You were silent for years not crutising the imbalances of our Healthcare. Neither did you provide proposals to resolve same. Like a whole lot of privledged elites you now come out the woodwork to critise the NHI cause you believe you privkedge is threatened.

    • Trevor Pope says:

      Not true. Try Googling a bit to see how comprehensively the short-comings have been documented.

    • Andre Fourie says:

      The imbalance between public and private sector healthcare is caused overwhelmingly by a failed government unable and incapable of implementing even the mildest public benefit policies and the rampant corruption of predatory civil servants and their cronies, all of whom will dip into the astonishing wealth of the NHI pot of gold. It’s not a matter of privilege but of principle.

      And Jesus man use a spellchecker!

      • Is there hope South Africa? says:

        As a Christian, I don’t appreciate your last sentence. It would have been better to just say: ” Next time you post a comment, a spellchecker would be a good idea”

        • Colin K says:

          As an atheist, I don’t appreciate your desire to limit the PUBLIC speech of others based on your PERSONAL religious belief.

          Bear in mind any argument that starts with “As a ____” is either a personal opinion or “call to authority” and neither hold water when addressing the substance of an issue.

          Perfectly acceptable in your home, but not as cudgel to police language in public.

    • Casey Ryder says:

      You have no idea how untrue your allegation is. Comments are only useful if the posters are informed. The author has always been a promoter of universal public healthcare (but on a rational, sustainable basis).

    • Middle aged Mike says:

      Where’s the ‘privkedge’ in losing the bulk of your income to tax and then using some of what’s left over to buy healthcare of a reasonable standard?

    • Thinker and Doer says:

      Professor van den Heever has been a very coherent and respected expert from the Wits School of Governance, who has made submissions to the Parliamentary Committees that were processing the NHI Bill, including back in July, 2021, which is on the Parliamentary Monitoring Group website.

    • Zamani Kutta says:

      Where have you been, Ntate Pillay? Articles, public debates, Radio discussions, submissions abound on the NHI issue since the inception of it’s proposal. You shouldn’t have left the woodwork because the denialism tactic – long employed by your comrades, has long lost considerable gas. The veil is off, the curtains have at last fallen and the centre of the once unwavering stage can no longer hold. It’s now time to start collecting sheep’s skin as walking around conspicuously might draw you some trouble.

    • Pieter van de Venter says:

      From the definition by the WHO, the current provincial hospital and municipal clinic system, makes the current system a Universal Health Care system. Unfortunately, we have the ANC cadres sabotaging the health care system and stealing everything that is not tied down with concrete. Look at Tembisa hospital en now the CEO appointment at Baragwanneth. ANC at it’s best!!!

    • Confucious Says says:

      I work damn hard to pay my medical aid so that I can get the best health care available. That’s not elitism! Its unthinkable that you/anyone would rather that everyone is worse off! . Everyone does have access to healthcare, but your dear government destroyed the quality for you. Not the medical aid users!

  • J vN says:

    The fact that the NHI is unimplementable and another cadre wet dream – like their Wakanda fantasies about bullet trains and manned missions with transformed astronauts flying to Alpha Centauri – is of course true. Even somebody as intellectually slow and dim-witted as Ramasofa (and every other halfwit in his intellectually challenged cabinet) knows this. That’s not the point.

    The point is the election. Promising the voting fodder free stuff, paid for by somebody else, easily convinces the backward and uninformed to vote for the ANC. When, not if, when, the Health Wakanda fails, you can likewise bet that Ramasofa and the rest of the lying, thieving, dim-witted cadres will blame imaginary white racists for yet another Wakanda spaceship crashing and burning, and their equally dim-witted voters will fall for it.

    There is, therefore, no downside to the NHI, from the cANCer’s point of view.

  • Sydney Kaye says:

    The fact that the few countries with a free health service are turning to the private sector would also have been investigated if this initiative was taken in good faith.
    The NHI in the UK was formed in 1947 and now 80 years later it is on the verge of collapse. People die waiting for ambulances or they lie on trolleys in corridors. Patients can’t get appointments with GPs. Seven million are on waiting lists for operatic such as hip replacements. Private hospitals are paid by the state to help out. Private insurance which has been taboo is booming as people fear for their health.
    So a simple question would be if a wealthy country like the UK with developed institutions and civil service , with no history of grand corruption, having 80 years of experience in a free health service, cannot make it work, how on earth would the ANC.

  • Just Me says:

    The true obstacle is to genuine health reform in SA is corrupt and greedy ANC politicians.

  • Denise Smit says:

    Thanks for clear well researched info to write the article

  • Geoff Coles says:

    An excellent article. Where does Dr Crisp stand on all this misinformation I wonder.

  • Middle aged Mike says:

    The NHI doesn’t warrant much serious looking into. It’s a kleptocommie gravy pumping scheme cooked up by the same people who gave us the arms deal and our existing state medical services.

  • Ompaletse Mokwadi says:

    Accusations and counter accusations are not very helpful for people in need of medical aid. So, what needs to be done s that health care is available and covers all and sundry?

    • Pieter van de Venter says:

      But the current system DOES cover ALL and Sundry. Except, of course, when nurses demand R 4,000 bribe to move your name to the top.

      Mr Mokwadi, you made the statement – please tell us who is South Africa IS NOT covered by the current public health system??

      Will you also support a bill that orders ALL citizens to only buy I10’s and only politically connected people can buy Q7 or Merc 500’s? Because this is what Ramasofa signed last week.

    • Andre Fourie says:

      People in need of free medical care should stop electing thieves and criminals to positions of power. The ANC has shown countless times that it is in government to enrich itself, not “Build a better life for all” as its election posters cynically claim. Stop electing the ANC to government, choose qualified, honest public servants, close the corruption taps in the healthcare sector (and every other sector for that matter) and insist that your representatives in government spend the limited tax money at our disposal wisely.

      You may just see a total transformation of our healthcare facilities, and better care for every person that visits a hospital or clinic. But that’s all a dream with this bunch of thieves in power.

    • Deon Botha-Richards says:

      A very simple solution is for government to allow the private sector to offer the low cost medical aid it has proposed. But the same government that proposed an unworkable NHI is vehemently opposed to low cost medical aid that could cover the vast majority of the population.

      • Richard Blake says:

        That’s is because the ANC can’t loot low cost medical cover. The NHI is cut and paste. It has nothing to do with universal health care. It is about looting.

  • Jon Quirk says:

    If the President was seriously concerned about the debacle that is the public healthcare “service”, he would appoint somebody like Professor Alex van den Heever, to Minister of Health to ensure maximum benefit and efficiencies from the R282 billion spend; however, it is more likely that the hyenas that ripped off the Covid relief funds, will again be in charge – and the extraordinary thing is “our Pres”, expects different results!!

    • Middle aged Mike says:

      He most certainly does not expect different results. Whatever he is it isn’t stupid and he knows precisely what will happen and who will benefit. Remember when he told us that the COVID money wouldn’t be looted?

  • Henry Coppens says:

    We need to realise that the NHI has NOTHING to do with the health of the nations’s citizens. The ANC could not care a whisker about the public. It is all about following the ideology in the National Democratic(?) Revolution to enable an elite to continue to loot and steal, to ensure that everything is under state control – for this very reason, and in so doing quell an anathema of socialism/communism, that of a thriving private entity, even though it actually happens to be the best in the world, yes, it is, and takes a huge burden off the state.

  • Thinker and Doer says:

    Thank you, Professor van den Heever, for your very helpful and insightful article and analysis on this critical legislation and policy.

  • Pieter van de Venter says:

    Very well laid out Prof.

    My main objection to Ramasofa’s approach, is the absolute disdain that the pres treats tax paying working people of this country. Because we have work (either in a full time job, or running your business) we a despised as “white and scum”. This should lead to a total withholding of ALL tax payments. It is also the same pool, that pays their municipal accounts. Unlike the ANC politicians, we as working people, cannot fly off to Russia, Thailand, Singapore or Cuba for treatment. We are stuck with what we have.

    How I spend my income (after the SARS theft), is surely my choice. What will the communists in the cabinet try to control next? Again Patel telling us we cannot buy long sleeve t-shirt? Surely, it is my choice – not Ramasofa, Phaala or any other unqualified talking head to tell me what to do with my money – after tax.

    Must be Bell Pottigenger in high gear again.

    BY the way, why do we still have this expensive window dressing called “Public Participation” when both certain groups in parliament and the unelected body of traditional leaders just ignore the outcome of the public views on bills?

  • ST ST says:

    Agree on a few things but I take some of this with a couple of pinches of salt, seeing that I’m speaking from personal experience (v scientific data). And your credentials are quite impressive.

    I know people who have actually been told they can’t have anymore funds. One had been paying for over 30 years and then had to pay out of pocket after a month or so of treatment. It may depend on the scheme or package. For for-profit, the bottom line is watched, or generally cost-effectiveness also gets into the mix. Somethings they just won’t pay for or pay to a certain amount. Even overseas e.g UK, people do reach a point where their private payer will stop and then go back to public healthcare. So, never running out of funds seems implausible.

    Medical scheme members pay from disposable incomes? no subsidies from government/employers? As far I know government subsidises employees. And yes, there is double paying. People can’t afford it. Private should be an add on.

    Unless private providers train their own staff, the taxpayer and therefore public purse trains healthcare staff, academics etc. And they leave for private, overseas etc

    The WHO study, will be interesting to see. Wonder, does it take into account that a potentially significant portion of SA may use traditional/spiritual healers or avoid hospitals/clinics, or give up as they know they cannot afford care?

    I will agree on the implementation challenges and the lack of proper assessment and planning for the NHI.

  • Colin Braude says:

    NHI = Life Esidimeni and Digital Vibes on steroids.

  • Karen G says:

    Excellent article thank you.

  • ST ST says:

    Also…I wonder, is ~30% “white” medical aid holders equally to ~100% white population? Where the other races in the remaining 70% or are they all ‘black’. Not making it about race, just asking based on this assertion

  • drew barrimore says:

    Spot on. Thanks.

  • Peter Lor says:

    I agree with most of Professor van den Heever’s logical and well-formulated assessment. I agree that the proposed NHI is not feasible and unlikely to come off the ground. However, I don’t think our private medical schemes are al they are cracked up to be.

    I’m 78, a pensioner, with medical conditions typical of my age group, and a member of a major medical fund. Due to rising costs I had to downscale my option, which is now roughly in the middle of the spectrum between executive and basic. The premiums now take more than 10% of my net monthly pension — and that is after subsidization by my former employer. In addition, for about four to five months of the year I’m in a “self-payment gap” of around R15,000. During this period I have to pay certain costs myself, including the cost of chronic medications which for some reason are not on the list of prescribed benefits. Trying to get explanations from the scheme’s byzantine automated system is a nightmare. The patient falls between the cracks separating my GP, my pharmacist, and the scheme.

    Ultimately, in the unlikely event that I should live for another ten years I will be unable to foot the ever-increasing bill and I will be mighty grateful for government-supplied health care.

    The government’s NHI will not work, but the private medical schemes could do with an overhaul too.

    • Hidden Name says:

      You are not wrong – the overcharging of members by medical practitioners is well documented. Some (certainly not all) providers will bill the funds for as much as they can legally get away with. Its an ugly reality – and its typically the elderly or infirm who are taken advantage of. Sadly, greed isn’t limited to politicians. Note: the medical aids do actually curtail a lot of this sort of behaviour and of course are fairly good at finding fraudulent providers (either medical practitioners or pharmacies) so they help quite a bit.

  • Reginald Broekmann says:

    It is possible to develop a National Health system using a different approach. Based on the referral system research done in KZN, it would be possible to organize health services into units based on regional hospitals with a formal referral process which controls the movement of health care seekers from community health workers up tertiary level services. Where shortages in this system occur, services could be bought in from the private sector. This would permit the development of each health hub within a defined budget, starting in the areas where health care is most needed and least available. Private sector involvement should be on a long term conract basis which would allow the private sector to invest in the areas where services are most needed and could attract health personnel within these long term contracts. As the hubs develop, additional hubs can be added and lessons learned can be applied in the new hub. This would allow for controlled development of the health system over time but could begin immediately with benefits to the most need areas being felt immediately.

  • TS HIGGO says:

    I strongly recommend that Cyril sees a neurologist to check for any signs of life above neck level before the private health care system is dismantled by the ANC

  • Peter Vlietstra says:

    For a Constitutional Court challenge to suceed, clear contravention of the constitution need to be proved. Unfortunately the constitution is not against stupidity.

  • Confucious Says says:

    According to my staff, under apartheid, they could still get medicine and treatment, al beit through a different door at the hospital. Nowadays, they can walk into the front reception but there’s no damn medicine or doctor to see! There’s no condoning apartheid, but more, to illustrate how useless the anc is!!

  • Terrance Magoro says:

    Professor, while you may find contentment in South Africa’s 11th ranking, I find it wholly unsatisfactory. Why should we settle for 11th place when we have the potential to rank first or at least fifth? It appears that you are being compensated to propagate narratives that undermine equality, and I must vehemently oppose such efforts. The findings of the Health Market Inquiry conducted by the Competition Commission are unequivocal regarding medical schemes. Benefits options lack standardization, and many medical scheme members exhaust their benefits and resort to public healthcare services. We witness this every day: private hospitals refer to these individuals as “state-funded patients” and routinely transfer them to overburdened public hospitals, often when they are on the brink of death. Even at the primary care level, immunization services are provided free of charge to many medical scheme beneficiaries. Medical aid primarily serves administrative purposes rather than prioritizing patient care. Furthermore, several principal officers of medical aids receive remuneration exceeding R5 million per annum, and it is evident that your advocacy serves to protect such interests. Moreover, the Health Market Inquiry exposes issues of market concentration and the co-ownership of private hospitals by administrators of medical schemes. Your recent research findings lack objectivity and fail to meet ethical standards, rendering your academic credibility questionable.
    Sincerely, TR

    • Andre Fourie says:

      Phew! Where to start?

      Firstly, “objectivity”, “ethical standards” and “credibility” are all absent anything to do with the Competition Commission, a blunt instrument with which a failing government attempts to legitimise its failed and failing policies.

      Secondly, do you honestly suggest that a country with the world’s highest unemployment rate, highest murder rate and among the highest recorded instances of corruption – especially in the public sector – should rank #1 GLOBALLY for the lowest out-of-pocket medical expenditure? What are the economics underpinning your suggestion? More tax of the middle class – as the NHI invariably would demand – or is there some magical pot of gold you intend our government to access. And not only access, but apply with integrity and honesty to fund public healthcare? Based on what evidence? In every measure our government breaks more than it builds, spends more than it earns, and steals everything that isn’t nailed down. Soon it will start stealing the nails too!

      Medical aids play a vital role by protecting healthcare – both providers and seekers – from the largesse and incompetence of a ravenous, predatory government hell-bent on destroying what little is left. Is your suggestion truly that we find ‘equality’ in healthcare not by raising the standard for all, but by dragging us all down the dark pit of the ANC’s incompetence?

      No thank you. The prof is correct, and his academic credentials intact. Your argument: not so much.

      • Terrance Magoro says:

        It appears that you may not be fully informed on this matter. Firstly, the professor was commissioned and compensated to investigate claims about medical aids nearing collapse and membership demographics by race, which he did not disclose. If you had conducted some research, you would be aware of the importance of objectivity and ethical considerations. While I don’t have the opportunity to explain this fully here, I’d be happy to discuss it further if you reach out. Additionally, nearly R22 billion was lost to corruption in the private medical sector over the past two years, a fact you seem to have overlooked. Given these points, it might be best to gather more information before commenting on such complex issues.

        • Andre Fourie says:

          “Nearly R22 billion was lost to corruption in the private medical sector over the past two years.”

          Cite your sources and I’ll gladly take a look. At the moment this seems to be an attempt to deflect from the ongoing catastrophic corruption in the public healthcare sector by creating an impression that the situation is similar in private healthcare. Which would be astounding as private healthcare providers have to be profitable and sustainable, whereas the public healthcare system merely requires the state to continue milking a shrinking, overtaxed base.

          • Terrance Magoro says:

            As I mentioned earlier, this discussion seems to be somewhat challenging for you, and you may be commenting on a topic you might not be fully familiar with. I urge you to read up on the subject to avoid making uninformed statements.

            Have you heard of the Council for Medical Schemes? Here is a brief summary of their recent report: At the last Fraud, Waste, and Abuse (FWA) Summit, the Council for Medical Schemes revealed that the healthcare sector incurs losses of between R22-28 billion per year due to fraud, waste, and abuse. Some estimates place the cost to the industry at around 15% of all claims due to these issues.
            TR

    • ST ST says:

      Thank you TR for this and the below.

      Now here’s something that rings more true about the limits to benefits and reflects the lived realities of some if not most privately insured, whether they admit it or not. Admitting in public may not be very fashionable especially when trying to (or programmed to?) associate anything to do with ANC with bad.

      Healthcare is expensive because of the cost of supply and demand of care itself. But also profit. It’s either you pay the shareholders and administrators or you support a more equal system. The public sector is costly but at least it will take you to all the way. The private sector will limit their costs when it threatens profits and bloated salaries. Those who support private healthcare can be proud of this and take solace in it when sent packing before well enough

      The non profit public sector when it works better eg., EU/UK cares more about your wellbeing. Their costs rise also because of the contribution of the commercial industries to disease, and the costs the very same industries levy on the healthcare systems with their ‘healthcare innovations’ created by publicly trained scientists. Disease caused at industrial level but costed at individual level, paid for by the public one way or another. No downside for commerce. They can strangle and cannibalise public healthcare and then use its struggles to justify why ‘socialised’ healthcare doesn’t work!

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