OPINION | The pros and cons of the National Health Insurance Bill

Universal access to healthcare and the ideal of a national system of health insurance are important concepts which relate directly to core human rights and as such are noble and necessary. However, as is often the case, an ideal may be fine in theory but fall short when it must be put into practice.

The National Health Insurance (NHI) Bill is no exception, and many concerns and critiques have been lobbied at the bill and its implementation, ranging from the migration of hospitals to semi-autonomous entities, the structure of the contracting unit for primary healthcare needs, establishment of the fund, the Health Patient Registration System, accreditation issues, purchasing of services, the amendment of other pieces of legislation to make room for the NHI and payment concerns.

Thus far, satisfactory solutions have not been offered to all these problems. For the NHI to be beneficial to all and truly live up to its potential for betterment, it should not be rushed.

Background

The provision of universal access to healthcare has long been envisioned by not only the constitution, which states in section 27 that everyone has the right to access to healthcare, but also by the National Health Act, which in its preamble declares an aim of the act as providing for a framework for a structured uniform health system within the Republic. The NHI bill is the manifestation of this statement.

The bill aims to ensure all South Africans have access to quality healthcare services and to provide for the establishment of a fund which will be used to pay for almost all medical treatments from accredited providers with rates to be determined by the state. Private health insurers will thus only be able to pay for treatments, health products and services not covered by the fund.

This bill, however, has from inception been contentious and has been fought against from the start. This is seen in the fact that a mere two weeks before the passing thereof in the National Assembly, the South African Medical Association rejected the bill in its current form. There have also been multiple court cases launched against the bill, and different voices have been raised against it.

In spite of this, the bill will most probably become law in some shape or form at some point in time, and it is thus pertinent to examine that which it espouses, national health insurance, as this concept is noble at its core, and the achievement of a more equitable society in context of access to healthcare.

Advantages of national health insurance

Proposed and hoped-for advantages of the system include:

• Lower overall healthcare costs by having the government determine and control the price of healthcare and by decreasing administrative costs.
• Finite determination of costs related to healthcare procedures with no unexpected costs or depletion of medical aid benefits.
• Potential improvements in healthcare due to higher standards being set for hospitals and clinics.
• Possible improvement in available services, hygiene and safety in public hospitals.
• The removal of health-related barriers to education for children with undiagnosed or untreated health issues.
• Stimulation of the economy by allowing for a healthier workforce where the NHI provides for preventive care. 
• Better salaries for medical practitioners in the public sector.
• Improvement of social security by, for example, preventing future social issues such as crime and welfare dependency.
• The promotion of equality by removing barriers to healthcare based on the ability to pay.
• A real attempt being made at the progressive realisation of socioeconomic rights and an addressing of the inequities and scarcity of healthcare resources.

Disadvantages

Disadvantages of the system include:

• A blow to autonomy, as all South Africans will be forced to make use of NHI, regardless of whether they want to.
• The healthy paying for the sick and increased burdens on taxpayers.
• Uncertainty and vagueness surrounding the financial aspects of the NHI.
• A decrease in financial incentives to be healthy and to remain healthy.
• Unemployment could rise as those previously employed by medical aid schemes may be retrenched due to whole departments of these enterprises becoming redundant.
• Medical practitioners will seek greener pastures and more financially lucrative employment overseas, leaving South Africa with a human resource deficit in context of healthcare.
• Long waiting times for elective procedures as the primary focus of the NHI will be directed towards basic and emergency healthcare.
• There may be fewer healthcare facilities and providers due to an uncertain system of accreditation.
• A decrease in the quality of care provided.
• Uncertainty regarding what will be covered by the NHI and what will not.
• The NHI may be seen to be political pandering rather than a real-life workable and practical system.
• NHI necessitates confidence by the people in a system under governmental control.
• The potential for corruption and misappropriation of funds.

What does it mean for South Africans?

The current two-tier system of healthcare provision has not sufficiently catered for good quality healthcare for all. This system has precluded the poor or those without medical aid from accessing a large number of health professionals, services and facilities. NHI will establish a single pool of healthcare funding for private and public healthcare providers and will pay both these providers on exactly the same basis while expecting the same standard of care from them.

Overall, a system of NHI may impact South Africans in the following manner:

• Access to healthcare could be improved for those who previously faced barriers due to financial constraints or geographical location.
• Healthcare could become more affordable as the NHI aims to pool funds to provide affordable healthcare services.
• Healthcare service delivery will be affected as the NHI fund will be responsible for purchasing services, which may result in changes to how services are delivered, organised, and managed.
• Equity in healthcare will be promoted.
• Healthcare quality will change due to the emphasis on “quality” care, which will necessitate increased scrutiny on the quality of healthcare services.
• The NHI may require changes to the healthcare workforce, which may include changes in the demand for these practitioners, their roles, and responsibilities as well as their training, retention and distribution across the country.
• Healthcare governance will be restructured, with the NHI fund having set powers and functions while policy-making, regulation and accountability will also be affected.

For South Africans without medical aid or in lower income groups, the NHI will be beneficial as it will offer more equitable access to healthcare services and will allow for these people to consult private healthcare practitioners and make use of private healthcare facilities and practices with the NHI footing the bill.

Not only will it provide health insurance to those not a member of a medical aid, but the NHI purports to improve the resourcing of public hospitals and healthcare services as the burden of care will be more evenly distributed.

For South Africans who do have medical aid, the NHI may be a shock to the system. Those who are accustomed to private care may have to settle for lower standards while continuing to pay a similar or higher fee.

South Africans within a certain income bracket will have to make mandatory monthly payments towards healthcare in addition to carrying a higher tax burden.

Implications for medical aid schemes

Once the NHI is implemented, medical aid schemes will not be able to offer any services offered by the NHI and will only be able to provide for “complementary or top-up cover” which does not overlap with that which is provided for by the NHI. South Africans will be able to use their free NHI cover for healthcare needs and no co-payments will be charged.

The bill does provide for gap cover, but the relevant section of the bill is greatly understood and interpreted as meaning medical aid schemes will cease to operate since current members will be obligated to make use of their NHI.

Arguments have been made that negating and destroying the role of medical aid schemes is counterproductive to universal healthcare as there simply are not enough resources to meet the needs of all South Africans and that limiting the right to choose to purchase health insurance is unprecedented, inappropriate and might even constitute a limitation of rights similar to making use of private education or private security.

The private sector, for now, will not be nationalised and as such, private practices, pharmacies and hospitals will continue to be available — and South Africans will be able to register with their preferred healthcare provider.

Dr Larisse Prinsen is a senior lecturer in the department of public law, University of the Free State.

• This article was first published in July 2023 on TimesLIVE