Everyone is talking about the National Health Insurance (NHI). How close is South Africa to a national health insurance?
On 8 February 2024, President Ramaphosa discussed NHI in his State of the Nation Address (SoNA).
Craig Comrie, Principal Officer and Chief Executive of Profmed, weighs in on the intent behind national health insurance, how it will be funded, and what concerns still need to be addressed as the NHI draws closer.
“Both President Ramaphosa and the Department of Health (DoH) have clearly stated that the purpose of a national health insurance is to improve both the quality of healthcare and equal access for all South Africans,” says Comrie. “It is a strong, powerful intention that will improve lives. According to the DoH, national health insurance will provide better healthcare for everybody at a much lower cost, and that cost is going to be absorbed by the taxpayer. In fact, the DoH indicates that people shouldn’t be required to pay anything as they access health services.”
Implementing something as complex and far-reaching as national health insurance takes time and a large investment of funds. According to President Ramaphosa, government plans to incrementally implement the NHI, dealing with issues like health system financing, the health workforce, medical products, vaccines and technologies, and health information systems.
A look back at the NHI journey so far
The NHI journey began in 2007. Government began moving away from social health insurance, and in 2009 South Africa began investigating a National Health Insurance Programme. This would require consolidating all of South Africa’s abilities to purchase healthcare into one pot. Consultations began, and soon the NHI Bill was adopted by Parliament. It was then moved to the National Council of Provinces, where it is was debated and approved despite inconsistent feedback from legal advisors that the Bill may be unconstitutional, and is now with the President, who has indicated that he will sign the National Health Insurance Bill, although he has not yet committed to a timeframe.
“As both the Profmed Board of Trustees and as a medical scheme, we made submissions to the National Council of Provinces regarding aspects of the bill that need to change for us to accomplish the intent or the promise that I initially spoke of,” says Comrie. “At Profmed, we are paying close attention to what politicians, funders and key stakeholders are sharing, while we continue to ensure that we safeguard the rights of our members balanced against the rights of uncovered South Africans who should all benefit from these reforms.”
For example, in 2013, then-Minister of Finance, Pravin Gordhan said that the pace of the NHI’s implementation was slower than expected. This was because new policy initiatives such as the NHI would only be affordable if South Africa succeeded in driving growth towards 5% a year, and government revenue doubled in the next 20 years. 11 years later, and growth has averaged below 2%, with 2023’s GDP achieving 0.6%. South Africa’s economic growth lags far behind the necessary growth required for such a huge change in the healthcare system.
“The intent for a better healthcare system for all needs to be funded,” says Comrie. “We have a burdened tax base that is shrinking; our economy hasn’t grown in the right way. We need to find alternatives in terms of how the universal health system is implemented. And so, it’s important to understand what all the different stakeholders in this space are saying.”
Currently, medical schemes are looking after a small group of members within South Africa, however, as Comrie points out, medical schemes exist to look after their members’ interests. At the national health debate level, schemes like Profmed are commenting, engaging in influence, and, when necessary, will constitutionally challenge the bill in terms of how it eventually gets implemented.
Deputy President Paul Mashatile indicated in 2023 that there are those who feel the NHI will affect medical aids and that there are many conversations and consultations that still need to take place before national health can be implemented.
Dr. Nicholas Crisp, the Deputy Director General at the DoH and assigned to implement national health insurance, has been a passionate advocate for national health insurance, but he also says you cannot switch on reforms of this magnitude in a short space of time.
“The Bill will be signed by the President imminently, but it is going to take decades to implement the NHI, and during that time we will be able to shape and influence how national health is implemented,” says Comrie. The reality is that there is still a lot to be considered, starting with practical steps of where the funding will come from in a low growth economy. South African Finance Minister Enoch Godongwana has even indicated that the NHI may not be the best solution to this problem and that a better solution might be investing more in upgrading our hospitals and our infrastructure to make them more attractive to everybody. Funding is, and will remain, an issue that needs to be solved, but there are other important issues that need to be addressed as well.
“One of our major concerns at Profmed is how the number of our doctors and specialists has regressed over the last 10 years; there is 0.8 of a doctor (less than 1 whole human being) for every 100,000 people in South Africa. Most developing countries have more than double the number of doctors that we have. The developed world sits with more than five times the number of doctors. These same countries still have shortages of doctors since the pandemic, and they are aggressively recruiting our doctors and specialists to solve their shortfalls. One of the biggest gaps in the current NHI Bill is a retention strategy keeping doctors and specialists in South Africa. We also need to produce more doctors and specialists here and retain them before we can provide broader-based access to healthcare in South Africa.”
According to Comrie, Profmed’s concerns can by summarised into these key points:
- How can South Africa fund a national health system when the country has such a low-income base and the economy is not growing?
- How do we grow the doctor to person ratio in South Africa? Strategies to recruit doctors from other African countries hasn’t worked in the past. We have to train and educate doctors in South Africa for South Africans.
- What is the role of medical schemes in terms of a partner approach in how we achieve universal healthcare? A national healthcare system must cater to every South African, improving access to and the quality of healthcare services across South Africa.
“These are important discussions, but national health programmmes take decades to design and implement. We will continue to monitor and contribute to discussions, contributing towards a national health system that benefits all South Africans.”
