Health professionals this week warned of a looming disaster in SA's already shaky public health service after the government published its long-awaited master plan for free health care for all.
Eight years after the plan was first officially proposed, it emerged this week that the government still does not know what it will cost, whether there will still be a place for private medical aid schemes or, crucially, whether patients will still have a say over which doctors they consult and which hospitals they are admitted to.
What the National Health Insurance (NHI) Bill does say is that the health minister will be given extraordinary powers to make regulations over the private and public health sector, including which medical practices and procedures are used, how much input medical aids have, how NHI funds are invested, how much doctors will be paid and how private-health services will be used.
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The NHI will essentially become a state-owned entity with an annual budget that could top R450bn.
These wide-ranging powers will create a "capturable governance structure", according to Wits School of Governance professor Alex van den Heever.
"It concentrates power in the hands of the minister. He appoints everyone to the NHI fund and the Office of Health Standards Compliance.
"To date no minister has been held to account for state capture. So what will be different here?" asked Van den Heever, who said the bill "centralises what it should decentralise, and is fiscally absurd".
"The pilot projects cost R4bn, achieving nothing. The department of health has a consistent history of failure."
Apart from references to extra taxes on individuals and companies - against a backdrop of record high unemployment and a stagnant economy - no indication emerged this week about what the plan will cost.
Economists questioned whether SA can afford the plan, amid suggestions that the government may soon have to approach the International Monetary Fund for a bailout, especially if ratings agency Moody's cuts SA to junk status this year.
A senior National Treasury official invited to welcome the bill at its release in Pretoria on Wednesday had left the building when health officials called for him to give input.
Among the concerns raised are:
- Renewed fears about mass emigration of doctors and other health professionals, which would kill any health plan that relies explicitly on there being more doctors;
- The refusal to allow the private sector a role in managing what will in essence be a state-owned enterprise at least twice the size of Eskom;
- The future of private health care, if any, and fears among middle-class South Africans that they, too, could soon be spending hours at a time in long queues at understaffed and under-resourced state hospitals;
- The estimated additional tax bill; and
- A nagging worry that the government cannot be seen by its adversaries, including supporters of former president Jacob Zuma, to be backing down on a populist measure.
The bill suggests two new taxes and that medical aids will end in their current form when NHI is fully implemented - which is estimated to be by 2026.
Profmed medical aid CEO Craig Comrie said it was not clear in the bill what "complementary space for medical schemes" means.
He said the schemes could have either a "significantly large or very restricted role".
Dr Chris Archer, CEO of the South African Private Practitioners Forum - which represents 3,000 specialists and 6,000 general practitioners (GPs), optometrists and physiotherapists - said its members are "extremely concerned".
He said the bill may drive emigration as those "who want to leave see it as a reason to do so".
On Wednesday, health minister Zweli Mkhize was asked about funding and said the Treasury would release a white paper.
"We have made it very clear that NHI will give broad principles of what is involved. Treasury will come with the money bill."
Amid confusion on how things will actually work, what is known is that:
- Medical aids will only be allowed as "top-up" cover;
- Patients will have to see GPs or nurses before they see specialists;
- A database of every South African - which is already in creation - with biometrics, residential addresses and health records - will belong to the government;
- Taxes will be raised; and
- All facilities and doctors will be inspected and accredited, meaning the Office of Health Standards Compliance will have more than 45,000 facilities and professionals to accredit every five years.
Health department deputy director-general Dr Anban Pillay said tax increases are on hold for now, with the bill stating that "due to the current fiscal condition, tax increases may come at a later stage of implementation".
Comrie said health professionals are already emigrating. His fund's members are mainly health professionals, of whom 17% leave each year. This rose to 30% in June and July, with a third of the health professionals who left in the two months emigrating.
Three different health insiders said CEOs and staff are, in private, concerned that NHI will destroy the health system, but that many organisations hope to provide services to the government so they have to show support for the bill in public.
Dr Katlego Mothudi, MD of the Board of Healthcare Funders, said there is still room for private sector services in the NHI.
"In our country the private sector is too well developed to be quashed," he said.
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