It would be hard to find anyone entirely opposed to the constitutional injunction for universal health coverage. In fact, many of those who censured the signing into law of the National Health Insurance (NHI) Act prefaced their criticism by acknowledging the nobility of the ideal of providing healthcare to the poor.
Health, it is said, is wealth. A lack of access to proper healthcare has led to premature and often preventable deaths, mostly among the poor. Theoretically, the NHI is meant to prevent people dying simply because of their low economic status. What is not helpful is the timing of the signing of the act, which at least superficially suggests it is a cynical attempt at vote-snatching ahead of a critical election.
Criticism of the government’s handling of the legislation is predicated on the dubious constitutionality of the act — and its section 33 in particular, which stipulates that medical schemes may cover only those services not offered under the NHI. Put differently, in the new system, rich and poor alike will receive the same care for services covered by the NHI.
The question is whether the government is violating any fundamental rights by taking away a citizen’s prerogative to choose to pay for a service offered for free by the state
Fears around levelling the healthcare playing field are linked to the notion that, once medical services are offered only by the state, the middle classes too will be at the mercy of incompetent and corrupt officials who have mismanaged public hospitals for years.
The question is whether the government is violating any fundamental rights by taking away a citizen’s prerogative to choose to pay for a service offered for free by the state. It may appear trite, but perhaps the country’s best legal minds need to test this issue in court. The government has said implementing the NHI is necessary given its constitutional obligation to ensure both rich and poor have access to equal healthcare.
Some private healthcare providers dread the burden of dealing with the ineptitude and red tape associated with government bureaucracy. What is more, once the NHI is fully operational, private hospitals will be inundated with patients trying to escape the incompetence associated with public ones. While private facilities will be duty-bound to provide such care, it is unclear whether they will be paid for the services they have render in a timely enough manner to ensure their continued economic viability.
Others have said the creation of the NHI Fund — which will be tasked with procuring all designated services for private and government hospitals, and which will be worth about R200bn annually when the NHI is fully operational — will become a magnet for corruption. In any case, they point out, the NHI is now simply not affordable because the state doesn’t have the means to raise the billions required to get it off the ground.
It is a tad unfair to accuse the government of planning to act corruptly on the basis of historical evidence of rampant state corruption. The truth is that across the globe we have seen how the private sector — in health, construction, banking, management consultancy, and many other spheres — is also afflicted by corruption. The private firms fingered in corruption in the state capture report, for example, are too many to list. We can’t reject a law because of a sense of foreboding about corruption. A more useful conversation would be about what systems should be put in place to curtail the potential rot.
Others have raised the unaffordability of the scheme as a reason not to proceed with it. Finance minister Enoch Godongwana said during his February budget speech that debt-service costs, a fifth of government revenue, would rise from 20.7% in the 2023/2024 budget to peak at 22.1% of revenue in 2026/2027.
For its part, the government has said it intends to roll out the NHI in phases, after further consultations. This appears sensible. It would also be sensible for the government to take steps to improve the working conditions of health workers in public hospitals, as well as the quality of the services provided there. If this is not done, the ensuing skills flight will paralyse what remains of our healthcare system.
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