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Opinion Article by Dr Larisse Prinsen, Senior Lecturer in the Department of Public Law, University of the Free State

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Earlier this month, the National Health Insurance (NHI) Bill was passed by the South African National Assembly. From there, the Bill will be sent to the National Council of Provinces and if also passed there, it will be signed into law by the President. This process may, however, still take years to complete.

The provision of universal access to healthcare has long been envisioned by not only the Constitution of the Republic of South Africa which states in section 27 that everyone has the right to access to healthcare, but also by the National Health Act of 2003 which in its Preamble declare 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 that all South Africans have access to quality health-care services and to provide for the establishment of a fund which will be utilised to pay for almost all medical treatments from accredited provides, with rates to be determined by the State. Private health insurers will thus only be able to pay for treatments, health products and services which are not covered by the fund.

This Bill, however, has from the 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 various 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 perhaps examine that which it espouses, National Health Insurance, as this concept is a noble one at its core – the achievement of a more equitable society in context of access to healthcare.

Advantages of national health insurance

Some of the proposed and hoped-for advantages of a system of NHI include:

• Lower overall health-care costs by having the government determine and control the price of healthcare and by decreasing administrative costs;
• Finite determination of costs related to health-care 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 health care based on the ability to pay; and
• A real attempt being made at the progressive realisation of socio-economic rights and an addressing of the inequities and scarcity of health-care resources in South Africa.

Disadvantages of national health insurance

Some of the disadvantages of a system of NHI include:

• A blow to autonomy as all South Africans will be forced to make use of NHI, regardless of whether they want to or not;
• 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 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 health-care facilities and providers due to an uncertain system of accreditation;
• A decrease in the quality of care provided;
• Uncertainty regarding what will in fact 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; and
• The (very real) potential for corruption and misappropriation of funds.

What national health insurance means to South Africans?

The current two-tier system of health-care 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 health-care funding for private and public health-care 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:

1. Access to healthcare could be improved for those who previously faced barriers due to financial constraints or geographical location;
2. Healthcare could become more affordable as the NHI aims to pool funds to provide affordable health-care services;
3. Health-care service delivery will be impacted as the NHI Fund will be responsible for purchasing services which may result in changes to how services are delivered, organised, and managed;
4. Equity in healthcare will be promoted;
5. Healthcare quality will change due to the emphasis on “quality” care which will necessitate increased scrutiny on the quality of health-care services;
6. The NHI may require changes to the health-care 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; and
7. Health-care governance will be restructured with the NHI Fund having set powers and functions while policy-making, regulation and accountability will also be impacted.

For South Africans without medical aid or in lower income groups, the NHI will be beneficial in that it will offer more equitable access to health-care services and will allow for these persons to consult private health-care practitioners and make use of private health-care facilities and practices with the NHI footing the bill. Not only will it provide health insurance to those not currently a member of a medical aid, but the NHI purports to improve the resourcing of public hospitals and health-care 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 still paying a similar or higher fee. South Africans within a certain income bracket will still 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 various health-care 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 that 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 still be available and South Africans will still be able to register with their preferred health-care provider.

In closing

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 falls short when it must be put into practice. The 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 health-care 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. The NHI cannot be avoided but perhaps, but for it to be beneficial to all and truly live up to its potential for betterment, it should not be rushed.