Recent pronouncements by President Cyril Ramaphosa and Democratic Alliance leader John Steenhuisen indicate the two main parties in the government of national unity believe they can reach an agreement over National Health Insurance (NHI).
In his opening of Parliament address on Thursday, Ramaphosa said the seventh administration will continue with the implementation of NHI.
Two days earlier, Steenhuisen said the NHI Bill is a “sticking point” between the DA and the ANC but expressed optimism that the differences can be resolved.
He told a DA briefing that every party in the GNU believes South Africans should have access to basic healthcare, the quality of care must be improved for every citizen, and no one should be deprived of good medical assistance based on their income. There were differences over the funding model and around the issue of choice.
The DA will be making “a very strong pitch” that instead of “tying up the NHI with decades of constitutional challenges and the like”, the NHI Act is revisited to achieve universal access to basic healthcare in a way that does not deprive people because they can’t afford it, and how the Act can be “tweaked”, “so we can start implementing something that can move towards improving the public healthcare sector and partnering with the private healthcare sector in a mutually symbiotic way” that results in universal access to basic healthcare, said Steenhuisen, who is also the Minister of Agriculture.
“I think there are some areas where the Bill can be amended or changed, or the approach and regulations can be changed, to reintroduce choice, to treat the private sector as a partner in fixing the public healthcare sector, but focusing like a laser beam on improving the way in which citizens, particularly our poorer citizens, encounter healthcare at the primary level, fixing our hospitals, making sure they’re efficient and effective, bringing electronic systems so their files can be moved amongst departments and different facilities easily, reducing queues, and making sure that the quality of care is excellent.
“And I think that we can find each other as the parties in the GNU on that because I think we all want the same thing; we just have slightly different ideas about how we’re going to get there.”
Steenhuisen’s pronouncements could be interpreted as the DA backing down from its more combative approach to NHI.
For example, on 15 May, the day Ramaphosa signed the NHI Bill into law, Siviwe Gwarube, who was the party’s chief whip, issued a statement stating NHI was “nothing more than a political tool wielded by the ANC to manipulate voters in this upcoming election”.
Gwarube, who is now the Minister of Basic Education, said NHI “is financially unfeasible, an election gimmick, and will burden South Africans with increased taxes. The potential for corruption is staggering, and the flawed parliamentary process further erodes public trust. The DA will pursue all legal avenues to challenge the NHI and ensure that the rights of all South Africans are upheld.”
Bringing stakeholders together
With respect to what should be done to improve the public healthcare system, Ramaphosa expressed similar sentiments to Steenhuisen in his address. He also said the differences over NHI could resolved.
“As we implement the National Health Insurance, we will focus on strengthening healthcare infrastructure, improving training of healthcare personnel, and using technology to improve healthcare management.
“While there is much contestation around the NHI, there is broad agreement that we must draw on the resources and capabilities of both the public and private sectors to meet the healthcare needs of all South Africans equally.
“In implementing the NHI, we are confident that we will be able to bring stakeholders together, and that we will be able to resolve differences and clarify misunderstandings,” Ramaphosa said.
Business Unity South Africa (BUSA) welcomed the President’s remarks.
The organisation said it was encouraged by Ramaphosa’s commitment to bring stakeholders together to find agreement over the NHI Act, as well as his acknowledgement that the resources and capabilities of the public and private sectors are necessary to meet the healthcare needs of all South Africans equitably.
“The NHI Act in its current form is unaffordable, unsustainable, and creates material risk for the country and taxpayers,” chief executive Cas Coovadia said in a statement.
The NHI Act needs to be amended to ensure the country can deliver healthcare reform and advance universal health coverage without damaging the economy and the existing skills, innovation, resources, and experience that reside in the private healthcare sector, he said.
“We believe a collaborative approach is crucial in advancing our nation’s healthcare objectives, and our collective vision for universal health coverage in particular. We look forward to engaging with the government on the NHI and other health-related matters and will be urgently seeking a meeting with the Minister of Health.”
It should be noted that Ramaphosa’s remarks about public-private co-operation over NHI are not new.
For example, on 20 May, he wrote: “Some people have claimed that the NHI will signal the end of private healthcare. To the contrary, the NHI aims to use the respective strengths and capabilities of both the private and public health sectors to build a single, quality health system for all.”
In his speech when he signed the NHI Bill into law, Ramaphosa said: “The NHI recognises the respective strengths and capabilities of the public and private healthcare systems. It aims to ensure that they complement and reinforce each other. Through more effective collaboration between the public and private sectors, we can ensure that the whole is greater than the sum of its parts.”
Minister of Health stands firm on NHI
It remains to be seen whether Ramaphosa and Steenhuisen’s irenic sentiments will translate into material changes to the NHI Act – that is changes that are favourable to the private health insurance sector.
During his department’s budget vote on 11 July, Health Minister Dr Aaron Motsoaledi (pictured) made it clear the government believes the fundamental principles on which NHI is based are sound.
“We will have to start implementing NHI in phases, as we are already in Phase 2. The rest of the building blocks of health will easily fall into place,” Motsoaledi said.
Tabling the Department of Health’s budget vote for the 2024/25 financial year in Parliament, the minister said his priorities for the next five years are the six building blocks outlined by the World Health Organization (WHO). These include leadership and governance, access to essential medicines, the health workforce, health systems financing, health information systems, and service delivery.
“Five of the six building blocks seem acceptable to everybody and debates around them are straightforward and clear. But one of them has generated a lot of heat and sometimes fury in some quarters. This is the health systems financing. In our country, we have decided to call this NHI,” he said.
“Some believe it is a system of health which South Africa is not ready for. Others believe it is a vintage, very expensive health system for which there is no money in the country. Let us clarify once more, NHI is health financing system, called Universal Health Coverage by the WHO. It is a health financing system which is meant to be an equaliser between the rich and the poor.
“There is no debate at all that South Africa is the most unequal society in the whole world. If you want to see what inequality means, come to the health sector in South Africa. Within the borders of the same country, some are getting a world-class healthcare, while others get such poor healthcare you may believe we live in different countries. We can no longer with our eyes open sustain such gross inequality.
“If there is something we can do about it, we must do it here and now and not in some distant ill-defined future,” said Motsoaledi, who was health minister between 2014 and 2019 in Jacob Zuma’s Cabinet.
According to the WHO, for a country to have a good healthcare system for everyone regardless of their financial status, it needs to spend at least 5% of its GDP on health, he said.
South Africa spends 8.5% of its GDP on health, while, on average, European countries spend 9%. “This means that our health system was supposed to be as advanced as countries in Europe. As is evident, that is not the case.”
As to the reasons for this, Motsoaledi said 51% of healthcare expenditure goes to serve only 14% of the population, while a “meagre” 49% goes to serve 86% of the population.
“Everybody agrees that we are the most unequal society, and this just proves it, and House Chairperson, I think we ought to stop this. It needs to end and end now,” he said.
“I haven’t heard up to now anybody in South Africa who says they don’t support Universal Health Coverage, but there there’s always a ‘but’. ‘I support Universal Health Coverage, but.’ And the ‘but’ is going to be that the country is not ready, the public sector is not working very well, it has got no management, there’s corruption, and all that. That is true and fair enough, but we cannot throw the baby away with the bathwater. We need to find solutions.
“We can’t say this system is good, but because it has got this and that and that, which things can easily be resolved, and then just throw it throw it away. Let us discuss the areas that need to be ironed out, and we have done so before as South Africans.”
In her response to Motsoaledi’s budget vote speech, DA MP Michéle Clarke said her party has always advocated for quality universal healthcare, “but it is of critical importance that we strengthen public partnerships with the private sector to achieve these objectives. The NHI in its current form is unaffordable and needs to be urgently reviewed.”
‘No’ to amending section 33
Business Day reported that Motsoaledi told the publication in an interview he was open to talking to stakeholders about their differences on NHI, but he was not prepared to soften section 33 of the NHI Act. This section will permit medical schemes to provide cover only for services not covered by the NHI’s package of basic benefits once NHI is “fully implemented”.
It said Motsoaledi dismissed the possibility, saying: “Medical schemes [as] they are now won’t solve the problems that we’re having [of inequitable access to health].”
Business Day also reported, “the minister panned the notion of low-cost benefit options (LCBOs) for medical schemes, saying it would be wrong to provide poor people with less cover than rich people who could afford more generous options”.
It quoted Motsoaledi as comparing LCBOs to “sticking a plaster on a crack”. “I don’t favour them. It’s wrong. It’s not dealing with health; it’s money,” he said.
