Special Reports:

National Health Insurance

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The National Health Insurance (NHI), for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa. The scheme will do this by creating a fund that the government will use to buy healthcare services at set fees from accredited public and private health providers. The NHI Bill was passed in the National Assembly in June 2023. It has to go to the National Council of Provinces for approval.

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NHI: History repeats itself

Universal healthcare schemes traditionally have been met with fierce opposition.


Looking at recent responses to the green paper on National Health Insurance (NHI), one is reminded of the saying “Hell hath no fury like a woman scorned”. Except here the woman is the medical schemes and private healthcare providers, aided and abetted by their various supporters.

If they are to be believed, South Africa is facing potentially disastrous times, with not just hell but damnation awaiting the architects of the insurance scheme and those who might try to implement it.

There is a clear sense of déjà vu for anyone familiar with the history of healthcare in the United Kingdom and Australia. In 1948 the UK introduced its version of NHI, the National Health Service, and in 1975 Australia started its version of universal healthcare for its citizens, Medicare. In both countries their launches were preceded by vitriolic attacks. In the UK, for example, the then minister of health, Aneurin Bevan, who was responsible for implementing the service, was called all sorts of nasty names, especially by doctors and their governing body, the British Medical Association.

But to put things in perspective, we must paint the picture of Britain’s healthcare prior to the national health service. For many people, healthcare was a luxury often simply beyond their means.

Thousands died unnecessarily. Tuberculosis was particularly rife. The poor often went without care. Does this sound familiar?

It was against this background that Bevan created the National Health Service with the promise that “everybody, irrespective of means, age, sex or occupation [should] have equal opportunity to benefit from the best and most up-to-date medical and allied services available”.

Many argued at the time that Britain could not afford the service. Some worried about socialised healthcare and dictatorial control of doctors by the state. Thus a chairman of the British Medical Association suggested: “The [National Health Service] Bill — looks to me uncommonly like the first step, and a big one, to national socialism as practiced in Germany. The medical service there was early put under the dictatorship of a medical führer. The Bill will establish the minister in that capacity.” The leaders of the association worked up such antagonism towards the Bill and Bevan that, as one of them, Dr Roland Cockshot, remarked after meeting Bevan: “We were quite surprised to discover he talked English!”

But there came a shift as things moved into gear in the National Health Service. For example, The Times (of London) suggested that “the masses had joined the middle classes”. It was accepted that a doctor had more than his or her own patients to look after, as the British Medical Journal argued: “The medical man, intensely individual, was becoming more and more aware of his responsibility to the community.”

That shift has been maintained. Today, as the UK coalition government seems intent on undermining the National Health Service, among those who are the stoutest defenders of it are those who in the late 1940s were its greatest opponents — the British Medical Association.

Health and Social Care Bill

Recently, the government introduced the Health and Social Care Bill, seeking major changes to the UK healthcare system that might destroy the National Health Service. The Guardian reported: “The British Medical Association’s council — voted to pass a series of motions critical of the government’s Bill — and crucially accepted that doctors ‘start a public campaign to call for the withdrawal of the — bill’.”

The introduction of Australia’s Medicare in the 1970s met with similar opposition. Social policy researcher Anne-Marie Boxall writes that “the Australian Medical Association embarked on a massive public relations campaign that aimed to bolster public support for the existing system. Association members were urged to speak to their patients, address public meetings and write to their local members about the problems [Medicare] would bring. Money — was used to produce publicity material such as pamphlets, posters and stickers, as well as fund newspaper, television and radio advertisements that would assist their campaign. One of those involved wrote: ‘We were trying to stir [the public] up, get them frightened.'”

Although there are, from time to time, calls from all political parties to make amendments to Medicare, no one asks for its abandonment today. There are sometimes fears that Australia may end up with a two-tier system, one for the rich and the other for the majority, but to date these fears have been unfounded. Nearly 40 years on, Medicare is a part of the social fabric — there for, used by and defended by both rich and poor.

So after some early, truly ­vitriolic opposition to their formation from some key players, the British and Australian universal healthcare schemes are now seen by the people they serve as always needing to be improved but nonetheless outstandingly successful.

In both countries there has been a fulfilment of Bevan’s words: “Society becomes more wholesome, more serene and spiritually healthier if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.”

Stepping back from the cut and thrust of the debate on the NHI in South Africa, maybe it would be helpful if we were to rethink just what we mean by the “thing” that this is all about: health.

I believe an excellent way of thinking about health is one recently reported in the British Medical Journal by Dr Alex Scott-Samuel and colleagues from the University of Liverpool: “Health is a condition in which people achieve control over their lives due to the equitable distribution of power and resources. Health is thus a collective value; my health cannot be at the expense of others, nor through the excessive use of natural resources.”

There may be — there is — much heat in the arguments of those in South Africa who oppose the formation of the NHI. For those in favour, be assured such heat has happened before but it burnt itself out. That is not an argument for complacency but it does strengthen your arm. For those opposed to the NHI, by all means fight to defend your patch — but recognise that history is against you.

I am confident that most South Africans want that “more wholesome, more serene and spiritually healthier society”. The NHI will prevail, and in a few years’ time it will be a part of this country’s social fabric — and proudly South African.

Gavin Mooney is a visiting professor in health economics at the University of Cape Town. He is visiting from Australia for the fourth consecutive year and takes a keen interest in the NHI and the debate surrounding it. In 2009 he was awarded an honorary doctorate by UCT as "one of the founding fathers of health economics"