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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 Act was signed into law on 15 May 2024 but before it will come into effect, Parliament will need to enact further legislation (including ones providing for its funding).

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Healthcare’s private parts to shrink

NHI details are not clear but it is certain that the privileged few will have to do with less.

“Healthcare in South Africa has to change and that’s going to come at a cost for some people,” said Paul Wayburne, an advocate, at the Board of Healthcare Funders conference in Cape Town this week.

“At the moment, we have a nice private sector and a not so great public one. Essentially what the government’s National Health Insurance (NHI) system wants to do is lessen the gap between the two. 

“Bringing private healthcare into a unified system means that more people will have access to private hospitals, for example, which can cause a number of issues for people who currently access these facilities through medical aid.”

The NHI is being phased in over 14 years. Eleven pilot sites have already kicked off, although the focus is currently to upgrade their facilities rather than to provide NHI services.  

According to Sha’ista Goga, a senior researcher at the social justice organisation Section27, patients who are accustomed to private healthcare may have to wait longer for procedures. 

“They may be placed on waiting lists for elective operations like hip and knee surgery but I don’t think it will affect emergency procedures.” 

South Africa spends about 8.5% of its gross domestic product on health, according to the World Bank, which is above the recommendation of 5% by the World Health Organisation.

According to the health organisation Health Systems Trust, the extreme inequality in South Africa is reflected in total health spending with more than half of it going to the 16% of the population who receive private healthcare through medical aid. 

Rationining depends on NHI white paper 

Goga said it is difficult to tell what patients who use private healthcare facilities may have to forfeit in the future because the promised NHI white paper has not been released. 

“It depends on what kind of structure the NHI takes, which we don’t know at the moment. The minister has spoken about retaining a private sector of sorts.” 

She said the private healthcare sector could become much smaller, as it has done in the United Kingdom, which has a government administered National Health Service (NHS) that all citizens belong to. 

“We may have a similar situation when the NHI comes into effect in South Africa where medical insurance will act as a ‘top-up’ that much fewer people will be able to afford. People may pay extra to for things like queue jumping,” she said.

According to Wayburne, the expected tax contributions, either in the form of payroll deductions or increased general taxes, to fund the NHI would be equivalent to the monthly instalments that medical–aid members currently pay. 

He said that “a lot of people are not going to be able to afford supplementary insurance” and the benefits that come with it and that there will be a more “needs-based rationing” approach to health for many people. 

Likely referral system 

Goga said that many people who are currently used to “going to the gynaecologist for a pap smear or who take their child with a cold to a paediatrician” will have to adjust. 

She said there is likely to be a stricter referral system, which would mean patients would not go directly to specialists but to GPs first. 

“This means that the specialists will probably be used more appropriately, like for sicker children.”

Although it might be a “mild adjustment” for those who aren’t currently restricted, she said that, “from a systemic point of view, this approach is more appropriate”. 

However, Goga said, many services may become better and more efficient. She said that Britain’s NHS has contracted Netcare to do eye surgery out of specialised mobile containers that move from place to place. 

“They’re only doing one procedure, which works out quicker and cheaper – their system is finessed. We could have similar successes here,” she said.  

“Whatever happens, there will have to be a mind shift that accessing healthcare might not be the same,” Wayburne said. 

“I’m not saying people won’t be able to have a bypass. I’m saying it’s likely there will be a levelling down of access in the private sector when resources are redistributed in accordance with the government’s mandate set out in section 27 of our constitution, which gives everyone the right to have access to healthcare.”

He said: “We can no longer have a situation where 8.5 million people have access to world-class healthcare and 45 million have severely inadequate access. There needs to be more of a balance.” 

Amy Green was a health reporter at Bhekisisa from 2013 until 2016.