Is there hope for changes to the NHI Act?

Feature images (89) — The country’s largest federation of business organisations, Business Unity SA (Busa), refused to sign the second presidential health compact. They will be submitting a proposal to the president, detailing their solutions to the problems they have with the National health Insurance Act. (GCIS)

By the end of October, Business Unity SA (Busa) — the country’s largest federation of business organisations — will submit a proposal to the president with solutions to their problems with the National Health Insurance (NHI) Act.

Busa refused to sign the country’s second presidential health compact in August, because it required signatories to explicitly support the NHI in its current form.

That means Busa, who was on the steering committee of the presidential health summit — that was held in 2023 — after which the compact document followed in 2024, won’t take part in any of the compact’s activities to better the health system.

In mid-September Busa met with the president, health and deputy health minister to discuss their concerns — Busa supports expanding South Africans’ access to private medical aids rather than the banning of private schemes in their current form, as the NHI Act stipulates.

Is there hope for change? In this podcast, Mia Malan asks Olive Shisana, the president’s special advisor on social policy, who also coordinated the compact, and Busa’s CEO, Cas Coovadia, what to expect. The interviews with both Shisana and Coovadia were done before the September meeting between the two parties took place.

In today’s newsletter, Mia Malan wonders if there is hope for any changes to the NHI. Sign up today.

[PODCAST] IS THERE HOPE FOR CHANGES TO THE NHI ACT?

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FULL PODCAST SCRIPT

Please note: Both interviews were conducted before the September meeting between the presidency and Busa took place.

INTRO:

OLIVE SHISANA
We can’t change. We’ve got a law called National Health Insurance Act, and that particular Act, it’s a law. I’m sure, Mia, you’re not saying that we must sit back now and change the law through bilateral discussions between the government and Busa.

CAS COOVADIA
Well, we won’t participate in the compact process. We’re not a signatory to it. That doesn’t mean that we don’t look for ways and means of working with the government to make a difference to the healthcare system in our country.

PRESENTER INTRO:
Welcome to this edition of Bhekisisa’s podcast. I’m Mia Malan.

The National Health Insurance (NHI) is one of the most contentious issues in our government of national unity. Only four out of the 10 governing parties support it.

But in August Health Minister Aaron Motsoaledi told Bhekisisa he’s not prepared to negotiate, especially not on the section of the NHI Act that says medical aids, in their current form, will become illegal.

MOTSOALEDI: I DON’T KNOW WHEN I TOLD ANYBODY THAT I WILL DO CONSULTATION. I DON’T KNOW WHERE THAT COMES FROM. CONSULTATION FOR WHAT?

The NHI is equally controversial among health workers and the business community.

So much so that the country’s largest federation of business organisations, Business Unity South Africa (Busa), and the South African Medical Association (Sama), which represents 12 000 doctors, refused to sign the country’s second presidential health compact in August.

The compact is a document which assigns specific tasks to signatories to improve the country’s health system.

The representatives of both Busa and Sama, originally served on the steering committee of the second compact, chairing two of the ten pillars of the agreement.

As a result of Bhekisisa’s interview with Motsoaledi, four political op-eds were published by mainstream media houses, and dozens of radio and TV interviews followed, which helped to pressurise the government to consult with business partners.

By mid-September, Busa announced it had met with President Cyril Ramaphosa, Motsoaledi, and his deputy Joe Phaahla. By the end of October, Busa will submit a proposal to the president with solutions to their concerns.

But Ramaphosa’s special advisor on social policy and also the coordinator of the compact, Olive Shisana, says Busa will have to accept the NHI Act as is, if they’d like to be part of the compact.

Olive Shisana (OS):
Well, let me put it this way, Busa’s input into the summit, which is pillar four of the summit, and [Sama’s] input into pillar six is there [in the compact]. If you look inside the compact itself, that copy of the compact includes a Busa person, a Busa representative, and that representative was Stavros Nicolaou, who spoke at the summit on behalf of Busa. They disagree with the word NHI. That is their disagreement. Their members, BHF [The Board of Healthcare Funders], have already gone to the court and launched a case against NHI, and I think the reason they didn’t sign was because it would undermine their case in court.

Mia Malan (MM):
But Professor Shisana, just to interrupt you here, I have a copy of the document that was signed. And if you sign this document, it does imply that you endorse the NHI. And Busa doesn’t feel comfortable endorsing the NHI in its current form, so if they sign it, they would essentially say they endorse it, and that’s what they’re unhappy about. And they say they weren’t consulted about how the NHI was portrayed in this document before the draft document was distributed. Did they have input into how this document was drafted?

OS:
They saw the big document. The full document. That full document was prepared since, I think the last draft that was sent to everybody was April.

MM:
But then they complained about it, and they said they wanted more input into it. Was there any consultation with them then between the draft document that was circulated and the signing?

OS:
We sent it to everybody who wanted to look at it. They were the only ones who didn’t respond positively because they said NHI was included. And we couldn’t understand because the summit itself, the theme was on NHI. The objectives that were there were on NHI. The pledge that was there on NHI, which everybody who was in that meeting was saying, actively support the National Health Insurance Bill and foster a culture of accountability as a rational means of attaining universal health coverage in South Africa, there was no objection. They were part and parcel of that in 2023 when we actually had the summit itself.

MM:
The broader business sector now wasn’t part of the second presidential health compact, because that is who Busa would be representing, the 48 organisations, right? What does that mean for cooperation in a structured way to improve the health system in South Africa, would there now be less cooperation?

OS:
No, no, no, no, no. They still will be able to be part and parcel of the health system, because, let me tell you, the NHI when it is implemented, will allow individuals to get services both from the public and private sector.

MM:
I hear what you’re saying, that both the private and public health sectors would be part of the NHI, but I want to talk about cooperation to improve the health sector. So not the NHI, but the compact. You know that the fact that it is a document that assigns responsibilities to different sectors, including business, as to what they can do to help improve the health sector. Now, the fact that Busa hasn’t signed, and 48 organisations that they represent are not part of the compact so responsibilities can’t really be assigned to them. How do you feel about that?

OS:
I’m hopeful that they will come back and sit at the table, because the place where we sort out our differences for all these five years before and the next five years are coming is in the presidential health compact discussions. That’s where we meet and have a conversation.

MM:
To get back to their issues of how to resolve this conflict, if I look at the document that was signed, it does imply that if you sign it, that you endorse the NHI. Now they don’t endorse the NHI, even if you feel they didn’t raise their voices. So how can you reach an agreement for them to be comfortable signing this document? Would you consider changing the wording, for instance?

OS:
I can’t change the document that we signed because we believe in NHI. Everybody, the majority of the people who were in the meeting, believed in NHI. So why should the views of the majority be subsidiary to the views of only one organisation or two organisations? Why?

MM:
What would the compromise then be to get them to buy in?

OS:
First of all, they’ve decided to take not Busa itself, but the Board of Healthcare Funders has decided to take up the case to court, and the case is in court, we live in a democracy. We can’t change. We’ve got a law called the National Health Insurance Act of 2023, and that particular Act, it’s a law. I’m sure, Mia, you are not saying that we must sit back now and change the law through bilateral discussions between the government and Busa?

Mia Malan
I think what they are also saying is that when the second presidential health summit happened, the NHI was not law yet. So they felt it was something that was in the future that they clearly were hoping wouldn’t become law, but now it’s law. And I hear you that we can’t just change a law, but where would the solution be?

OS:
They had come in as friends of NHI, putting their logos to say, NHI. That’s where I don’t understand. That’s where I get confused in terms of what Busa stands for. What do they stand for? So how do we negotiate?

MM:
So do I hear you correctly? You’re saying either they buy into the NHI or they don’t, but if they don’t buy into it, then so be it.

OS:
NHI is going to continue, but to continue, and it’s not unusual, by the way, the British, when they introduced their NHS [National Health System], they had similar problems, they had doctors refusing to sign up on it. It’s a matter of transformation that we’re dealing with here. We are transforming a system that is unequal to having a system that ensures everyone has the right to access quality healthcare from the resources available in the country, public or private.

PRESENTER LINK:

Cas Coovadia is Busa’s CEO. He disagrees with Olive Shisana that the NHI, in its current form, is set in stone. He says he’s encouraged by the meeting Busa had had had with President Cyril Ramaphosa in mid-September and his team would now like to look at what the possibilities are to use the NHI Act in a different form to make it easier for the private and public sector to work together to give everyone in the country access to good healthcare. By the end of October the president and health minister would have received their proposals.

I asked Coovadia about what kind of changes Busa would like to see to the NHI Act.

Cas Coovadia (CC):
It talks about the state actually taking responsibility for healthcare for everybody in this country through a single fund. We believe that that’s not the route to go. That’s not utilising optimally the resources we have in this country, in both the public and private sector.

MM:
When you say there shouldn’t be a single fund. Are you implying that we should use private medical aids as well to give universal access?

CC:
Absolutely. Yeah.

MM:
And what would that look like, giving more people access?

CC:
Well that’s what I’m not going to go into detail publicly. Those are the discussions we need to have with the president.

MM:
To get back to the compact document. To be fair, the first document did make it quite clear that all these efforts of building the country’s health system and improving it was to implement the NHI, although the NHI was not law yet then. But in this second document, those references were different, because it was already an Act. I’m trying to understand your level of surprise with the second document, in the sense that the NHI was mentioned so prominently, within the context that the first document made it very clear those efforts were in preparation for the NHI.

CC:
At that time, the NHI was under discussion. We had made lots of submissions related to that. The NHI was not settled. There was no NHI Act. After that the President signed the NHI Act, and we publicly had expressed our concerns about the Act in its current form, knowing that we had the reservations, to use the compact to try and force through an Act, knowing full well that that that’s the state of affairs, to use the health compact to try and force through a piece of legislation that they know is problematic to critical players In the sector, is totally unacceptable. The compact is supposed to be something that signatories agree to. We never agreed to that.

MM:
Olive Shisana says you didn’t raise any concerns at the summit in 2023 in preparation for the compact. Is that correct?

CC:
No, it’s not. We raised issues. People like Stavros Nicolaou [Aspen Pharmacare Group’s senior executive responsible for strategic trade development] and others who were representing us raised issues, and Stavros was absolutely clear that those issues were not taken into account.

MM:
Professor Shisana says Busa wrote pillar four of the longer document of the health compact, Is that correct? It is the private sector involvement, pillar four.

CC:
I’m not too sure we wrote it. I have no doubt that we gave substantial input into it, but we wouldn’t have written it and expected to have what we’ve written taken into the compact without any discussion. So I have no doubt that we played a critical role in crafting it, but we didn’t write it.

MM:
Olive Shisana says the real reason why you don’t want to sign the Act is because of the court action of the Board for Healthcare Funders, and she believes they are a member of Busa. Is that correct?

CC:
Yeah, that’s correct, but that’s not the reason why we haven’t signed the compact. A number of organisations are talking to attorneys about possible legal action against the NHI Act, but for us, the NHI Act and the compact should never have been confused. To be quite honest, we didn’t discuss the compact at all in our discussions on what our approach is to the NHI Act after it was signed, not once did we discuss the compact. So to say that we didn’t sign the compact because the Board of Healthcare Funders, or anybody else, for that matter, is considering legal action. It’s just not correct. I don’t know, she’s got information elsewhere, but I am involved in this discussion. It’s just not correct.

MM:
What are the implications of the fact that you haven’t signed? The compact is a formal way, or structured way, for everyone to work together to improve the health system. What does that mean for your participation in that process?

CC:
We won’t participate in the compact process. We’re not a signatory to it. That doesn’t mean that we don’t look for ways and means of working with the government to make a difference to the healthcare system in our country. The compact is not the only instrument through which we can do that in our normal ongoing engagement with the government. If we find each other on things, and we find that we can work in partnership to make a difference, as we are doing in energy, logistics and law and order, we’ll do that.

MM:
If you had to say in a nutshell in the previous compact what was your contribution? What do you think was the most meaningful part of it?

CC:
I think we worked together to address issues in the compact. We raised money where we needed to raise money, we brought members to the party, particularly in the healthcare sector, to achieve certain things. We mobilised resources and capacity where they were appropriate, and that’s what we would have done under this health contract.

MM:
If your consultation doesn’t result in anything, if there is no compromise of any sort, will court action then be the next avenue?

CC:
We made it very clear that court action is definitely on the agenda. If our engagement doesn’t lead to anything, then we will regroup and look at our next steps.

That was Business South Africa’s CEO Cas Coovadia, talking about the business sector’s concerns about the NHI Act in its current form and the sector’s hopes for what their talks with the president could result in. We’ll be publishing our analysis of the content of the second presidential health compact in October, so this month. It’s a document of over 100 pages, so do keep an eye on our website and social media channels if you’d like to read it. Until next time, goodbye.