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NHI: Our hope to realise universal health coverage and health for all

Health Minister Joe Phaahla during the National Health Insurance (NHI) workshop at Garden Court OR Tambo International Airport in Johannesburg. Photo: Siyabulela Duda​

Health Minister Joe Phaahla during the National Health Insurance (NHI) workshop at Garden Court OR Tambo International Airport in Johannesburg. Photo: Siyabulela Duda​

Published Jul 17, 2023


Dr Thabiso Makola

The National Assembly in parliament debated and adopted the National Health Insurance (NHI) Bill on June 12. Following the adoption, the Bill has been sent to the National Council of Provinces (NCOP) for concurrence. The adoption of the Bill has once more brought into sharp focus the debate around the implementation of the National Health Insurance.

The NHI is a proposed mechanism for transforming the financing mechanism for healthcare services in South Africa to align with the principles of Universal Health Coverage. It is perhaps opportune to both inform and remind South Africans that the country’s decision to deliberately move towards universal health coverage is in line with reforms currently underway in various parts of the world. The World Health Organization (WHO) passed a resolution at the World Health Assembly in 2005 in which it explicitly called for all member countries to transition their health systems towards universal health coverage.

The WHO has consistently sought to clarify that universal health coverage is not something that countries implement but rather consist of deliberate policy reforms and interventions at health system level that are meant to ultimately result in addressing the three pillars of universal health coverage being:

- population coverage

- healthcare services coverage

- financial protection

It is therefore important for South Africans to appreciate that the policy decision by the African National Congress to adopt the NHI as a vehicle for the progressive realisation of universal health coverage is not unique but rather is in tandem with the global health system reforms as advised by the WHO. However, it is worth underscoring the point that while South Africa is not unique in transitioning its health system framework towards universal health coverage, there is general acknowledgement that health reforms in any country must take into account the unique historical and contemporary socio-political and economic circumstances and realities in that country.

A number of articles, in both print and online platforms, have been published as well as ongoing commentary by various commentators on the appropriateness or lack thereof of the NHI as a vehicle for transitioning the South African health system towards universal health coverage. The majority of these articles and commentary have sought to argue and assert that the NHI is not the appropriate vehicle for institutionalising universal health coverage as part of fundamental transformation of the health system in South Africa.

Unfortunately, these articles and commentaries have, in the main, failed to sufficiently and comprehensively outline the exact reasons why South Africa should not proceed to transition to universal health coverage. At best, they have raised issues of the state’s possible technical incapacity to drive these reforms, risks of maladministration and corruption, lack of clarity on the funding mechanisms, and possible constitutional issues related to the reforms.

South Africa has to move beyond the often-sensational reportage on the NHI and seek to comprehensively debate the merits of the proposed NHI reforms anchored on sound conceptual understanding of universal health coverage and the aspiration to redesign the health system to reflect the values of our society.

The NHI is essentially and fundamentally a health financing system meant to mobilise and consolidate all funds meant to finance healthcare services into one pool with the purpose of purchasing and providing access to quality and affordable healthcare services for all South Africans based on their health needs irrespective of their social and economic circumstances.

As South Africa continues to reflect on the implications of the NHI, it is important to locate these proposed critical reforms in the correct conceptual context of what constitutes a national health system. This clarification will allow every South African to have a comprehensive understanding of the political and policy context within which these reforms are located. The health system, according to the WHO, comprises six components which are:

1) Leadership and governance

2) Service delivery

3) Health financing

4) Health information system

5) Health workforce

6) Medical products, vaccines, and technologies.

It is therefore important for South Africans to keep in mind that the NHI is first and foremost about reforming the health financing framework. This aspect of health financing is but one of the six components of the health system and not the sum total of the entire system. Of course, the health financing framework and its mechanisms has direct implications for the other five components.

It is imperative that South Africans are reminded of the socio-political and economic reasons that support the immediate implementation of various policy reforms towards attainment of the goals of universal health coverage. These can be summarized as follows:

– South Africa’s Constitution is unequivocal in recognizing access to healthcare services as a fundamental human right.

– The current South African health system is fragmented, financially unsustainable and perpetuates health inequities in terms of access to services and health outcomes across the population.

– Social solidarity and equity should be non-negotiable principles upon which we build our health system.

The systemic challenges within the public healthcare system of poor quality of care, insufficient budget allocations, inadequate health workforce and medical supplies, weaknesses in leadership and governance, health infrastructure inadequacies, and compounded by constrained sovereign fiscal position are supportive of the endeavour to undertake this much needed reforms now. In addition, the systemic challenges within the private healthcare system such as uncontrollable and unsustainable costs, overservicing, maldistribution of health workforce, lack of clinical governance mechanisms, transparency and accountability also constitute compelling reasons enough for immediate reforms to the entire health system.

Health systems are dynamic and inherently complex systems and therefore reforms are never simple and predictable. However, the complexity and unpredictability of the outcomes of health system reforms is not enough reason to prevent South Africa from embarking upon this crucial transformation of the health system.

* Dr Thabiso Makola is a Public Health Medicine Specialist.

* The views expressed in the article do not necessarily reflect the views of Independent Media or IOL