Healthcare Showdown: South Africans gear up for heated vote on controversial NHI Bill

In a move that promises to reshape South Africa's healthcare landscape, the National Council of Provinces is gearing up for a pivotal vote on the contentious National Health Insurance (NHI) Bill this Wednesday. The bill, which seeks to overhaul the current two-tier health system, has sparked a fierce debate across the nation. Picture: Chris Collingridge/Independent Newspapers Archives

In a move that promises to reshape South Africa's healthcare landscape, the National Council of Provinces is gearing up for a pivotal vote on the contentious National Health Insurance (NHI) Bill this Wednesday. The bill, which seeks to overhaul the current two-tier health system, has sparked a fierce debate across the nation. Picture: Chris Collingridge/Independent Newspapers Archives

Published Dec 4, 2023


The controversial National Health Insurance (NHI) Bill will come before the National Council of Provinces (NCOP) for a vote on Wednesday where a bruising battle is expected to unfold.

The vote on the contentious bill was unexpectedly postponed last week after the Select Committee on Health and Social Services resolved to pass the contentious healthcare bill without any amendments, much to the chagrin of opposition parties and business who have all added their voices for the bill to be halted.

The healthcare sector has openly expressed their dissatisfaction with the NCOP's decision to not introduce any amendments to the bill.

The central point of contention for many business groups, particularly concerning Section 33 of the bill, revolves around the proposed changes to the National Health Insurance (NHI) system. This section specifically addresses the gradual introduction of the NHI and the corresponding gradual discontinuation of private medical aid insurance. As per the bill, once the NHI is fully operational – a decision to be made by the Health Minister – medical schemes will be restricted to offering only complementary coverage for services not covered by the NHI fund.

Critics argue that the stipulations in this section could challenge constitutional rights, particularly the right to health. Solidarity, a prominent trade union, has already announced plans to contest this aspect of the bill on constitutional grounds.

At its core, the bill seeks to dismantle the existing 'two-tier' health system in South Africa. Currently, the majority of healthcare expenditure is concentrated in the private sector, serving a minority, while the larger population depends on the comparatively under-resourced public health system.

The proposed legislation envisions the establishment of a unified NHI Fund, under state management. This fund would be responsible for purchasing healthcare services from both the public and private sectors.

A key feature of the bill is the provision of free services at the point of delivery to the public. Additionally, it outlines that once a healthcare service is incorporated under the NHI, medical schemes will be prohibited from covering it. This clause essentially signals the gradual elimination of private medical insurance in the country.

The Health Funders Association (HFA), a representative body for medical schemes in South Africa, has raised significant concerns over the National Health Insurance (NHI) Bill, highlighting potential obstacles to the nation's journey towards equitable healthcare access for all. The association warns of the political influence overshadowing the primary mission of enhancing national wellbeing in this critical healthcare reform.

Craig Comrie, chairperson of the Health Funders Association (HFA), expressed deep concerns about the practical execution of the NHI as proposed in the bill.

"The practical barriers to successfully executing NHI as it is laid out in the bill are hard to ignore, and yet the numerous concerns and suggestions raised in the consultation process have not been considered or implemented," Comrie said.

He pointed out the overlooked shortcomings of the NHI Bill, especially regarding practical funding mechanisms and collaboration with experienced health funders. According to Comrie, only the Western Cape has rejected the bill in its current form.

Comrie urges for the reconsideration of the bill, highlighting that it is still possible to amend the legislation effectively.

"There are constructive solutions to address the problems identified in the NHI Bill effectively, and it is not too late to fix the legislation," he said.

Comrie also commented on the timing of the bill's advancement, suggesting political motives ahead of next year’s election.

"The timing of the recent flurry of activity in moving the bill through the necessary hoops ahead of next year’s election invites the notion of a blunt instrument, an unrealistic election promise, rather than a pragmatic solution for the highly complex health challenges South Africa faces," Comrie added.

The official opposition party, the Democratic Alliance (DA), plans to reject the bill when it comes for debate on Wednesday, citing several reasons for its opposition, including financial feasibility in a post-pandemic economy, increased taxation burden, potential emigration of doctors, and inadequate public health facilities. They also express concern over the extensive powers the bill would grant to the Health Minister without adequate oversight.

Business Unity South Africa (Busa) and Business for South Africa (B4SA) have also raised alarms over the bill’s progress through the NCOP, expressing deep concerns about the lack of due process and constitutional issues. In their letters to the NCOP and Deputy President Paul Mashatile, the organisations have urged for a deferral in considering the bill until substantial engagement on the comments and proposals by stakeholders, provincial legislatures, and the Department of Health has taken place.

Cas Coovadia, CEO of Busa, condemned the manner in which the NCOP is handling the bill.

"For the National Assembly and the NCOP to disregard proposed amendments that will have a beneficial and tangible impact on citizens, or indeed would prevent harm to citizens, in the interest of rushing the bill through Parliament, is unconstitutional," Coovadia stated.

Busa and B4SA argue that the NHI Bill, in its current form, is unimplementable and poses severe consequences for South Africa's economy and citizens.

Coovadia points out the lack of clarity in the bill regarding funding, benefits, management, and governance, among other critical aspects.

The organisations have also cautioned against the establishment of a single fund for the NHI, warning of unsustainable tax increases and economic risks.

A key criticism from the two bodies is the bill's lack of provision for public-private sector collaboration.

They have proposed an amendment to Section 33 of the Bill, which currently restricts the role of medical schemes upon full implementation of the NHI. This restriction, they argue, would limit healthcare access for over nine million South Africans and destabilise the private healthcare sector.

Martin Kingston, chairperson of the B4SA Steering Committee, highlighted the potential legal challenges and ramifications of hastily passing the bill.

"Government’s mandate is to act in the best interest of all of its citizens. It is totally irresponsible to rubber-stamp into law (something) that will have such a severe impact on the country and her people," Kingston said.

Both organisations emphasise the importance of integrating low-cost medical aid options and implementing the 2019 recommendations of the Government's Health Market Inquiry to reduce private medical aid costs. These measures, they argue, would relieve pressure on the public healthcare sector and align with the goals of the NHI without imposing undue financial burdens.

By amending the NHI Bill and implementing these reforms, Busa and B4SA believe that South Africa can construct a more effective healthcare system, attracting investment and retaining healthcare professionals, without resorting to unsustainable tax hikes or increasing national debt.

“These proposed amendments and reforms will strengthen the NHI, to secure access to quality healthcare for all citizens, for generations to come,” Kingston said.

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