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State of SA Hospitals: Are we ready for government's ambitious National Health Insurance?

Picture: Pixabay

Picture: Pixabay

Published Apr 22, 2022


Durban - Despite the setbacks of the Covid-19 pandemic, South Africa will forge ahead with the rollout of the National Health Insurance said Foster Mohale, the national spokesman for the Department of Health.

“Parliament has opted for virtual public hearings few months ago to process the bill,” said Mohale.

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He said the implementation of the NHI will ensure that all people - poor, rich young and old, would have equal access to quality, accessible and affordable healthcare services.

“Of course there are many challenges facing the public health sector which include shortage of specialists who are attracted by good salary packages in the private sector, and overseas job opportunities.

“However, we believe that once all legislative process have been concluded, this will be implemented in phases.”

But is South Africa ready to roll out the National Health Insurance?

According to Dr Ozayr Mahomed a public health medicine specialist based at UKZN, it is highly unlikely.

Citing a number of recent publications and reports, Dr Mohamed, attributed the Covid-19 pandemic and the precarious position of the South African economy that has resulted in a reduced budget being allocated for the NHI, to reach its target by 2030.

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“A limited costing of the national health insurance policy proposal has shown that it would require about R40 billion per year in additional funding in the first five years, and perhaps considerably more over time.

“At present, however, there is insufficient capacity in the health sector to work substantively on national health insurance,” said Mohamed.

He said other reasons included that the national health insurance indirect grant had been underspent.

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“The National Health Insurance Fund has not yet been established, and the National Health Insurance Bill still needs to be passed by Parliament.

“It is therefore unlikely that national health insurance will be implemented in the previously stipulated time period.”

Unpacking the NHI, Mohamed said in 2020 healthcare spending in the country equated to an estimated R 332 billion.

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Despite the huge investment in healthcare services, the health outcomes in South Africa are poorer than many lower middle income countries largely due to the inequitable distribution of resources.

He said South Africa has a two-tiered system characterised by a large and under resourced public health sector that caters for an estimated 84% of the population.

The private sector, said Mohamed which was funded through voluntary medical aid contribution, provides first-world health care to approximately 16% of the population.

He said it was important to note that spending in the private sector is equivalent to the amount in the public health sector.

The South African government proposed the National Health Insurance in 2011, in a move in a bid to transform to a unified health system that would allow the country to move towards universal health coverage (UHC), and reach the sustainable development goals (SDG) by 2030.

The seven features of the NHI are linked to the three principles of universal health coverage namely

• Population coverage- All South Africans including asylum seekers will have access to needed health services that are of sufficient quality and are affordable without exposing them to financial hardships.

• Service coverage: NHI will cover a comprehensive set of health services that will provide a continuum of care from community outreach, health promotion and prevention to other levels of care

• Cost coverage- NHI will ensure that individuals and households do not suffer financial hardship by eliminating various forms of direct payments such as user charges, co-payments and direct OOP payments to accredited health service providers

“Although the overall aims, objectives and outcomes of the National Health Insurance will be beneficial, the attainment of this ideal has a number of hurdles to cross prior to reaching fruition.

“Except for intermittent announcement to raise the hype and score brownie points communication on the specifics is vague and the entire process is proceeding too slowly and in a way that is not sufficiently clear,” Mahomed said.

The journey has to begin whether we are ready or not’:

Russell Rensburg, the Director of Rural Health Advocacy Project, said while we may never be ready for the NHI, we have to begin the difficult journey of health reform.

“The pandemic did unmask the inequity between the public and private health systems.

“Despite private healthcare only covering 15% of the population, close to half of Covid-19 related hospital admissions occurred in the private sector, suggesting that the ability to pay was a greater determinant of access to care than need,” said Rensburg.

The NHI is a financing mechanism which can drive improvement in how public heathcare is funded, organized, and delivered.

“It can strengthen public sector facilities by creating a mechanism to contract in capacity and improve health care for all. I don't think it will displace medical schemes, but it can improve the accessibility and responsiveness of healthcare.”

Rensburg said there were a myriad of challenges from sufficient funding to distribution of capacity like human resources for health.

“We simply don't have the funding to meet all our healthcare needs and we must begin looking more intentionally at how best we use existing resources to better serve people most in need.”

He said despite significant investments in health system to address the Covid-19 risks the death toll remained amongst the highest in the world.

The official death rate was just over 100 000 for the two years , while the excess deaths was almost double this taking the total death rate to over 300 000.

“As publicly funded healthcare is reliant nationally weak economic projections (growth with only return to pre pandemic levels in 2 years) suggest the aftershocks to publicly funded programs may weaken an already fragile health system.”

Rensburg concluded that South Africans in general were not a healthy nation.

“We use the Universal Healthcare index which tracks three broad areas - Reproductive and Maternal Child Health.

“This includes access to sexual reproductive health services, childhood routine vaccinations and ante natal care.

“Prior to the onset of Covid we were making progress, but this progress is now at risk with access to reproductive health services remaining a particular challenge.

“In respect of infectious diseases like TB, deaths have risen for the first time in a decade and non-communicable diseases such diabetes continue to rise.”


The National Health Insurance Bill was tabled in Parliament on the 26 th of July 2019.

Phase 1 commenced in 2012 and was completed in 2017.

The first phase piloted various health system strengthening interventions focused at the primary health care (PHC) level.

The interventions implemented during this phase were mainly funded by a direct NHI Conditional Grant to provinces.

The National Minister established six work streams in 2015 to make recommendations to the Department.

The six work streams wer identified to support the phased implementation of NHI. These workstreams comprised a combination of health department technocrats and external experts to :

  • Prepare for the establishment of the NHI Fund;
  • Design and Implementation of NHI Health Care Service Benefits;
  • Prepare for the purchaser-provider split and accreditation of providers;
  • The role of medical schemes in an NHI environment;
  • Complete NHI Policy paper for public release; and
  • Strengthening the District Health System.

Although, Phase 2 of the NHI was initially envisaged for 2017-2022, the National Health Bill was submitted before parliament in 2019.

The Covid-19 pandemic has diverted resources from the implementation of the NHI.

The second phase of the NHI now expected to commence in 2022 will entail the development of systems and processes to ensure effective functioning and administration of the NHI Fund. These reforms are categorised into four items:

  • Financing;
  • Health service provision;
  • Governance;
  • Regulatory.

Phase 3, between year 2021-2025, will be the introduction of mandatory prepayment for the NHI, contracting for accredited private hospital and specialist services, finalisation and implementation of the Medical Schemes Act, and finalisation and implementation of the NHI Act.