The praxis of statecraft: NHI made law “puts to an end the apartheid two-tier health systems”

President Cyril Ramaphosa signing the NHI into law at the Union Buildings in Pretoria.

President Cyril Ramaphosa signing the NHI into law at the Union Buildings in Pretoria.

Published May 17, 2024


Finally, the long-awaited unprecedented progressive National Health Insurance Bill (NHI), was signed into law by His Excellency President Cyril Matamela Ramaphosa, which will grant access to free equitable, quality healthcare to the rest of millions of South Africans, ‘without financial hardship’ consequently put an end to the apartheid two-tier health systems.

An enormous “due consideration” and public signing ceremony was a turning point in South African history, which was an irreversible legislative hallmark towards Universal Health Coverage (UHC) by removing all the barriers to integration of the people, to have access to health care services. The NHI ACT will ensure that every South African has “access to equitable quality of health care services, without facing financial hardship to reduce maternal mortality and addressing inequality” as outlined by the United Nations Sustainable Development (UNSD) goal number 3 under UHC.

But despite this progressive fundamental policy shift since 1994, under the ANC-led government’s great strides, I was "utterly dismayed" by barrage of propaganda and myths floodeding South African media discourse by the forces opposed to progressive change in our country, such as the Democratic Alliance, Afriforum and Solidarity who paraded outside the union building in protest against transformation health care for all, demanding that apartheid two-tier systems ‘status quo’ of health inequality must remain after 30 years of democracy

President Cyril Matamela Ramaphosa said “NHI is fundamentally about social justice. NHI will ensure that all our people, whether you are black or white, rich or poor, will be able to access a comprehensive range of health care services”

Accordingly, the root of the problem can be found in our two-tiered health system we inherited from the apartheid era, which reproduces the inequalities in access and good quality care. It is a system made of medical-aid funded and highly resourced private health care (“the first tier”), designed primarily for the rich and the publicly under-funded public health care for the poor majority (“the second tier”).

The NHI Act has proposed a publicly financed national health insurance programme that would fully cover health care for all South Africans. NHI is therefore universal, comprehensive, and affordable and will provide free health care at the point of use. This will eliminate the need for a two-tiered healthcare system dominated by private health insurance and create a single, unified national health system.

We in the African National Congress (ANC), have long declared that the answer to our two-tiered healthcare system is not an incremental, market-driven solutions as suggested by the Democratic Alliance (DA), to problems of health coverage and quality healthcare. All DA seeks to do, is to maintain the central role of private health insurance dominated by Health Administrators, in our national health system, thereby reproducing the inequalities in health care.

What needs to be changed is the two-tiered Health Systems itself

As the NHI White Paper notes: NHI represents a substantial policy shift that will necessitate massive reorganisation of the current health care system, to address structural changes that exist in both the public and private sectors. It reflects the kind of society we wish to live in: one based on the values of justice, fairness and social solidarity. Implementation of NHI is consistent with the global vision that health care should be a social investment.

The White Paper also notes that: “ The implementation of the NHI is underpinned by vision 2030 of the National Development Plan (NDP which envisions that by 2030, everyone must have access to an equal standard of care, regardless of their income and that a common Fund should enable equitable access of health care regardless of what people can afford or how frequently they need to use a service”

In this regard, the NHI Fund will be fully functional, with access to all revenue collections; covering the majority or entire population; and purchasing capacity to pay accredited health providers who meet quality standards.

The DA press conference outside the Union Building was hogwash characterised by myth, which we have a national duty and obligation to demystify bare before the people.

Myth #1: ‘Healthcare will be nationalised’

The DA claims that the NHI will “nationalise healthcare”. Nowhere in the NHI ACT, NHI Bill, nor in the green and white papers, is the word ‘nationalisation’ used. Instead, the bill says it will purchase services from public and private healthcare providers – which include hospitals, private specialists and general practitioners as well as allied health professionals in private practice. The NHI is not going to do away with private health providers, but it will operate in a completely different environment from the status quo.

• Firstly, the NHI will not allow health providers to charge the huge fees they do, especially private hospitals.

• Secondly, a healthcare provider will not be allowed to start treating patients and then send them away once their medical aid funds are exhausted

• Thirdly, private ambulance providers will no longer be allowed to pick up only people who have medical aid, credit cards or cash at the scene of an accident and leave behind the poor. Under the current system, a private provider may charge you extra cash over and above what your medical aid has paid it.

Myth #2: ‘We cannot afford NHI; it is too expensive’

It is the current system, in which South Africans spend over R400 billion, that shows signs of unsustainability. Government spends 4.4% of our gross domestic product (GDP) on the health needs of 17% of the population, leaving 83% with a measly 4.1% of the GDP. The World Health Organisation (WHO) and the Organisation for Economic Cooperation and Development (OECD) have declared South Africa to be an outlier as we are the only country to spend so much on a minority of the population – a practice akin to apartheid, differing only by income levels.

The NHI is designed to ensure that existing health resources – funding and human resources – are rationally distributed and shared among all citizens. It will guarantee healthcare to the entire population, based on principles of social solidarity (the rich subsidising the poor), efficiency (reducing waste in the current healthcare funding model) and effectiveness. So, it is not about whether the NHI is affordable, but about making it affordable.

Myth #3: Additional tax burden

To redistribute existing healthcare resources to ensure equity, there will be changes in the way we collect revenue for healthcare. This will include removing user fees in the NHI-funded services and increasing our taxes, based on the principle of social solidarity. Out-of-pocket expenses will play no role, and medical scheme contributions will need to be reduced as the future role of medical schemes is redefined. The DA plan does not say how it will offset the high cost of out-of-pocket expenses experienced by South Africans who have medical aid or not.

Myth #4: NHI fund will be a ‘state-owned enterprise’

Nowhere is the NHI fund called a state-owned enterprise (SOE). It will operate like a Section 3A public entity. It will create a single pool of funds for universal health services, enabling the country to have the capacity to strategically buy services from public and private health providers, and achieve significant efficiencies. In many countries with single strategic purchasers like the NHI fund, administration costs are below 2% – far lower than medical schemes’ existing costs, which average between 10% and 12%.

Like other SOEs, we are aware that the NHI fund may be vulnerable to corruption, and in this context, we will ensure that it is not only managed with transparency and accountability but that it also has built-in anti-corruption measures in place, with robust oversight by the legislature, our investigative agencies, civil society groups and other agencies. The Presidency has already established fraud detection and prevention strategies before a cent is transferred to the NHI fund.

NHI is the bedrock in which the African Claims was founded in 1943, coupled with freedom Charter clause number 08, which asserts “A preventive health scheme shall be run by the state; and free medical care and hospitalisation shall be provided for all, with special care for mothers and young children” Those who doubt the President they do so in their own peril, South Africa witnessed a watershed, great leap forward in health care for all

DA, Afriforum and Solidarity are opposed to constitutional democracy

Don’t be fooled. the DA and Afriforum and solidarity in their philosophy represent narrow minority ‘white supremacy’ and the apartheid era separate, two-tier health care systems, they represent private individual dominant health care represented by super-rich administrators, a network of the health insurance and medical schemes not the majority of people precisely because they are against section 27 of the constitution. They want the court to make the law, not the legislatures which is against the principle of our representative, participatory, constitutional democracy, and against the rule of law

It is time for the DA, Afriforum and solidarity, to stop political grandstanding and misleading our people, whilst they know as a subjective factor that they represent and defend the old apartheid-era policy which in objective reality has no room in the democratic era. All patriots to the front to defend health care for all in the form and content of the National Health Act. Let's join our collectively efforts to help address the health needs and aspirations of our people through the implementation of an NHI that we can be proud of, after more than 350 years of persistence of the dominance features the colonialism of a special type.

We salute His Excellency President Cyril Matamela Ramaphosa for statecraft, a clear and explicit decision-making process in the interest of the population as a whole

“Let ‘s do more, together”

Tshilidzi Munyai is a former ANC Whip and Acting Chairperson on the Health Portfolio committee and current ANC Gauteng PWC Member, ANCGP Convenor of the Subcommittee of the PE Chairperson on Education Portfolio Committee, Chairperson of the Economic Cluster, and Principal of the ANC Caucus Department of Political Education and Training.

The Star