KATLEGO MOTHUDI: Smoke and mirrors hide NHI’s flaws

The second presidential health compact, which was signed by the government and a few signatories from the health sector, purports to be a framework for co-operation for good healthcare outcomes. However, it has deviated from this path, using smoke and mirrors to promote the legally flawed and unconstitutional National Health Insurance (NHI) Act.

In defence of the second compact, the government has made several misrepresentations about the private sector and its support for the previous compact, which was signed in 2019. Most importantly, it has misleadingly stated that the first compact focused on the NHI and that the private sector was involved in the development of both compacts.

However, the first compact was meant to strengthen the existing health system — it was not about the implementation of the NHI, or an agreement to do so. Being a signatory to the first compact was therefore not an indication of support for NHI.

The emphasis in the second compact falls squarely on NHI as what is now the prevailing health policy in the country. Holding the view, as we do, that the NHI Act deserves constitutional scrutiny means we cannot be seen to be in support of the second compact as it is framed. This approach is entirely consistent since, as most people realise, the NHI will weaken, not strengthen, the health system. 

This is because the NHI Act if implemented in its current form  would complicate and compromise provider contracting and impose significant limitations on members of the medical profession. It is also unaffordable and will concentrate excessive power in national government.

While the first compact envisaged public-private partnerships to create stronger health systems, the second compact is aimed at supporting the implementation of the NHI Act, which at its core aims to centralise healthcare. The Board of Healthcare Funders (BHF) wholeheartedly rejects this approach because it will have the effect of undermining the government’s stated aim of achieving universal health coverage.

The BHF was a signatory to the 2019 compact because we are committed to working with government to achieve the provision of high-quality universal health coverage, and because the 2019 compact envisaged meaningful inputs from the private sector in formulating an appropriate health policy for the country. Yet in a breathtaking display of bad faith, the flawed NHI Bill was introduced in parliament a month after that compact was signed.

Critically, the government did not include the BHF in any discussions on the second compact or expressly request us to be a signatory. In fact, the latest compact was drafted unilaterally by the government, with limited inputs from the private sector. For this reason, we view it as nothing more than a tick-box exercise designed to co-opt stakeholders into supporting the NHI Act and creating the illusion of public participation.

No amount of smoke and mirrors will conceal the defective lawmaking process that culminated in President Cyril Ramaphosa signing and assenting to the NHI Act. Yet based on recent statements in the media by the health minister, no amount of engagement will change the NHI Act as it stands either.

The BHF has been clear about our concerns on the NHI and we used every avenue available to us, including the public comment processes, to make our submissions when the bill was before parliament (in both houses). However, every material input made by organisations and concerned citizens during the public participation process was ignored by the president when he hastily signed the bill a few weeks before the general elections.

This is why the BHF has gone to court to compel the president to provide his record of decision on the matter. The truth is that the NHI Act is unworkable and unconstitutional. It will reduce the critical role the medical scheme sector plays in providing access to quality healthcare to at least 9-million South Africans.

And, contrary to the misperception peddled in some quarters, medical scheme members come from all backgrounds, with 68% from previously disadvantaged groups. The bulk of medical schemes’ members are not wealthy. They are ordinary workers who have chosen to part with their hard-earned income to be able to access quality healthcare.

Contrary to some messages being peddled, providing NHI benefits is not just about adding healthcare expenditure from the private sector to public expenditure. Doing so will reduce the benefits available to beneficiaries and potentially to the public.

Reducing healthcare benefits, even for just one medical scheme beneficiary, is unconstitutional because section 27 of the constitution provides a right of access to healthcare services, and the NHI will place severe restrictions on the kinds of services people are able to access, and the manner in which they currently access those benefits.

While the legislation is fundamentally and fatally flawed, our concerns should not be misinterpreted. The BHF is not opposed to the implementation of a scheme that achieves universal access to health coverage. We simply believe that if universal health coverage is the goal, the people of this country will be better served if the NHI and medical schemes are able to coexist. If people choose to access healthcare through a medical scheme provider, that is their right.

In fact, an alternative, multi-payer model that allows the private sector to provide the same services the government does would lessen the burden on public healthcare, increase much-needed funding for healthcare and play a vital role in furthering access to healthcare for all South Africans.

Our stance towards the second compact and the NHI is not one of stubborn opposition, but of principled apprehension. This is why the BHF participated in the public hearings and parliamentary processes around the NHI Bill — because we believed considered inputs and meaningful dialogue would bring us closer to a workable NHI model and meaningful universal health coverage.

The BHF remains committed to working with the government to strengthen the health system so that all South Africans are provided with access to good quality healthcare. We are therefore deeply concerned that the government has chosen to ignore the private sector’s inputs and is now using the second compact to feign buy-in from stakeholders to what is stated in the NHI Act.

The second compact cannot fix what is fundamentally flawed in the NHI Act, and to believe otherwise is a dangerous and legally fatal assumption.

• Mothudi is MD of the Board of Healthcare Funders.