Unpacking the new National Health Insurance white paper

While the world’s attention was diverted by the news that President Jacob Zuma had fired former Finance Minister Nhlanhla Nene in December 2015, another equally important news story affecting the future of all South Africans almost went by unnoticed.

Health Minister, Dr Aaron Motsoaledi published the eagerly-awaited white paper on South Africa’s proposed national health insurance (NHI) in early December – a critical policy document that has been in the making for four years.

Initial reaction to the white paper has been mixed. Many critics point out that there is not enough clarification on a number of issues; such as how the new healthcare system will be funded, how doctors in private care will be affected and how government will ensure enough doctors and nurses are available to provide services in rural areas.

ICON Chief Operating Officer Ernst Marais says while the NHI should be commended for wanting to improve access to healthcare, there are many questions about the practicality of the document in terms of implementation.

“We agree with the minister that quality healthcare in South Africa needs to be more affordable and accessible to all,” says Dr Marais. This is, after all, one of the biggest driving forces behind the Independent Clinical Oncology Network (ICON) – delivering quality cancer treatments at affordable rates to more patients.

Dr Motsoaledi has said that the NHI is not about abolishing private healthcare, rather it is about re-engineering the primary healthcare system. The new NHI is envisioned as a state-administered fund paying for all healthcare, with medical aid schemes providing only top-up cover.

According to the government website, the NHI wants to: “transform the South African healthcare system with emphasis on the promotion of health and the prevention of diseases. It also seeks to provide access to quality and affordable healthcare services for all South Africans based on their health needs, irrespective of their socio-economic status.”

It will be implemented within 14 years and pilot districts have been established in all nine provinces. One of the big issues is financing – the cost of implementing the NHI is projected to be R225 billion by 2025. It is not clear where the money will come from to finance implementation. Some options put forward include a payroll levy for all employed South African citizens, increased VAT or an income tax surcharge.

This will no doubt not be welcomed by most South Africans, who already have to deal with rising food and electricity prices on top of a weak currency and an escalating drought.

It is also not clear how the private sector will work alongside the public sector and how all of this will impact on medical aid schemes or doctors who may be required to work in certain areas. Some experts have expressed the opinion that this could lead to a brain drain of doctors and nurses.

Neil Kirby, director of Healthcare and Life Sciences Law at Werksmans Attorneys, says the proposed NHI brings with it controversies relating to both the scope and ambit of the services to be provided and the costs of providing those services. He also says the possibility of raising taxes and levies and the constitutionality of forcing people to belong to a system and then nevertheless requiring them to pay for that privilege also poses problems.

The public has been given a period of three months to comment on the white paper.

“South Africans should get involved in this process,” says Dr Marais. “Improving on healthcare and ensuring all South Africans have access to doctors and medical services is of paramount importance to all – both in the private and public sector.”