In 2018 the Ministry of Health released two bills which could make universal health care a reality for South Africa. These were the National Health Insurance Bill (NHI Bill) and the Medical Schemes Amendment Bill (MSA Bill). The NHI Bill will facilitate the implementation of National Health Insurance (NHI). NHI is a financing system that will ensure that all South African citizens and legal residents are provided with essential affordable healthcare, regardless of their economic status and / or their ability or inability to contribute monetarily to the NHI Fund.
The NHI Bill in particular is expected to materialise the right to universal health care which is one of the 17 Sustainable Development Goals of the World Health Organisation. The realisation of this goal would ensure that all people receive the health services they need without “suffering financial hardship”.
The rationale behind legislating NHI is that it will be publicly financed to provide uniform, affordable and accessible quality health services to South Africans based on their needs, irrespective of their socio-economic status. It also seeks to eliminate the huge disparities between access to health care services in the public and private sectors.
According to government’s White Paper on NHI, it will cost R256bn in annual funding, to fully implement NHI. However, funding such a bill could be the NHI’s biggest stumbling block to its implementation. This is because funding the NHI could be seen to be at the expense of other National Development Plan programmes such as education.
The NHI Bill represents a substantial policy shift and for it to succeed, government needs to strengthen a number of key aspects. Firstly it needs to address its long standing human resource issues. Secondly, it must address financial management in particular with respect to procurement and supply chain management and lastly and equally importantly it must address the need for proper and regular maintenance of infrastructure. Government will also need to address the perception by most of the public that they do not and will not receive quality health care from the public sector.
The above will need to be addressed as a matter of urgency so as to avoid the repetition of the Life Esidimeni tragedy.
The MSA Bills interaction with the NHI Bill is not fully apparent. What is apparent however is that the MSA Bill is expected to improve the regulation of the medical schemes industry and to align the regulatory framework. Technically the MSA Bill will not only regulate medical schemes it should also eliminate the payment gap members of medical schemes would have had to cover for private healthcare.
The road to implementation of NHI began in August 2011 when the Green Paper on NHI was introduced and it was announced that it would be implemented after the completion of three phases. The first phase, from 2012 to 2017, focused on piloting health system strengthening initiatives, the establishment of the NHI Fund and key institutions; and the moving of central hospitals to the national sphere.
Phase 2, from 2017 to 2022, will be focused on ensuring the NHI Fund is fully functional and has the required management and governance structures so that the purchase of services and population registration can begin. Phase 3, from 2022 through 2026, will signal the introduction of mandatory prepayment and the contracting of accredited private hospital and specialist services as well as the finalisation of the Medical Schemes Amendment Act.
Following the parliamentary process, which includes a public participation phase, and the referrals to the National Assembly and thereafter to the National Council of Provinces (NCOP), the Bills will then be be referred to the president who must sign them to enact them. During this time DOH will need to continue preparing for implementation by continuing to register patients into a master patient register to prepare for the implementation of NHI.
The Ministry of Health will also have to set up an NHI Implementation Office to prepare for the introduction of the NHI Fund.
Already there have been key interventions including the filling of vacant posts for health personnel, improving and maintaining hospital and clinic infrastructure, improving access to medicines, equipment and medical products. But much more remains to be done. The Office of Health Standards Compliance will certify health facilities that will become part of NHI.
The National Quality Improvement Plan will be implemented in preparation for the accreditation of providers and establishments to provide NHI services. Only time will tell if all these interventions will ensure that NHI will indeed become a reality.
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