Comment: NHI issues; basket, budget and biceps

Nurse takes blood pressure. (File photo)

Much has been said, and, and in all likelihood a lot will still be said about the proposed National Health Insurance Scheme for South Africa.

Health care remains a volatile topic as a mirror to reflect the socioeconomic status of millions of South Africans. As such, the construction of a National Health Insurance Scheme remains both topical and controversial.

The matters that feature prominently in the architecture of any proposed National Health Insurance Scheme are arguably the following –

  • the basket, being the particular range of benefits that will be available to subscribers of the scheme. The range of services to be provided is an important aspect of any National Health Insurance Scheme. To date, the indications are that the basket will consist primarily of primary health care benefits with an emphasis on preventative health care with the delivery of such care taking place primarily at municipal and primary school level;


  • the budget, being the costs of constructing, running and maintaining a National Health Insurance Scheme and how those costs are to be determined and from where those costs are to be obtained in light of South Africa’s current fiscal circumstances and those that are projected to continue well into the future. The financing of a National Health Insurance Scheme is yet to be determined and have only been mooted in a white paper for possible consideration. However, proposals pertaining to the payment of the subscriptions by salary deductions or through employerbased incentives, remains controversial especially in light of the spotlight thrown onto health care budgetary constraints by the Life Esedimeni Report and the subsequent recommendations by the Health Ombud;


  • the biceps, being a matter in twofold: both the staffing of the National Health Insurance Scheme by properly resourced and qualified healthcare practitioners and the strength of the National Health Insurance Scheme actually to address the burden of disease in South Africa. The availability of healthcare practitioners is problematic with recent reports of a complete absence of trained personnel in oncology in the public Health Department in KwaZulu-Natal and a 2014 article that appeared in the New England Journal of Medicine by B M Mayosi and S R Benatar entitled “Health and Health Care in South Africa – Twenty Years after Mandela”, which deals with research conducted on the status of the availability of health care practitioners in South Africa. With reference to the availability of health care practitioners in South Africa, Mayosi and Benatar comment as follows –

“However, expectations that equity in health care delivery could be achieved at levels close to current privatesector levels appear to be unrealistic. It is clear from the disparities in funding of the private and public sectors and the very large number of additional health care professionals required that this is unlikely and, if achievable, would take a very long time.”

NHI malnourished

National health insurance is touted as the answer to South Africa’s socioeconomic and health care delivery woes. However, as it currently stands, the National Health Insurance Scheme is entirely malnourished suffering already with a lack of healthcare expertise in the form of appropriate resources for the delivery of services to the current South African population, with reference to the existing burden of disease based on HIV and AIDS, tuberculosis, malaria and physical injury. In addition, determining appropriate funding remains largely problematic on the basis of an already beleaguered population dealing with corruption and State capture which implicate billions of Rands.

The idea of a National Health Insurance Scheme, which has been in the offing since the Essential Drug Policy was published in 1996 and the Green Paper published on 15 September 2011, is in stark idealistic contrast to the social problems now besetting South Africans. Promises of access to health care are powerful statements, which is why such a statement is set out in the Bill of Rights. However, making a statement pertaining to accessing health care for millions of South Africans who may not enjoy that privilege currently, becomes emotionally distressful when that access is either not provided or fails to meet the health care expectations of South Africans in desperate need of even the most basic health care.

Clarity needed

For Government to achieve the successful construction of a National Health Insurance Scheme, in my view, clarity is required on at least those issues referred to above, being the basket, the budget and the biceps. According to Mayosi and Benatar –

“Efforts to achieve sustainable improvements in health with limited resources and much reduced prospects for economic growth call for improved health care management and governance and wide spread shifts in attitude to ‘doing better with less’. Sustaining the ambitious national shift into a new paradigm arguably requires that other countries also make major shifts in their policies and expectations to facilitate survival on a planet with increasing constraints on natural resources and many threats to a now fragile ecologic environment.”

Neil Kirby is Director of Health Care and Life Sciences Law at Werksmans Attorneys 



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