This week President Cyril Ramaphosa signed the National Health Insurance (NHI) scheme into law, saying that it’s an important instrument that will tackle poverty and also make healthcare easily accessible to every South African.

“The rising cost of health care makes families poorer.[ By contrast], health care provided through the NHI frees up resources in poor families for other essential needs. The NHI will make health care in the country as a whole more affordable,” Ramaphosa said. 

Globally there’s been a push towards ensuring that everyone has access to quality health care where and when they need it, regardless of their socioeconomic status. This is a concept known as universal health coverage (UHC). Various countries have introduced different iterations of the concept, most famously the United Kingdom’s NHS. 

In South Africa, the NHI Fund is the vehicle that the government will use to implement universal health coverage. All monies spent on health services in the private and public sector will be pooled into a single, state-owned NHI Fund. South Africans will then be able to access a select package of health services from doctors and facilities in either the public or private sector, without paying these healthcare providers out of pocket. 

But this isn’t going to happen overnight. Professor Charles Hongoro, the deputy executive director of Human Sciences Research Council’s Developmental, Capable and Ethical State research division, explains that the NHI is one of the major transformative policies to be implemented since 1994.  

“NHI will integrate our currently mixed health system which does not benefit the majority of people because of the disproportionate allocation of resources for a few. The NHI act bill and policy will be implemented incrementally,” Hongoro says. 

Right now, nothing changes. People who are on medical aid will continue paying membership contributions and making use of private health services. And those who cannot afford to pay for private care will continue suing government health facilities.  

Phases of implementation 

Speaking at the signing of the NHI Act, Health Minister Dr Joe Phaahla explained that the NHI will be rolled out in two phases. The first phase started in 2023 and will run up to 2026. “In the first phase the focus will largely be on setting up the institutions needed for a successful NHI,” he says. 

Some of these institutions such as the Office of the Health Standards Compliance already exist.

“The second phase is expected to run from the middle of 2026 to 2027 and will focus more on the actual implementation of the programmes and purchasing of the services.”  

Health policy expert Dr Bandile Hadebe adds that, for the act to be functional, around 20 regulations need to be introduced. 

“One of the biggest mistakes we have made in navigating the NHI conversation is assuming that the act is a silver bullet. For a functional health system there are several other things that need to be considered. NHI will not suddenly give us 10,000 doctors overnight or give us quality infrastructure, there needs to be funds for that.” 

Points of concern

Dr Jeremy Nel, head of the Infectious Disease Research Institute at the University of the Witwatersrand, says there are three major hurdles to the NHI project:

• “The first is whether it is even a good idea in theory, given that we already have a state funded healthcare system with universal access to health enshrined in the constitution.
• “Even if the proposal is a good idea, there doesn’t appear to be any viable way to fund it. 
• “There are also obvious concerns with any big centralised asset base under the current government’s control given the dismal record of corruption and maladministration in almost every other state project,” he says.

Various political parties, doctors organisations and healthcare funders have said that they would turn to the courts to challenge certain provisions of the NHI Act. – Health-e News

Additional reporting by Oratile Kekana