23/06/2018 06:55 SAST | Updated 23/06/2018 07:01 SAST

NHI: What, Why, When, How? — All Your Questions Answered

What is National Health Insurance and how will it affect you? It's complicated. Here are a few of the things we know.

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On Thursday, Health Minister Aaron Motsoaledi introduced two new pieces of legislation that, if implemented, will overhaul the healthcare system. Ultimately, they will create a new system for medical aids and a universal, state-run healthcare system. In tandem, these changes are supposed to do away with the unequal system we have now, where poor people are forced to use the low-quality public healthcare system while the rich can afford top-notch, private facilities.

But how this is going to work, when, and with whom, is still very much up in the air. In short, the system is going to be complicated, and even the best experts and journalists in the field have many questions. Here are the answers to a few things that we know:

What bills?

Motsoaledi wants to create a single healthcare system that would provide free, quality healthcare for all. In order to do this, he has gazetted two bills for public comment. They have been approved by Cabinet, and will go some way to creating the enabling legislative framework to create this single system. (It's a little more complicated than just two, bills, however, as Motsoaledi said at least 12 more pieces of legislation would need to be amended to make these two bills legal.)

The bills are:

Medical Aid Schemes Bill

Motsoaledi wants all the public and private healthcare funds to be pooled into one fund run by the state. This fund will act like a state-run medical aid for everyone.

Government also wants a centralised database of everyone who is on medical aid, which will include all of their personal details and treatments. It is unclear how this will work since the public healthcare system is still paper-based. The bill also aims to regulate medical aid tariffs. The minister wants uniform tariffs. "We cannot continue to run a system where people are paid differently for the same services," he said. It is not yet clear what these tariffs are or how they will be determined. There will also be no copayments on fees. Motsoaledi says medical aids have R60-billion in reserves which can be used to replace this. However, medical aids are legally required to pool this money, something they have opposed for years.

National Healthcare Insurance Bill

In short, the bill is to give effect to the need for an inclusive, free, quality healthcare system run by the state. In the minister's own words:


Both bills have now been gazetted for public comment, and they will be sent to Parliament after this process. So for now, they are not the law.

At the briefing, Motsoaledi explained that while the NHI is to be phased in incrementally, the medical aid scheme beneficiaries "need immediate relief from serious challenges experienced..."

So some aspects of the National Health Insurance (NHI) will also be implemented while the Parliamentary process is unfolding.

Four NHI projects will be implemented now, with R4.1-billion from Treasury.


Motsoaledi says South Africa is an outlier, internationally, in terms of how much it spends on healthcare versus the outcomes it gets. He says South Africa spends about 8 percent of its budget on healthcare, but does not get the kind of mortality rates and other indicators that measure the success of a public healthcare system, as other countries that spend less than that.

And about 16 percent of South Africans use private healthcare, which is "exorbitantly expensive", while the rest are using the public healthcare system, with its well-documented failures. We need one system that will equalise things and ensure that everyone has access to good quality healthcare, he said.

(The numbers are up for debate, however. Africa Check reports that while roughly 16 percent of people have medical aid, this is not the same as saying 16 percent of the population uses private healthcare. In fact, anywhere between 20 percent and 40 percent of the population uses private healthcare at some point in their lives, and most are using a combination of both.)

But the public healthcare system is already collapsing. Won't this make it worse?

Motsoaledi said he knows the healthcare system is not working properly, but the private healthcare system is not the answer, either. This is because of it exorbitant costs, and the fact that the declining number of medical aid schemes shows it is also overburdened.

Motsoaledi also said he cannot wait for the public healthcare system to reform before introducing free, universal healthcare, because this will take forever. He also promised that the new system will not meet the same fate as state-owned enterprises on the verge of collapse due to mismanagement and corruption.

According to Times Select, Motsoaledi said, "It will not be like Eskom and SAA. A judge has been appointed to investigate state capture. We are not going to repeat the same then from NHI. We are going to copy the British National Health Service," he said.

Who will pay for it?

Everyone. According to Eyewitness News (EWN), the NHI won't be funded by the department of health, but by taxpayers. Just how, and how much, is still unclear, and it is up to National Treasury to do the sums and decide whether this will mean more taxes. But on an ideological level, Motsoaledi said the changes in the system will ensure that the rich subsidise the poor, and the healthy subsidise the sick. "NHI is going to be a mandatory for health services, meaning once it's a law, all South Africans will need to contribute into it if Treasury rules that it is to be funded through contributions from the population. "We don't know what they're going to rule but if it's mandatory, it means you can't opt out of it, just like the Constitution," he said.

What say the experts?

They range from cautiously optimistic to outright sceptical. Discovery Health CEO Jonathan Broomberg, for example, said the NHI was a step in the right direction. According to TimesLive, he praised it for its initial focus on priority projects for vulnerable groups like oncology and high-risk pregnancies.

"The inequalities in access to quality healthcare services for all South Africans is a major concern for all South Africans," he reportedly said.

On the other end of the spectrum, in an interview with Business Day, Werksmans attorney Neil Kirby questioned the wisdom of introducing enormous reforms into an already strained system.

"Whilst the proposed NHI may ... satisfy the requirements of government's obligations to progressively realise access to healthcare services, [it is a] paper-based set of aspirations largely divorced from the realities of public sector infrastructure problems and endemic capacity constraints.... It's a bit like building a house with no land on which to put it," he said.

Others say funding will be the biggest hurdle that government will have to overcome.

According to Fin24, at 2010 prices, the NHI is going to cost about R256-billion per year. At an assumed growth rate of 3.5 percent per year (our economy is estimated to grow just 1.5 percent this year), by 2025, a funding shortfall of R72-billion is expected.

Healthcare practitioners took to Twitter pointing out that, until conditions in public healthcare improve, the minister's plans are not going to work. Paediatrition Alastair McAlpine said: