The National Health Insurance (NHI) Bill: the view of PHM-SA

The Treatment Action Campaign march against poor services at Khayelitsha District Hospital and clinics in the township. Photo by Elitsha reporter

The People’s Health Movement South Africa (PHM) supports the NHI, but with some reservation.

Cape Town, South Africa

The NHI is essentially a funding mechanism to buy essential health care for everyone according to their need, paid for up-front by those who have the ability to pay. The Bill establishes a tax-based NHI Fund (NHIF) to purchase the services in a way that also builds social solidarity. Through progressive taxation the young, healthy and better-off will subsidise health care for elderly, less healthy and poor people.

Membership of the NHI will be compulsory for everyone, rich and poor. Those who can afford it will be able to pay for additional care outside the NHI, but they can’t opt out of their NHIF contributions and will still pay the tax. All users must register with a primary care provider — they must attend this provider before being eligible for specialist care.

The NHIF will buy health care from accredited public and private providers, based on the principle of Universal Health Coverage (UHC). UHC means that all people and communities can access the health services they need, of a quality that is effective, without financial difficulty. Services include health promotion, disease prevention, curative care for illness, rehabilitation, and palliative care, and will be free at the point of delivery. UHC has become a priority around the world.

Documented refugees and asylum seekers will be eligible for free emergency services, care for conditions of public health importance (TB, HIV and other infectious diseases) and services for paediatric and maternal conditions.

The NHIF will be the only purchaser of NHI services. A single payer is able to choose the most appropriate services strategically so as to meet the priority health needs and ensure equity and efficiency.

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A board of 10 persons appointed by or approved by the Minister, and accountable to parliament, will oversee the NHIF.

PHM supports both the single payer system and UHC as the the most appropriate mechanisms to purchase and deliver health care.

 Some reservations on the NHI

Apart from general principles, the Bill gives no detail of the benefit package (the services the NHIF will cover), which should be identical for all users of NHI-funded providers.

A Benefits Advisory Committee will decide what should be in the package. This important body has representation from medical schools, provinces, private hospitals, medical schemes and the World Health Organisation, but none from civil society or labour. It will be supported by a Health Benefits Pricing Committee comprised of only technocrats.

There is thus no meaningful public participation in these committees. This biases them towards hospital-centered specialist care and a narrow biomedical approach instead of community-based primary health care. It is essential to include civil society and labour on these committees.

Furthermore, their proceedings should be open, transparent and accountable to the Minster and Parliament, and the public. The evidence and reasoning behind their choices should be open to public scrutiny.

Only the Stakeholder Advisory Committee has representation from indigenous practitioners, NGOs and civil society, although they are greatly outnumbered by representatives from professional and statutory bodies.

Purchasing services is to be devolved to provincial, district, and sub-district levels. District Health Management Offices will play a coordinating role. We have concerns about whether sub-district and district entities have the capacity for such detailed and complex activities.

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Snaking queues inside and outside clinics have become all too common in townships in big cities. Photo by Noluthando Matshoba

PHM is also concerned that urban and private providers are more likely to be accredited than rural and public providers. This risks aggravating existing urban-rural and private-public sector inequities.

The Bill specifies 3 transitional phases extending to 2026. The human resources for health (HRH) development plan will be established only in Phase 3, running from 2022 to 2026.

PHM has two concerns about this. Firstly, a HRH plan is needed urgently to ensure the development of a robust public health sector, especially at district and community level so that the NHI can operate effectively and efficiently in underserved areas. Secondly, given their unimpressive record to date in transforming health sciences education and training, it is unlikely that these structures dominated by hospital-based clinicians and educators will implement an appropriate HRH plan.

The Ministerial Advisory Committee on Health Care Benefits will be a precursor to the Benefits Advisory Committee which will advise the Minister on priority setting. Although the composition of this structure is not specified in the Bill, a previously released gazette proposed a composition dominated by senior government officials and medical scheme representatives. This structure too creates a concern that the emphasis will be on facility-based clinical medicine and that primary and community-level promotive and preventive care will be marginalised.

PHM calls all citizens of South Africa and civil society to unite behind a People’s NHI that ensures that the principles of the Right to Health, Universality and Social Solidarity are adhered to throughout the implementation process.

To join the People’s NHI Campaign, please do one of the following:

 

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