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Is the NHI Bill good or bad for your health?

- Wits University

Experts shed some light on the debate over the recently published National Health Insurance (NHI) Bill.

Poor communication, vague details and unresolved questions remain concerns of the NHI Bill that came under the spotlight at a panel discussion hosted by the Mandela Institute at the School of Law on 11 September 2019.

The Bill, which will be the funding mechanism for South Africa’s push towards universal health coverage, is currently before Parliament and is open for public comment. It has become one of South Africa’s hottest topics right now even as it continues to be criticised for being too ill-defined and not being inclusive enough in bringing more of the general population into the debate.

Advocate Adila Hassim, of the Johannesburg Bar and co-founder of Section 27, was part of the panel. She criticised the scant details – “the bare bones” - in the current iteration of the NHI Bill and flagged three key areas of the Bill that need closer scrutiny. These, she said, relate to governance and the concentration of power of the fund solely in the health minister’s hands; missing specifics of benefits packages including the role of private providers; and the how the money pie will be divided between national and provincial government.

“Our Constitution requires that government works for progressive realisation of the right to health and that quality healthcare improves over time for everyone,” she said.

The “everyone” includes people who can afford and want the right to choose private healthcare. This in light of enduring concerns that the public healthcare system in South Africa is not able to offer quality services. In highlighting the complexities of these choices, she referred to a 2005 Canadian case that came before the Supreme Court in that country. The Chaoulli v Quebec case ruled that prohibiting private medical insurance under the Quebec Health Insurance Act and the Hospital Insurance Act in the face of long hospital wait times violated the right to life and security of person as outlined in the Quebec Charter of Human Rights and Freedoms.

However, despite its gross shortcomings and unresolved issues, Hassim said the NHI Bill is long overdue. She said: “It’s good to see the Bill finally before Parliament as it’s been part of the ANC’s health plan since 1994. The NHI Bill is less about the law and more about economics and political will. But it cannot be about bullying or driving the Bill through Parliament. Government needs to listen to others to improve the draft law so that the NHI works well and there will be proper governance.”

Neil Kirby, director at Werksmans Attorneys and head of its health care practice, said that the NHI Bill will be tested against the enshrined rights in the Constitution. He also cautioned that debate had to be “level-headed”, not about alarm. A lack of constructive debate, he said, could mean the Bill becomes tied up in legal challenges.

Along with the concerns raised by the two legal minds, Professor Karen Hoffman director of Wits’ PRICELESS Institute raised issues of economics in balancing costs with outcomes and value in better health of the nation.

Hoffman called for more harmonising between different government sectors to address public health through interventions like proper sanitation, health education, tax on sugary drinks and addressing alcoholism.

She also said the public had to be central in debates and need to be provided with clear, transparent information. Hoffman said: “The general public has not been included. We need to know what’s in, what’s out and ultimately what the trade-offs are.”

Dr Nicholas Crisp, consultant in the Minister of Health Office, responsible for establishing the NHI fund office, responded to the input from his fellow panellists and a packed auditorium at the Chalsty Teaching and Conference Centre. He acknowledged that the slow pace of getting the NHI set up has been a failing, so as the lack of better information disseminated. He acknowledged that there is still a “long way to go for massive reform”.

Crisp however, said NHI and the goal of universal healthcare has to become a reality for South Africa that is a hugely unequal society. He said: “The evolution of two dichotomous systems of public and private healthcare means that neither side is getting a good service. Hardly anyone is really happy with the healthcare that they have.”

He said those who have private healthcare face rising costs, poor coverage and shortfalls in funding. Those reliant on the public sector complain about the likes of long queues, poor quality of care and simply falling through the cracks of an overburdened healthcare system.

“Reform has to be national – public and private – and we have to use a pooling of resources to get us there,” Crisp said. He added that government has to be able to secure contributions through whatever mechanisms of collection are finally approved. This especially as he said trends show that more people who are currently paying for private medical aid and medical insurance are downgrading packages or choosing to opt out and to “take their chances with the public sector”.

Crisp said this scenario would add increased pressure on the public health service while simultaneously diverting private funds away from healthcare.

Crisp was unable to give specifics about the Bill, which he acknowledged added to the public’s frustration, loss of confidence and the circulation of misinformation and half facts.

He said NHI would “take a long time and we don’t know all the details of what it will look like in the end and we know we will have to be flexible”. On costs he was equally vague, and said “it will cost as much as we can afford” and will be implemented in phases.

He was however, unequivocal that preparatory work for universal healthcare cannot be stalled, and added: “We can’t sit and wait; we need the legislation to be in place for an enabling environment in which to move forward.”