ANC’s rogue NHI version is an untested experiment

President Cyril Ramaphosa signed the National Health Insurance Bill into law on May Picture: Jacques Naude / Independent Newspapers

President Cyril Ramaphosa signed the National Health Insurance Bill into law on May Picture: Jacques Naude / Independent Newspapers

Published May 25, 2024


mind boggles! South Africans living abroad and registered to vote, casting the first salvos of the 2024 General Election last Friday and Saturday, uncannily coinciding with the signing of the ruling ANC’s controversial National Health Insurance (NHI) Bill into law by President Cyril Ramaphosa last Wednesday.

Across the socio-political spectrum including the radical extremes, the epithets, metaphors, hyperbole and even imagery are embarrassing in their abundance – some in praise of the hope of a long overdue initialisation of a transformation of a healthcare system perceived by most as still steeped in several of the accessibility inequalities of apartheid.

Some judging by their vitriol against the NHI Bill bordering more on gratuitous fear mongering and doomsday scenarios, rather than concentrating on contributing towards the mitigation discourse of the legitimate shortcomings of the NHI Bill such as its affordability, the lack of fiscal space in raising the billions of rands of annual funding needed to underwrite the system, its lack of capacity building and human capital from clinical to allied staff and services, its sustainability and the straitjacket of co-opting millions of reluctant middle class compatriots into the NHI Fund and forcing them to abandon their private medical insurance plans.

Others still – mainly the rural and urban poor and disenfranchised - merely bystanders, subdued and despondent by their sheer marginalisation in a polity perceived as driven by cadre deployment, cronyism, self-enrichment, and pockets of administrative incompetence, which not surprisingly has led to increased apathy with the political process and politicians alike, especially among the GenZ youth and under-forty fives.

Democratic South Africa is celebrating its first 30-year cycle since the historic year zero general election on April 27, 1994. At the cusp of the nascent democracy’s second 30-year cycle, will Ramaphosa’s state-funded NHI signal another history making event?

In fact, even before the actualisation of the NHI scheme and the covering of the first South African patient under the scheme, it is already globally unprecedented – the first of its kind.

In other state-funded healthcare systems such as the UK’s National Health Service (NHS), with its free at the point of delivery ethos irrespective of wealth and socio-economic status, people are at liberty to take out private medical insurance to receive treatment they want from private providers in addition to free access to NHS hospitals and services.

The current travails of the NHS in the UK are not due to the structure of the system itself, albeit some parts are in urgent need of reform especially in management structures, leadership quality, addressing a serious clinical staff shortage, and cutting wastage and duplication.

It is due to chronic near criminal under-investment over the last 14 years by successive Conservative governments in the NHS at a time of a rising ageing population and one of the lowest spend on public healthcare by a developed economy as a proportion of GDP in the the Organisation for Economic Cooperation and Development (OECD) countries. There is also an underbelly of a neo-liberal ideological resistance to the NHS in the psyche of the minority yet vociferous die-hard Tories who look across the pond in America for inspiration through creeping privatisation of the NHS under the guise of outsourcing to private sector providers.

The spectre of the NHS today supplementing staff shortages by hiring agency clinicians, allied staff and nurses at exorbitant rates is self-defeating and self-serving ideological hubris, which only undermines the very ethos of the NHS. The resort to using costly, poorly negotiated, and inequitable public-private-partnerships (PPPs) to build new hospitals some of which tied NHS Trusts into 25 years of debt servicing as both the Tories and Labour did in the UK, should be a warning to Ramaphosa’s NHI scheme and flawed strategy.

This polarised support for and opposition to the NHI perhaps reflects a microcosm of the damaging divisions in South Africa’s body politic and society. One cannot escape the sheer irony of perhaps the most radical party contesting GE2024, the EFF calling out the ANC’s flagship public healthcare system as “misguided, disingenuous, and opportunistic.”

That would be more in line with the DA accusing Ramaphosa of signing the "death warrant" of healthcare in South Africa and warning that the scheme could be very costly, and fuel corruption.

To the DA, the very thought of a universal nationalised healthcare system is anathema. It seems to be more concerned about the alleged erosion of the profit margins of private medical purveyors as a result of the proposed NHI, than the fact that almost 85% of the country’s 62 million population are bereft of any medical insurance because they can ill-afford it and have to rely on an “overburdened,” fragmented, neglected and decaying public health system, with all its attendant debilities.

Universal health care tends always to be a major electoral issue. Remember Obamacare and the vicious and subliminally racist and laissez faire right wing Republican resistance to it.

The NHS in the UK with its cutbacks, long waiting lists, chronic staff shortages and low levels of staff retention, procurement profiteering especially during the Covid-19 pandemic, and policy short-termism similarly is already featuring prominently at the numerous hustings in the run-up to the UK general election, on July 4.

Brits are rightly endeared to it. Its roots and very raison d’etre largely overlap with those of the NHI (apartheid withstanding) – the working classes and the poor unable to afford access to doctors, which prompted Nye Bevan, the then Labour Health Minister to advocate and establish this NHS.

South Africans should be stone cold sober when deliberating the pros and cons of the proposed NHI, and the prospects for its administrative, infrastructural, financial, procurement, clinical and nursing, accessibility and equitable delivery integrity and oversight.

The NHI scheme is not a silver bullet or panacea for the good health of the citizenry.

It may seem like an electoral boon for the ANC, but the current NHI structure could turn out to be a poisoned chalice. Already research by Krutham projects a mini bounce back for the ANC at just under 45% of the popular vote – much higher than other pollsters.

While the concept of a universal healthcare system is commendable, the ANC’s NHI version is a rogue and uniquely untested experiment driven by ideological hubris; a flawed financial model which targets the tax-paying middle and SME classes; infrastructure, staff, administrative and governance deficits; and an implementation timeline which could span between 10-30 years, exacerbated by the real possibility of opponents using lawfare and litigation to stall its progress.

South Africans should be under no illusion that NHI delivery and access would be in the near term. For the ANC government to solely blame apartheid for the current state of public health and after 30 years in power still claim it is the constitutional right of compatriots to a free healthcare system at the point of delivery, is disingenuous.

The NHI is in urgent need of reform, in which an endeared public sector cooperates with a measured private sector, cooperating and not competing, in our own unique version of healthcare ubuntuism based on inclusion not division!

Cape Times