Africa Health Congress: SA's new NHI - path to UHC or empty promise?

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As South Africans anxiously await the impact of this monumental legislation on their lives and the wellbeing of their families, questions abound on whether the NHI will ultimately prove to be a positive intervention in the nation's healthcare landscape.

Although many countries in Africa have tried to address the imperative for UHC by scaling up health insurance programmes, SA's new NHI is unprecedented in scope, as it aims to provide comprehensive, high-quality health services to all South Africans, regardless of their socio-economic status.

The bill promises that state actors will strategically purchase services from both public and private providers through a centralised fund, with the ambitious goal of eliminating disparities, and giving the entire population access to health services with a high quality of patient care.

Amid this atmosphere of uncertainty and anticipation, the 2024 Africa Health Congress, the continent's foremost gathering for the medical industry, is set to explore the implications of the NHI. The topic will feature prominently on the agenda in October, especially within the Public Health Conference track.

NHI Fund clarified

“Despite being a hot topic, the NHI is still widely misunderstood. It’s not an all-encompassing system intended to replace current healthcare infrastructure, but rather a fund – a pot of money from which government will purchase healthcare services for the people, from both private and public institutions as service providers,” explains Cynthia Makarutse, spokesperson for the Africa Health Congress.

She notes that Africa Health and the NHI essentially share the same goal of achieving universal health coverage, but that said the challenge lies in striking a balance that benefits everyone.

“We can only achieve this through robust inclusive discussions with all stakeholders, and an enabling environment of equitable public-private collaboration.”

One of the primary sources of contention surrounding the NHI is its financing mechanism, which relies heavily on South Africa's relatively small and highly unbalanced tax base.

With just 7.1 million registered taxpayers, and three million contributing 90% of the personal income tax Sars receives, the proposed solutions to close the funding gap include a surcharge on income tax and payroll tax payable by employers and employees, further disadvantaging those already bearing the brunt of the tax load.

Government maintains that the NHI will not threaten or usurp the operations of private healthcare facilities and services and would in fact make them more sustainable as the NHI effectively broadens the patient base and promises a ready supply of funds for their remuneration.

Conflicting points of view

Nevertheless, various stakeholders remain concerned, chief among them being medical-aid schemes (as well as their members), who stand arrayed against the government, bringing their considerable influence and financial muscle to bear on the legal front. Along with various other contesting parties, they have threatened - and begun preparing - for court action.

The future of medical-aid schemes under the NHI looks bleak, as they will be limited to covering only those services not included in the NHI package, drastically reducing their income potential, and potentially rendering membership as an unappealing proposition to consumers.

Groups representing doctors, such as the South African Medical Association who are opposed to the new bill, have also resolved to take the matter to court. Some doctors have even threatened to emigrate now that the NHI is official, citing concerns about their autonomy and the potential impact on the quality of healthcare they can provide.

A cynical reading suggests that the NHI's true purpose is more about centralising government control over healthcare, more than efficiently providing UHC. The bill’s detractors have pointed to the lack of clarity around service levels and potential hidden costs as red flags that could lead to ballooning expenses and declining quality of care.

But, despite the valid concerns raised by various stakeholders, it is important to acknowledge that free healthcare can work and is working in many parts of the world. Although there are countless reasons to be sceptical about the implementation of the NHI in South Africa, there are also glimmers of hope that suggest the country could lead by example on the African continent.

Committed to progress

Africa Health remains committed to evidence-based decision-making and views the upcoming conference as an opportunity to objectively assess the early stages of the NHI's implementation, identifying areas for improvement and proposing constructive solutions.

While key indicators – like a reduction in child mortality and maternal deaths in recent years show that South Africa’s healthcare system has made progress in recent years, the challenge now lies in ensuring the transition to the NHI accelerates this progress, and does not stagnate, or worse - reverse our trajectory,” says Makarutse.

Ultimately, the success of the NHI will depend on clearly defining the scope of services, securing adequate funding, and maintaining a delicate balance between public- and private-sector involvement. Africa Health recognises these complexities and remains dedicated to facilitating open, constructive dialogue to help shape a healthcare system that benefits all South Africans, she says.

“Investing in health is one of the wisest choices a society can make, as it lays the foundation for a thriving, productive population. Economic theory supports the notion of free healthcare, and a free-at-the-point-of-use system is inherently fairer, as it ensures that access to healthcare is not determined by an individual's financial status,” says Makarutse.