The right to quality healthcare includes the duty to provide it

By Lee Callakoppen, Principal Officer, Bonitas Medical Fund

South Africa’s National Assembly approved the introduction of National Health Insurance (NHI) on the 12 June 2023. However, the NHI Bill in its current form, was passed in Parliament without taking into amount the numerous objections by a number of role players in South Africa. 

Critics of SA’s proposed NHI do not object to the concept of Universal Health Care (UHC), accepting that access to healthcare should be a constitutional right rather than a privilege. They object to a Bill that is so inherently flawed that it will jeopardise citizens’ rights to health care.  What is important to remember is that this means there is a responsibility and duty to provide quality healthcare. 

Section 27(1)(a) of the Constitution states: ‘Everyone has the right to have access to healthcare services, including reproductive health care. What is worrying is the lack of detail around the implementation of this national health blueprint.’ 

However, the NHI Bill in its current form is a funding mechanism not UHC which would: 

• Improve access to quality healthcare 
• Enhance quality of life of all South Africans 
• Contribute to addressing the social-economic imbalances, injustices and inequities of the past 

The devil is in the detail 

Pragmatically, the path to UHC through the phased implementation of NHI must start with cover for the vulnerable groups, before it is expanded to cover better-off sections of the population. This implies that there will be an inevitable period of co-existence between medical schemes (as they currently exist) and the NHI Fund. In this scenario, the NHI Fund should start by offering comprehensive primary healthcare services before adding higher cost items, such as hospitalisation. This would allow time for developing the necessary purchasing capability within the NHI Fund. 

However, at this stage the Bill is still not clear on what will and will not be offered by NHI and the role – if any – private medical aids will play. What is of concern is that the Bill suggests the scrapping of medical aids in its current form and only refers to complimentary services. What this means is unknown. However, we believe that the only way for the healthcare system to evolve is through inter-dependent relationships, with public and private healthcare co-existing. 

Points to ponder 

Before debating concerns about the implementation of NHI, we should discuss: 

• Taking away the rights of healthcare providers and healthcare recipients is unconstitutional and forcing this on the citizens of the country is not an option. We believe NHI and private medical schemes can and should co-exist. As is the use of medical aid reserves to fund NHI. These funds belong to the members of those schemes 
• The ramifications of curtailing the role of medical aids. Medical aids and associated services make an enormous contribution to the annual fiscus. The industry contributes significantly to employment and, in turn, to the economy of the country 
• Sound corporate governance is of critical importance in preventing mismanagement of assets, corruption, inefficiency, illegality, unethical conduct, abuse of the Fund’s resources and the collapse of the Fund. In our experience of managing a Fund of similar nature, the sustainability of the Fund is highly dependent on Governance structures in fulfilling its fiduciary duties 
• Considering our unemployment, low GDP, socio-economic status, SEO failure and service delivery we cannot blithely adopt a universal healthcare system that works in another country. It is simply not feasible; South Africa is unique  
• It has been stated that NHI will be phased in over several years. This implies that there will be an inevitable period of co-existence between medical schemes (as they currently exist) and the NHI Fund. In this scenario, the NHI Fund should start by offering comprehensive primary healthcare services before adding higher cost items  

Engagement with the Department of Health  

Our presentations outlined our main concerns which are around the funding of NHI and a rationale for medical schemes to co-exist with the NHI Fund. Some of the key points include: 

• That it is illegal and unconstitutional for people not to purchase healthcare should they have the means to 
• All international concepts of universal healthcare make provision for freedom of choice 
• Medical schemes should be able to continue to act as purchasers and payers of healthcare services 
• The NHI should be phased in – starting with cover for the most vulnerable population groups 

NHI as a priority?  

We are of the opinion that universal healthcare is a right, not a privilege. Bonitas does not resist the reasoning behind the Bill in principle and agree with the notion that the right of access to quality, healthcare services in South Africa, is currently disproportionate.  

We wish to be clear that Bonitas supports the notion of UHC and sees the NHI Bill as a positive progression towards UHC for South Africa.  

But there needs to be a transitional path that ensures improved delivery of primary healthcare services. Currently, Section 33 of the NHI Bill states that medical schemes will only be restricted to a ‘complementary’ role once the NHI is ‘fully implemented’. In this respect, we suggest that the policy position outlined in Section 33 of the Bill be restructured to cover the same scope of services as offered by the NHI Fund. This process would be consistent with the Health Market Inquiry (HMI) final recommendations on introducing a standardised base benefits package, to create an enabling environment for strategic purchasing, value-based contracting, performance-based reimbursement and contracting linked to quality health outcomes. 

We need to focus on public and private enterprise working together, strong leadership, accountability and dealing with social-economic issues as an integral part of the process.