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Moving closer to quality healthcare for all

In August, the much-publicised National Health Insurance (NHI) Bill was tabled in Parliament, bringing this landmark piece of legislation one step closer to becoming a reality. The Bill has been at the centre of much debate in South Africa, but is essential for transforming our healthcare landscape to one where all citizens have access to quality health services.

The NHI, that provides quality healthcare cover to all South Africans, has been within government’s sight for the past decade. After years of careful consultation with all stakeholders, the NHI Bill is the final solution for addressing the current inequalities in access to healthcare. While a few privileged in the country can afford expensive medical aid schemes, millions of ordinary South Africans have to struggle with inadequate services as the effects of apartheid segregation and inequality continue to linger.

Over the past few years, the pros and cons of the NHI Bill have been fiercely debated amongst politicians, academics, the pharmaceutical industry, civil society associations and healthcare professionals. This constructive process of debate is not yet over, as the public now has the opportunity to make submissions on the Bill and how it will impact their lives. Public hearings across the country will give a clear idea of what South Africa wants.

There are arguments about the affordability of the NHI, and whether it may result in job losses, and some believe that the NHI will harm private sector healthcare, resulting in a negative impact on the economy.

Arguments over costs are based on incorrect assumptions Dr Olive Shisana is a decorated public health specialist and social scientist who has become a leading expert after 30 years in the field.

Dr Shisana said that many of the negative comments on the NHI, particularly about the costs of implementing the system, are based on false information.

“Most of the comments on the cost of NHI are based on incorrect assumptions or inadequate knowledge of healthcare expenditure patterns in the country,” she pointed out.

Government has estimated that R256 billion will be needed to implement the NHI. Dr Shisana explained that this money will not appear out of thin air, but rather fall within the existing patterns of healthcare expenditure.

“The myth being propagated is that the R256 billion required for the NHI will all be new money. This is not the case. South Africa already has R231.7 billion towards the R256 billion required in the 2025/26 financial year. The country has enough money in the system to start implementing NHI, which will require some reprioritising. Clearly, we cannot say that the NHI is unaffordable.”

She said that the costs do not yet take into account the efficiency gains that will result from the new system.

“These include the introduction of new initiatives such as telemedicine (allowing doctors to diagnose patients over distance, using technology), coupled with home-based care, which will decongest the health system.”

Quality of healthcare

Some parties have argued that the implementation of the NHI will result in a drop in the overall quality of healthcare and possibly cause a collapse of the national healthcare system. Dr Shisana said that there are several reasons why this will not be the case.

“First, only health facilities that are certified to be fit for purpose and those that meet the quality standards can receive funding from the NHI. This ‘active purchasing’ is an excellent motivator to strengthen clinics, hospitals and doctors’ offices, since they must comply in order to be paid for their services.”

Dr Shisana added that with more money made available to employ additional staff waiting times and overcrowding will be reduced.

“Additionally, the Presidential Health Compact requires that the Department of Health build and maintain health infrastructure. The result will lead to patient satisfaction. The department has compiled an inventory of all public health infrastructure. Centralising the procurement and pricing of health products, medicines and equipment, the result will be a reduction of price and shortages; this will improve the quality of services provided.”

Research supporting implementation of the NHI

The achievement of Universal Health Coverage (UHC) has been identified as a pressing need by global organisations such as the World Health Organization and the United Nations.

Extensive research has gone into the NHI, particularly from Ministerial Working Groups and the Health Sciences Research Council (HSRC), which have investigated best practices and models, implications for the economy and legal factors.

“Researchers have used domestic and international research conducted in countries that have successfully implemented similar programmes. The White Paper on NHI cites abundant research that informed the design of the NHI. Furthermore, several studies conducted in South Africa point to the desirability of the NHI, provided that the quality of healthcare can be improved,” said Dr Shisana.

The HSRC's research has concluded that there is broad public acceptance of the NHI, indicating that an overwhelming majority of South Africans would prefer this system to the current model. Other studies have similarly found that the majority of South Africans support efforts to establish the NHI, and that the current system does not fulfil the human right to access to healthcare.

Preparation for implementation

Government has started to prepare for the implementation of the NHI by developing detailed strategic and operational plans. Work includes designing a structure and operational budget of the NHI Fund. This structure includes the staffing, equipment and offices that will be required to manage all the functions of the NHI Fund.

“Once the Bill is passed into law, the NHI will be incrementally implemented at those facilities that meet the certification and accreditation requirements articulated in the NHI Bill. Facilities that do not qualify will be improved until they are ready to provide quality services.

“They will receive the normal budget for service provision. The NHI will adopt a phased process of implementation, as provided for in the Bill, which will ensure that clinics and hospitals provide good quality services,” explained Dr Shisana.

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