The implementation of the NHI is effectively stuck in court and constitutional conflicts, hampering South Africa's most comprehensive health reform since 1994. We spoke to health economist Susan Cleary to find out whether the NHI is a wise way to move forward.

  • National Health Insurance Act (NHI) was signed into law in May 2024, planning a large state-run fund that purchases health services from both the public and private health care sectors. but at At least 12 court cases Now its constitutionality and the manner in which this Act was signed into law is being challenged.
  • in February, Ramaphosa announces he will not campaign Neither part of the Act can be implemented until the Constitutional Court rules on the two applications in May, meaning the NHI cannot be implemented in the meantime. In an agreement between the President, Health Minister Aaron Motsoaledi and other major organizations involved in the NHI court challenges, these applications have also been temporarily put on hold until the court's May decision.
  • However, Business Day reported on Thursday Motsoaledi told MPs in Parliament that at least some NHI planning preparations were ongoing.
  • Motsoaledi told Health Beat, Bhekisisa's TV program in March that he is prepared to change the Act if Parliament votes for it, and admitted that talks with organizations taking the Act to court would be better than waiting for decisions.
  • We spoke to the University of Cape Town health economist susan cleary What is working and what is not about South Africa's current public health system, and whether the NHI is a sensible way forward.

Less than two years after President Cyril Ramaphosa's signature National Health Insurance Act (NHI) into law in May 2024, South Africa's most ambitious health reform since the end of apartheid is effectively stalled – caught between a government determined to push it forward and a growing group of opponents who say it is impractical, unattainable And unconstitutional.

The Act proposes a centrally controlled state fund that would purchase health services from both public and private providers, eliminating the current form of private medical aid, which is around 15% of South African Pay for it while promising better care for the 85% of people who rely on public health services. To replenish that fund, it would be trust taxes And, essentially, on redirecting medical aid premiums, because the Act Makes private medical aid illegal To cover similar services as NHI.

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But as soon as Ramaphosa put pen to paper, cases started piling up.

at least 12 court cases Now challenge the constitutionality of the Act with allegations like procedural flaws and inadequate public participation unrealistic financing structure and this blocking access to treatment For asylum seekers and undocumented migrants. A South African case study in Global Health Watch A Lancet-published analysis of global health improvements released in January raised similar concerns.

At the end of February, Ramaphosa announces he will not campaign Neither part of the Act can be implemented until the Constitutional Court rules in May on two applications related to the public participation process – meaning the NHI cannot be implemented in the meantime. Also sitting before the Court of Justice: his appeal against an earlier decision, under which he had to show that he had taken the public submissions seriously before signing them.

in one Agreement between the President, Health Minister Aaron Motsoaledi and those involved In Other major NHI court challenges These applications have also been temporarily put on hold until the court's May decision. This includes The South African Medical Association (SAMA)'s own High Court challenge with the people they brought togetherness The Hospital Association of South Africa , Heath Funders Association (HFA), South African Private Practitioners Forum And sakeliga .

embed Subtitled version of HB here.

However, Business Day reported on Thursday that Motsoaledi told MPs in Parliament that at least some NHI plan preparations are underway in the meantime.

Motsoaledi defended the single-fund model, arguing that it was easier to protect one central pot from corruption than nine provincial budgets. But critics also include groups such as Section 27 and this HFA – Let's say that's actually the problem: the Act gives too much power to the Minister, allowing him to appoint and fire board and committee members at large as he sees fit, with very little independent scrutiny.

recently Episode of Health Beat, Bhekisisa's TV programMotsoaledi said he was prepared to vote in parliament for the changes, and acknowledged that talks with organizations taking the Act to court would be better than waiting for decisions. “But that's in an ideal world,” he says, “and we don't live in an ideal world.”

University of Cape Town health economist susan cleary spoke to Mia Malan about what's working – and what's not – about South Africa's current public health system, and whether the NHI is really a sensible way forward. The following is an edited version of their conversation.

Mia Malan (MM): NHI is stuck in slow motion. What should the government focus on now?

Susan Cleary (SC): The idea of ​​universal health coverage has been on our agenda since democracy, and it's a good thing. But we already have the beginnings of a universal health system – our Public sector covers about 80% of the population. The obvious thing to do is to continue to strengthen the system that will be the backbone of any future system. There's plenty to do in the meantime.

MM: What is the difference between our current model and NHI's proposal?

SC: In the current model, the staff providing services at the facilities are salaried government employees. Under the NHI, the government will also be able to contract services from independent entities – private GP practices, private hospitals. That private participation would be more clearly accepted and encouraged. There are potentially huge benefits for private GP and private hospital groups.

MM: What are the advantages and disadvantages of a large central fund?

SC: The advantage is purchasing power – the ability to negotiate good prices and contracts. Our current public sector already has this available to about 80% of the population. NHI will increase this to 100%. The disadvantage is that if that one pot of money is not managed well, there will be no alternative. Right now, various provincial departments of health and the private sector all offer options. Under the NHI, they largely disappear.

MM: Are there adequate safeguards against corruption in the Act?

SC: There are real concerns. The Minister has great authority to appoint the Board Chair, the CEO of the Fund and the members of the Appeal Tribunal. There are not enough checks and balances. What people want to see is a greater separation between the political and administrative spheres – and Parliament should play a greater role in approving key positions rather than ministers and cabinet.

MM: How should South Africans think about what the NHI can actually deliver?

SC: If the NHI provides services similar to the current public sector – broadly R5 000 per person per year – increasing this from 80% to 100% of the population is probably massively cost-effective.

But if it means estimate private sector At around R15,000 per capita, we are aiming to spend around 30% of our GDP on health care. This is absolutely not possible. The honest answer is that we don't know what it will cost, because we still don't have a defined benefits package. We can't put a price until we know exactly what services will be covered.

MM: So private sector users will get less, public sector users will get something better – somewhere in between?

SC: Yes – there's a lot of complexity hidden behind it. But broadly, yes.

MM: What needs to be decided before the NHI can work?

SC: Two things stand out. First, electronic patient information systems. we have seen Quality of care improved significantly Since its introduction into the public health care system in the Western Cape. This needs to happen at a national level, and it does not require the NHI – this should have happened a decade ago. We need such a system in the private healthcare system also. Second, priority setting: being clear and honest about the package of services that the public sector can actually provide equitably. We are not clear about this right now, and it is possible that what is in our standard treatment guidelines is not cost-effective – otherwise we would not see stockouts and poor quality of drugs.

MM: Is it realistic to fund the NHI through taxes? 30% unemployment rate?

SC: At our current rate of economic growth, covering 100% of the population in a single health system – and making it better than the current public sector – is very ambitious. Many countries making good progress on universal health coverage have plural systems: public and private sectors, or different social health insurance models co-exist.

MM: What is the most evidence-based path – the big bang or the phases?

SC: Definitely phase. We must be wary of losing the strength of our current public sector. Our model is actually similar in some ways National Health Service of the United Kingdom And I don't think we've adequately justified replacing it with something more sophisticated and harder to manage – especially given that governance is not our strong point. Universal health coverage does not require a unitary system. We are already scoring relatively well on universal health coverage metrics. We should not assume that everything is terrible.