Rob RoseThe odds of National Health Insurance (NHI) being implemented – at least in any form resembling the miracle salve sold to the population by the ANC – are sharply narrowing.
The outcome aligns with what many executives had privately predicted would happen, even after President Cyril Ramaphosa signed the NHI Bill into law in a poorly executed attempt to bolster the ANC’s popularity ahead of the May election. As political analyst Moeletsi Mbeki explains, the way NHI’s failure to resonate with voters highlights the party’s identity crisis and its failure to grasp that its appeal lies more with the black middle class than with the poor.
Business Leadership South Africa CEO Busi Mavuso sees no end to the challenges facing NHI. “The good news, if I can call it that, is the legislation is unworkable – there is simply no funding for it [and] it also faces many legal challenges,” she says.
Adrian Gore, CEO of Discovery, which owns the country’s largest health-care administrator, believes that implementation of the plan is likely decades away, adding that “we see no scenario in which there is sufficient funding for a workable and comprehensive NHI in its current form”.
To meet the low end of the NHI’s funding requirements, the government would have to implement steep tax hikes, such as raising payroll taxes by 31% or increasing VAT from 15% to 21%, both of which would have a severe impact on already anaemic household budgets.
Mavuso’s sentiment was underscored recently when the Pretoria high court ruled that parts of the National Health Act are unconstitutional. The clauses in question force doctors to register for a “certificate of need”, and while this ruling does not directly address the NHI, these certificates have been touted by the architects of the new legislation as vital enabling tools, necessary to control where and how health-care providers work.
Trade union Solidarity had argued in court in March that requiring these certificates “would have empowered the government to capture medical practices almost entirely and to manage them at will, rather than them being run at the discretion of the doctors”.
This would have amounted to the “expropriation” of these health-care operations, it said.
Judge Anthony Millar agreed, finding that these rules amount to an “impairment of the right to freely practice a trade, occupation or profession” and are akin to “an attempt to indenture the private medical service in the service of the state”.
Health minister Aaron Motsoaledi downplayed the ruling, arguing that the provisions were drafted 20 years ago and have no direct connection to the NHI. “It is purely mischief to assert a connection [between the certificate of need and the NHI] and is part of a deliberate campaign to discredit NHI,” he said in a statement.
This isn’t how others see it, of course.
Solidarity’s Dirk Hermann, for instance, said that the court victory dismantled a cornerstone of NHI. “The government wants to change to a system in which health care is nationalised and health-care practitioners become servants of the state so that the provision of all health care can be centrally controlled by the state.”
Motsoaledi rubbished this view, pointing out that 14 other countries, including the UK and Australia, also have certificates of need. “This war going on in the courts, media and all public institutions about [the] provision of health care is a proxy war between the rich and the poor,” he said.
Headed for court
The health minister has seemed surprised at the private sector’s antipathy to legislation that will, effectively, banish medical schemes to the fringe of South Africa’s health-care sector, remove the ability of patients to choose their provider, and centralise health-care spending under a single state-run fund.
Ramaphosa in July suggested a welcoming thawing of the government’s firm view on implementing NHI as drafted; in his opening of parliament address, convening South Africa’s seventh administration, Ramaphosa struck a conciliatory note when he said that “we are confident that we will be able to bring stakeholders together and that we will be able to resolve differences and clarify misunderstandings”.
But it seems Motsoaledi didn’t get the memo. This sets the stage for an almighty court showdown, in which the ANC seems to be preparing to shift the blame for its poorly planned legislation onto the “selfish rich”.
Discovery, the country’s largest medical scheme, has said it’s preparing to throw its weight behind the legal challenge to NHI, warning that the legislation is “unworkable” without the private sector.
It is hard to see an outcome from a constitutional challenge to NHI that doesn’t mirror the smackdown that the state sustained in Millar’s court.
Top image: Animation. Currency.
