NHI will never see the light of day

The government’s National Health Insurance (NHI) scheme is highly unlikely to ever be implemented, even if there were no litigation against it. 

This is because the scheme has no clear funding mechanism, and its institutional design means it is unlikely to achieve what it sets out to. 

Rather, the only impact of the government’s pursuit of the scheme is a steady deterioration in the quality of healthcare in both the public and private sectors as resources are redirected towards the NHI. 

Instead of pursuing the scheme, the state should focus on implementing key reforms within the healthcare industry to improve the provision of care in the public sector and enhance governance in the private sector. 

This is feedback from governance expert Professor Alex van den Heever, who outlined why the ongoing litigation against the NHI is the least of the problems for the scheme’s implementation. 

Van den Heever’s comments were made following a notice issued by the Office of the State Attorney on behalf of President Cyril Ramaphosa, where he undertakes not to promulgate any provision of the NHI until certain existing court cases are settled. 

“The agreement is that no further litigation will happen until the Constitutional Court matter is heard in May. The flipside of this is that the government will not attempt to implement any part of the NHI Act in the meantime,” Van den Heever explained to Newzroom Afrika. 

The specific public participation challenges causing this roadblock refer to two cases, one from the Board of Healthcare Funders and another from the Premier of the Western Cape. 

“In essence, it is a reasonable thing to do because the Constitutional Court case may render all the other litigation moot, should it succeed,” Van den Heever said. 

While these challenges in the Constitutional Court have a strong legal basis and are likely to succeed, Van den Heever explained that even if they don’t, the NHI is unlikely to ever become a reality in its current form. 

“A large part of the argument against the NHI itself is that it does not actually propose feasible reforms. And so, in effect, nothing will happen even if there is an attempt to take the Act forward,” he said. 

“There is likely to be an endless series of largely immaterial reforms going forward.”

However, despite the fact that the NHI may never become a reality, Van den Heever said there is a very good chance that the reforms will damage the existing healthcare system.

“It is not that there is anything being held back. The real problem that quite a lot of people have raised is that the government is saying this is the only way to fix the healthcare system, when it is likely to do the opposite,” he said. 

“There is no effort to deal with the current governance flaws in the public and private healthcare systems. Those need urgent attention and have nothing to do with the NHI Act.” 

Dead on arrival 

The structural issues with the NHI Act, as currently envisaged, render the scheme largely unimplementable in South Africa. 

However, while it may be unimplementable, the government’s focus on it and the redirection of resources towards it are likely to significantly impact the performance of the existing healthcare system. 

Van den Heever explained that challenging the NHI in court is likely to force the government to engage with what actually needs to be done to improve healthcare in South Africa. 

“What is very important is to focus on what we are meant to be doing instead. We have not had that conversation for 20 years,” Van den Heever said. 

The professor explained that the credible proposals to tackle challenges in the South African healthcare system have nothing to do with the NHI. 

“We have effectively had no structural policy interventions for the past 20 years. That is a very problematic situation as the public system is deteriorating and the private system is quite inefficient,” he said. 

As a result of this, South Africa’s healthcare outcomes have steadily deteriorated in recent years, with regard to coverage and quality of care. 

“Unless we have a government that genuinely focuses on this issue and proposes a credible universal coverage programme, this progressive deterioration will continue,” he said. 

This is the argument put forward by many litigants, who do not oppose universal healthcare but rather the NHI as a mechanism to achieve it. 

“The NHI is unlikely to ever see that light of day. One way or the other. Even if this Act were unopposed, there is no way it could be funded,” Van den Heever said. 

“The institutional design itself is in serious question, and it is not really going to achieve what it aims to. And so, we are going to be left with a poorly performing healthcare system.”