An NHI for the people is important and possible

*Update* Thank you to all our members and partners. Together we submitted over 170,000 public submissions calling for a NHI that works for the people. This is an important first step towards shaping the delivery of quality healthcare for all.

*Update* Thank you to all our members and partners. Together we submitted over 170,000 public submissions calling for a NHI that works for the people. This is an important first step towards shaping the delivery of quality healthcare for all.

*Note we have restructured and tweaked our submission under two key themes; accountability and resources. However, the original blog post can be found below*

You have the power to shape the NHI to deliver quality healthcare for all. But we have to act now, we only have until Friday 29th November to make our voices heard. Send in your submission here: https://awethu.amandla.mobi/petitions/demand-an-nhi-that-works-for-the-people

Minister Zweli Mkhize has presented the National Health Insurance (NHI) bill to parliament [1]. It’s a bit complicated but basically the NHI is a reform that aims to improve how healthcare resources are allocated, rather than having one system for the rich and another for the poor, like we currently do.

For example; at the moment if a domestic worker from Alexandra gets sick they will have to wait in a long line at the local public clinic, while those living in Sandton with medical aid can get on-the-spot health care. But under the NHI, there could be more funding for health, so the public clinic in Alex could have shorter waiting times because of more doctors. If the public clinic in Alex doesn’t have a specialist, the clinic could refer the domestic worker to the nearest specialist. Even if this specialist is at a private hospital in Sandton, the NHI fund will pay for this.

1) Accountability

– Significant measures to stop corruption, increase accountability and stop capture
Inequality and corruption are linked, and in SA corruption is both a feature of the private and public sector. Austerity and conservative economic policies are not going to reduce inequality, but progressive ideas such as the NHI could reduce inequality if done well. But this will only be achieved if the NHI fund is accountable and can’t be captured by either the public or private sector. The accreditation process needs to be in line with the NHI’s goal to serve people, and give satisfactory health services to shown health needs.

– Transparency
The public and civil society must be able to quickly and easily access information for free on NHI processes, decisions, transactions and contracts etc. Transparency must be built into every aspect of the NHI so that corruption and other issues can be quickly identified and addressed.

– Effective Implementation
We have many strong laws, policies and regulations, but implementation is critical. The NHI will introduce major changes to our health system, these must be managed effectively and changes made to address issues that might come up. As pointed out by Section 27, “..as the bill now stands, we are bringing the establishment of these new structures into law, with no way to turn back if they fail, and without any transition provisions that could stagger implementation and allow for learning”. This means there must be ways to test new systems and structures before signing them into law. This could mean a complaints board needs to be implemented so that patients and staff can report problems.

– Board and committees composition
The NHI bill gives the health minister sole power to appoint the board, and with the board appoint several committees to serve on the NHI. This gives the minister too much power and does not protect them from undue influence. Civil society must have enough mechanisms and representation on the board and committees to stop the NHI fund from being captured by greedy companies, fat cats, corrupt politicians or unaccountable bureaucrats. Good governance is important and means that power must be decentralised.

– Regulate the private health sector
With the recent report by the competition commission [2] showing the greedy monopoly existing in the private sector and its inflation of prices that robs patients of just care; it is important that the private sector is given stricter regulations. Access to services in the private sector for the rest of the population via the NHI must not be seen as championing the private sector as the superior alternative [5]. What is more the final Bill and any regulations must not have loopholes the private sector can exploit for profit and to undermine the NHI.

– Improve health care services
The government must table a plan of how it will fix current health facilities to make sure that they are equipped and able to handle the health demands of the population. The NHI must improve our public and private health sector by enforcing strict National Core Standards and the Ideal Clinic Programme. A lot of our public health care facilities are currently not meeting requirements of the health department [5], while many private facilities are focused on profit, not health. The Bill must ensure competent public health centres will affect the effectiveness of primary health care. Our clinics and other sites need to be competent on matters of sanitation, management and access. The rights and dignity of patients, staff and the public more broadly, must be ensured, where our health systems fails to uphold this, there must be swift but fair action to right any wrongs and ensure issues don’t happen again and again.

– No one is illegal
I support that the NHI makes provision for asylum seekers and undocumented immigrants receiving “(a) emergency medical services and (b) services for notifiable conditions of public health concern”. It, however, leaves them vulnerable in the face of serious health complications, as well as not dignify them when ill. South Africa must not carry Xenophobic policies, and it is important that the NHI is not seen as another tool used to leave immigrants vulnerable and in danger. The bill must not refer to undocumented immigrants as illegal, and allow access to primary health care services to all and not just children.


2) More resources, interventions and services for those most in need

– A single-payer system with mandatory pre-payment :
I believe the wealthy must pay their fair share and we must put an end to medical aids and private companies profiteering. A single-payer system with mandatory pre-payment will help achieve this by pooling all funds into a central fund from which all health services will be strategically purchased and paid, to meet defined health goals. Mandatory pre-payment forces everyone to pay their fair share into this central fund. The majority of wealth in Mzansi was built on the exploitation of our land and people, so the wealthy should not be able to opt-out when it’s convenient. To fund the NHI, true social solidarity means government and parliament must increase the personal income tax and the corporate income tax. When companies didn’t pay taxes properly or avoided paying altogether, we the people were forced to shoulder the burden through a VAT hike. Not again.

Bridging the two-tier health system:
I support the bridging of a two-tier health system that makes other people enjoy better health services than others. I support the NHI fund paying health facilities directly for services so there are no provincial or other middlemen to act as health service buyers.

– Increasing specialists and community health workers
We need more community health workers, and they should be made permanent employees with strong management. Community Health Workers should be a key part of the NHI and where its funds go. The majority of medical specialists currently work in the private sector, and with the NHI this must change. Access to a wider variety of specialists will reduce the divide between the private and public health sector. I support that everyone will now have access to a wider variety of specialists currently locked in the private health sector.

– The rural/urban health divide
Where you live should not affect the quality of your health services. The NHI must end the rural/urban health divide. Rural health services should, in fact, receive major focus [3]. This could mean building more clinics and buying more ambulances, as well as the current upgrading of current facilities and equipment.

– Prevention is better than cure
Implement Front of Pack Labeling, push Treasury to increase the Health Promotion Levy to 20% and expand it to cover all unhealthy drinks and food. Pass the Tobacco Control Bill as it stands (But ensure it includes Nicotine Free Electronic Non-NIcotine Delivery Systems) so that we can reduce the burden on our health system and budget. This will make the NHI more financially viable by helping to reduce non-communicable diseases. Taxes on sugar, tobacco, ENNDS and alcohol could also help fund the NHI.


[1] http://www.health.gov.za/index.php/nhi http://www.health.gov.za/index.php/national-health-insurance-right-menu?download=3583:bill-national-health-insurance-2019

[2] You’re paying more for private healthcare and getting less, Competition Commission investigation reveals, Laura Lopez Gonzalez for Fin24, 30 September 2019

[3] To have or not to have the NHI, Louis Reynolds and David Sanders for people’s health movement South Africa, August 2019

[4] Spotlight on NHI: Why NHI should focus on cutting costs in the private sector first, John Ashmore for Section 27, October 2019

[5] http://ohsc.org.za/ohsc-annual-inspection-report-for-the-public-sector-health-establishments-inspected-during-the-2016-17-financial-year/

*Original blog post of our analysis of the NHI Bill and what it needs to be effective and progressive*

Minister Zweli Mkhize has presented the National Health Insurance (NHI) bill to parliament. The NHI is “ The National Health Insurance (NHI) is a health care financing system that is designed to pool funds to actively purchase and provide -access to quality, affordable personal healthcare services for all South Africans based on their health needs, irrespective of their socioeconomic status.” [1] 

It has been met with a lot of mixed negative reactions from medical aids and groups like Afriforum. Our reality is that every day, the majority of South Africans can’t access proper health services. 

Long waiting times, stock-outs of critical medication, shortages of equipment and staff are often the norm at clinics and hospitals.  And going to a private doctor or hospital is too expensive and does not guarantee quality care. A report by the competition commission has shown that even though you pay more for private healthcare, the service is less than satisfactory, and is run by greedy profit maximising monopolies [2]. 

If done well, the NHI could be an important step towards ensuring quality healthcare for all by availing doctors to clinics and primary health care sites, as well as providing community health workers. It is not without faults, as seen in the pilot sites, this is why it is important to add your voice to shaping it to best represent the health needs of a majority of South Africans. 

The NHI could mean an end to the impossible decision the majority of South Africans have to make, whether to put food on the table or get efficient healthcare.

The NHI must not be captured by medical aids or greedy capital. At the core of their disapproval, there seems to exist a dislike of accessing the same services as poor people. The government must also improve their ability to implement services, free from corruption or patronage, to make sure that their failures do not capture the NHI. 

Minister Zweli Mkhize must take into account that 84% of people living without medical aid have less data, time and money to do public submissions, even though they are the most affected by the NHI. 

The NHI bill is necessary,  must serve poor majority and these are some of the things it must include to do that:

  • A single-payer system with mandatory pre-payment:

The wealthy must pay their fair share and we must put an end to medical aids and private companies profiteering. A single-payer system with mandatory pre-payment will help achieve this by pooling all funds into a central fund from which all health services will be purchased and paid, to meet defined health goals. Mandatory pre-payment forces everyone to pay their fair share into this central fund. The majority of wealth in Mzansi was built on the exploitation of our land and people, so the wealthy should not be able to opt-out when it’s convenient. The government must increase the personal income tax and the corporate income tax. We the people had to shoulder a VAT hike.

  • Significant measures to stop corruption, increase accountability and stop capture

Inequality and corruption are linked, and in SA corruption is both a feature of the private and public sector. Austerity and conservative economic policies are not going to reduce inequality, but progressive ideas such as the NHI could reduce inequality. 

But this will only be achieved if the NHI fund is accountable and can’t be captured by either the public or private sector. Measures such as regulation can ensure the accreditation of service providers. The accreditation process needs to be in line with the NHI’s goal to serve people, and give satisfactory health services to shown health needs. Civil society must have enough mechanisms and representation to stop the NHI fund from being captured by greedy companies, fat cats, corrupt politicians or unaccountable bureaucrats. 

  • Bridging the two-tier health system

We support the removal of a two-tier health system that makes other people enjoy better health services than others. Also, support the NHI fund paying health facilities directly for services so there are no provincial or other middlemen to act as health service buyers. The government must table a plan of how it will fix current health facilities to make sure that they are equipped and able to handle the health demands of the population. The NHI must improve our public health sector through more resources, but also the National Core Standards and Ideal Clinic Programme.

  • The rural/urban health divide

Where you live should not affect the quality of your health services. The NHI must end the rural/urban health divide. Rural health services should, in fact, receive a major increase in funding.

  • No one is illegal

We support that the NHI makes provision for asylum seekers and immigrants receiving basic primary health care. It, however, leaves them vulnerable in the face of serious health complications, as well as being vague on undocumented immigrants. South Africa must not carry Xenophobic policies, and it is important that the NHI is not seen as another tool used to leave migrants vulnerable and in danger.

  • Prevention is better than cure

Implement Front of Pack Labeling and increase the Health Promotion Levy to 20% and expand it to cover all unhealthy drinks and food. Pass the Tobacco Control Bill now will reduce the burden on our health system and budget. This will make the NHI more financially viable. 

  • Increasing specialists and community health workers

We need more community health workers. Community Health Workers should be a key part of the NHI and where its funds go. A majority of specialists currently work in the private sector, and with the NHI there is a possibility to have access to a wider variety of specialists as the divide between the private and public health sector is diminished. I support that everyone will now have access to a wider variety of specialists as the divide between the private and public health sector is diminished.

  • Regulate the private health sector

With the recent report by the competition commission[3] showing the greedy monopoly existing in the private sector and its inflation of prices that robs patients of just care; it is important that the private sector is given stricter regulations. Access to services in the private sector for the rest of the population via the NHI must not be seen as championing the private sector as the superior alternative. This includes the pharmaceutical industry.

[1] http://www.health.gov.za/index.php/nhi   http://www.health.gov.za/index.php/national-health-insurance-right-menu?download=3583:bill-national-health-insurance-2019 

[2] You’re paying more for private healthcare and getting less, Competition Commission investigation reveals, Laura Lopez Gonzalez for Fin24, 30 September 2019

[3] To have or not to have the NHI, Louis Reynolds and David Sanders for people’s health movement South Africa, August 2019