NHI: Behind the proposals

Mia Malan raises some of the most frequently asked questions about the intended national health insurance.

What is national health insurance?
The national health insurance (NHI) scheme is mandatory health coverage that aims to give all citizens of a nation access to healthcare, regardless of their income level. It is usually financed by taxes. There are many different administration models. In the United Kingdom the system is administered by the state. In many European, Latin American and Asian countries the administration is provided by a range of private health insurers.

What is the NHI ministerial advisory committee?
A 25-member committee appointed by Health Minister Aaron Motsoaledi in 2009 to advise him on the development of policy, legislation and the implementation of the NHI. It comprises individuals with skills relevant to the NHI and is led by Dr Olive Shisana, chief executive of the Human Sciences Research Council.

Will the NHI really be implemented?
The ANC has publicly committed itself to create “one health system for everyone”. There is considerable pressure on the ANC from Cosatu and the South African Communist Party to follow through on this. Once certain legislation has been passed, the government will be compelled to establish an NHI system. However, some health industry experts argue that, realistically, only a “watered-down” NHI will be implemented in the form of a “reformed” public health system simply branded an NHI scheme.

A leading player in South Africa’s health sector, who did not want to be named, said: “The health minister has realised a fully fledged NHI is unrealistic — But he can’t be seen to resist efforts in public sector reform, even if he has his doubts about how such reforms can be successfully implemented.”


Motsoaledi reacted: “People are entitled to their opinions and perhaps out of anxiety say [the NHI] won’t happen. But we have 14 years to implement this system and time will tell us what is possible. To say that we shouldn’t change our current health system is not an option.”

How soon will the NHI start?
Some parts of the NHI have already kicked in, such as the health ministry’s Office of Standards Compliance to enforce basic healthcare standards. Formally the NHI will be implemented in 2012 once the relevant laws have been passed. According to Discovery Health chief executive Jonathan Broomberg, the government is likely to focus its resources initially on partnering with private doctors and hospitals in rural areas to improve healthcare in areas with poor resources. Graham Anderson from Profmed medical scheme said the NHI system would begin next year with a “small pilot project” in rural areas and certain urban areas with high unemployment rates.

What will happen to medical aids?
A 2010 ANC discussion document said all South Africans would be compelled to join the NHI, but that everyone would be free to take out private health insurance as well, should they wish to do so. Broomberg said medical aids had price “inelasticity” — that is, as in the case of electricity, it was unlikely that people would stop buying health coverage when prices increased. He said NHI taxes and higher medical aid premiums were unlikely to result in people abandoning their medical aid cover.

In countries such as Australia and England, where high-quality public health systems can be accessed for free, 35% and 11% of citizens, respectively, still buy private health insurance. Roly Buys from the Medi-clinic hospital group said many South Africans would continue to buy private insurance because they want freedom of choice regarding which doctor to consult, a “better quality” service and “may not want to queue for long”. But Alex van den Heever from the University of the Witwatersrand’s School of Public and Development Management said tax increases could force lower-income medical aid members to drop their private cover entirely.

How will the private healthcare industry be involved in the NHI?
The NHI is likely to purchase health services from both the public and private sectors. Private healthcare could be used to supplement specialist services. But in South Africa private healthcare services are more expensive. The NHI is unlikely to be able to afford private healthcare prices. The minister has made it clear that private health professionals will have to decrease their fees.

Where will all the doctors needed for the NHI come from?
According to Motsoaledi, South Africa needs “at least” to triple its number of doctors to implement the NHI successfully. However, for the past decade the country’s eight medical schools have produced only 1 200 doctors annually. Some developing countries produce significantly more doctors. Cuba, with a population of 11-million, compared with South Africa’s 50-million, produces more than 4 000 doctors every year from its 21 medical schools. The health minister plans to increase the number of South African doctors produced annually to 3 600.

The ministry is funding new medical schools and planning to build more training hospitals, the first of which will be a medical school at the University of Limpopo. Motsoaledi plans to expand several health institutions, including Soweto’s Chris Hani Baragwanath Hospital and Tygerberg Hospital in Bellville.

Anderson said the introduction of the NHI could result in the emigration of many South African health professionals with “vital” skills because “they may not get paid enough by the NHI and may not want to work in dysfunctional public hospitals”.

Mia Malan works for the Discovery Health Journalism Centre at Rhodes University

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Mia Malan
Mia Malan
Mia Malan is the founding director and editor of the Bhekisisa Centre for Health Journalism at the Mail & Guardian. She heads up a team of fifteen permanent and freelance staff members. She loves drama, good wine and strong coffee, not necessarily in that order.

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