'Implantation of NHI will take decades' - expert

The bill, which was signed into law by President Cyril Ramaphosa in May last year, seeks to achieve universal healthcare for all South Africans.

Briefing the media on the reasons why NHI remains unimplementable in the country,  Van Den Heever said the NHI reforms have become an obstacle to progressive health reforms in the country.

"The proposals are not in harmony with the current health system, so that includes both the public and the private subsystems and are generally regarded as harmful to health access. They haven't really been designed with access in the specific modalities of the design.

"Largely, people promise access, but there are no measures that are introduced that will ensure that access will actually be improved in any part of the health system on a sustainable basis and this is largely because it involves a severe rupture of existing health systems in order to implement the model that is anticipated in the White Papers and the Act.

Van den Heever added that the current NHI proposals, both within the Act and those yet to be implemented, lack any possibility of improving health access.

"...because not everything in the Act actually implements the full framework, is generally recognised as lacking both feasibility and any possibility of improving health access, the lack of feasibility is an important issue, particularly if you bring all other reforms to a halt, because you're waiting for this system to be finalised and implemented."

He said public hospital services throughout the country are compromised by poor leadership arising from weaknesses in the governance framework.

This includes the separation of powers from the executive, creating opportunities for systematic corruption and associated poor leadership appointments.

For over two decades, systemic weaknesses – including governance failures, inadequate service delivery in both public and private healthcare have remained unaddressed.

"As a consequence, because of the NHI process, no health system reforms of any substance have been implemented since 2004, and we've left in place many obvious weaknesses in the health system that require urgent attention.

"Nothing has essentially been done, and it appears as though no problem that appears in the health system has any kind of team or approach to address them, because somebody is waiting for some final solution that will solve all problems.

"We're stuck with the system as we have no systemic change at all, which is extremely problematic, so the reform framework that's considered in the report begins with an unavoidable financial reality that has to be taken into account. In any health system, and in social security systems generally around the world, an effective system of universal access and coverage cannot be exclusively financed by tax revenue in any foreseeable future fiscal scenario," Van Den Heever said.

At the same briefing, Universal Healthcare Access Coalition steering committee member Dr. Aslam Dasoo also explained there is a crisis to implementing National Health Insurance in the country.

He refers to the allocation made to provincial governments as a substitute for provinces exercising their own powers of taxation to finance functions allocated to them by the Constitution, including healthcare services.

Dasoo added that the NHI was supposed to be progressively implemented.

"Despite all the difficulties the NHI will face, including litigation, while it gets its plan together, that crisis will worsen, and they don't have a plan B. This proposal we've made, picks up from that which was rolling out well and planned, and we were all hopeful that by 2012-2015, we would have this integrated system that was predicated on the original plan.

"...but as we know, the Jacob Zuma administration came in and defenestrated it, just tossed it out, and just stopped everything, and gave us an uncosted, unresearched NHI, which they have been spending the last 15–17 years retrofitting into this act, which makes even less sense than when they started with it,” he said.

-SONA REACTION-

In response to President Cyril Ramaphosa’s State of the Nation address, where he said the government would proceed this year with "the preparatory work for the establishment of the NHI", UHAC steering committee member Dr Aslam Dasoo said this signalled the crumbling state of healthcare would continue "while government tries to figure out how to fund and implement an unworkable NHI".

"Effectively, the SONA promised little more than policy stagnation and an untenable status quo. The UHAC has developed a concrete, workable reform pathway to address the very evident failures in the public and private healthcare systems and achieve a high-performing system of universal access and coverage in South Africa".

UHAC steering committee member Dr Mvuyisi Mzukwa, chair of the SA Medical Association (SAMA) meanwhile described the NHI Act as deeply flawed.

"The NHI does not materially depart from the weaknesses of the current system but instead centralises control without resolving fundamental problems. The Act as it stands is unworkable, lacking a clear implementation pathway and timeframe. Crucially, the NHI model of a single tax-financed fund to provide healthcare access and cover for the entire population is unfeasible and unattainable in the country’s current and foreseeable economic future.

"UHAC proposes a mixed funding model of medical scheme contributions and general taxes, with some re-alignment of existing taxes, which better aligns with the country’s fiscal constraints and will ensure long-term sustainability,” he said.

Fellow UHAC steering committee member Dr Simon Strachan, said the public system is failing due to institutionalised corruption enabled by flawed governance structures.

"Needed reforms to the private system, most recently outlined by the Health Market Inquiry in 2019, have inexplicably been put on indefinite hold – an apparent consequence of the irrational and counterproductive perspective that medical schemes would no longer exist.

"There have been contradictory statements recently on whether changes will be made to the Act to continue allowing private medical schemes to operate fully, but this is in any case insufficient to ‘fix’ the NHI,” Strachan added.

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