There is no ‘fixing’ the NHI

A coalition representing most of South Africa’s healthcare professionals, workers and patient advocacy organisations says that the government’s National Health Insurance (NHI) scheme is unworkable and unfixable.

The controversial scheme has made headlines again these past few weeks, with reports of parties within the Government of National Unity (GNU) agreeing to rework the laws and essentially ‘fix’ what is seen to be broken within the system itself.

However, NHI critics in the private sector say that the NHI cannot be fixed because it does not address the core problems of South Africa’s healthcare system—arguably, it makes them worse.

The Universal Healthcare Access Coalition (UHAC), which has 28 signatories, includes the South African Medical Association (SAMA), Progressive Health Forum, and the South African Private Practitioners Forum.

It has proposed replacing the NHI with its more implementable and scalable reforms.

The group formally submitted its proposal in response to President Cyril Ramaphosa’s call in 2024 to the private sector to not just criticise the NHI but engage with it and provide workable alternatives.

However, Ramaphosa’s State of the Nation Address made it clear that the scheme is continuing undeterred – while the National Health Department has dismissed talk of any ‘agreements’ to change the laws.

“The SONA promised little more than policy stagnation and an untenable status quo,” the UHAC said.

It said that the current healthcare system in South Africa is polarised, with an underperforming public sector and an expensive private sector.

The public system is failing due to institutionalised corruption enabled by flawed governance structures, and needed reforms to the private system have inexplicably been put on indefinite hold.

The group said this is “an apparent consequence of the irrational and counterproductive perspective that medical schemes would no longer exist.”

“There have been contradictory statements recently on whether or not 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,” it said.

Dr Mvuyisi Mzukwa, chair of the SA Medical Association (SAMA), said the NHI is deeply flawed and fails to depart from the weaknesses in the current system, opting instead to centralise control without resolving any problems.

“The Act as it stands is unworkable, lacking a clear implementation pathway and timeframes. 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,” Mzukwa said.

“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.”

The core of the proposal is to address these issues by improving governance in the public system and regulating the private system for cost efficiency and equity.

The UHAC’s plan involves separating political influence from healthcare management through independent supervisory boards. This would improve accountability, reduce corruption, and enhance service delivery efficiency.

Healthcare funding – taxes and medical scheme contributions – and risk management will be pooled at national level to ensure equitable distribution of resources, while it is proposed that purchasing of healthcare services be decentralised for more efficient, localised decision-making.

It said a publicly sponsored medical scheme, to which individuals can choose to contribute instead of a private scheme, is also proposed to increase competitiveness and affordability in the sector.

The UHAC said it has secured support for the proposal from the major formations of health workers and professionals, along with patient advocacy organisations.

It said it is continuing consultations across the spectrum of business, academia, civil society, and state organs.