Big NHI surprises ahead for South Africa

 ·8 Nov 2023

The National Department of Health has responded to more concerns submitted in response to the National Healthcare Insurance (NHI) Bill – but has given no further clarity on what the system will cover or how the private sector will operate under it.

This means that medical aids, private healthcare providers and South Africans at large are still in the dark – and will remain there – until the laws are passed and the department eventually reveals its full plans through regulations.

The National Assembly passed the NHI Bill in June 2023 and is currently with the National Council of Provinces (NCOP) for consideration.

The bill has been closely scrutinised by various stakeholders in the healthcare sector, and concerns have been raised by medical schemes, insurers, doctors, and various others about the effect the Bill will have on their current businesses and general access to healthcare.

Across all commentary, however, a massive problem with the bill keeps cropping up: it lacks detail.

This has been acknowledged by the NCOP’s select committee on health and social services, which noted this week that commenters are constantly seeking more detail about the NHI, especially around how the scheme will be funded, how medical aids and other private insurers will operate, and what exactly the scheme will cover.

Commenters have explicitly stated that the lack of detail in the NHI Bill – especially around what services will be covered – is directly misleading the public because South Africans have no idea what they will actually get from the scheme.

Unfortunately, for anyone seeking those answers, the NDOH has nothing to say.

More specifically, it does not yet know.


Responding to the latest round of questions, the department said that the NHI Bill is a framework that will enable the NHI Fund and other aspects of universal healthcare – and all the details will come later through regulations.

“The NHI Bill provides a framework that requires regulations – not every single detail can be outlined and incorporated into a founding Act,” it said.

This means that the department doesn’t know exactly how the scheme will be funded, as this is something that will have to be regulated later – once the laws have passed – in collaboration with the National Treasury.

The department also cannot say what medical services will be covered by the NHI because, again, this is something that will only be determined later through regulations set by the health minister.

“The NHI Bill outlines the framework that will apply in terms of the institutional and organisational structures for the (NHI) Fund. It also outlines the principle in terms of the health entitlements that will be covered, which are outlined as ‘comprehensive’ and covering the ‘full continuum’ of care.

“The exact details of what will be covered cannot be outlined in the founding Act, but will rather be provided in the regulations. This is important to allow for flexibility around planning and proactively addressing population health needs as changes occur over time,” the department said.

What about private healthcare?

The department argued that it’s not stopping any economic activity or private healthcare providers from operating because they can do so outside the NHI system.

However, unlike the private sector, the NHI will be exempt from all competition laws.

“(This) is based on the recognition that health is a public good that should not be left to the whims of the market,” it said.

The department also noted that the NHI Fund is not a procurement body but rather a “strategic purchaser”. For example, the Fund will not procure health products on behalf of the private sector but will instead set prices for products that accredited providers can procure at.

What does the department know?

In lieu of any details stakeholders actually want, the department has given some indication of what the scheme will entail.

  • The scheme will be funded through taxes: The specific taxes are as yet unknown – however, the removal of medical aid tax credits is all but guaranteed.
  • It will cover something: The Bill describes NHI coverage as “comprehensive”. Anything beyond that description is still a mystery waiting to be unveiled.
  • Private medical aids and health services will continue: In what form is still to be determined, but the department stressed that the NHI will not repeal the National Health Act and Medical Schemes Act.
  • The Health Minister is in charge: While there are some new oversight measures in place, it will be within the power of the minister of health to determine much of what will and won’t be part of the NHI.
  • Individual rights come second: Whatever Constitutional concerns have been raised, the department is adamant that individual rights cannot outweigh the greater good.

For exact details on the scheme, however, this will only be determined by the department and the health minister once the foundational laws are in place.

Despite the many unanswered questions, concerns and unknowns, the NHI Bill is expected to pass through the NCOP.

However, stakeholders have already lined up legal challenges – something the department has previously said it is ready for.

Read: 30% more taxes for 70% less healthcare – the NHI’s big problem

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