3 ways the NHI can be ‘stopped’ in South Africa

South Africa has three potential options to stop the creation of the National Health Insurance (NHI) in its current form—and hopefully open the way for a better system.

The NHI was signed into law earlier this year by President Cyril Ramaphosa after facing widespread criticism from doctors, medical aid schemes, opposition political parties and even parliament’s own legal team.

The President said that the NHI would level the playing field of South Africa’s healthcare apartheid—where the private sector only helps a small percentage of the population while the public sector is overburdened and underfunded—through the creation of universal healthcare.

However, the new laws have been fraught with controversy and backlash—particularly from the private sector—including widespread uncertainty around funding, cover, and execution, as well as fears of government corruption, mismanagement, and maladministration.

The funding question alone remains unanswered. Conservative estimations put the cost of the NHI over R200 billion per year, with some estimates going as high as R1 trillion.

To fund this, ridiculous tax changes would have to be implemented: either VAT would have to increase from 14% to 21.5%, personal income tax would have to increase by 31%, or an additional payroll tax of R1,500 per month would have to be imposed on every working person—or some combination of all three.

According to healthcare experts, the bad news is that the NHI horse has already bolted, and there are now limited options to contain what could be a disaster for healthcare in South Africa.

However, a spark of hope exists in the fact that South Africa has entered a new era of politics with the creation of the Government of National Unity (GNU).

After the ANC lost its majority in parliament for the first time in the democratic era, it formed a GNU with several other parties, including the DA and IFP. The DA has been a long-time critic of the NHI and has threatened to take the matter to court.

Despite forming an alliance with the DA, the ANC is still pushing ahead with the NHI. Reappointed health minister Aaron Motsoaledi, in his first address in the portfolio in the new administration, said he is determined to push ahead despite legal challenges.

How to stop it

Momentum Health Solutions and political lobbyist Ehicore said that several voices will influence the NHI’s impact on health policy.

“The ANC will default to its policy resolutions as it holds the position of Minister of Finance, Minister and Deputy Minister of Health.”

“However, it will be pushed and challenged inside the cabinet.”

“Previously, the Cabinet has always made decisions by agreement and consensus following consultation and discussion. This meant that no threshold or veto existed for moving on an issue.”

The seventh administration cannot reverse the status of the NHI Act now, with the President unable to return it to parliament.

That said, parliament is empowered to repeal old acts and to make decisions informed by the nature of the legislation and legislation that may have already been initiated, introduced, or passed.

Now, only three mechanisms exist in terms of the NHI Act, which can impact its implementation.

1. An agreement on a phased approach and only promulgating certain clauses in the Act at differentiated times are subject to consultation between the President, Minister of Finance, and Minister of Health, primarily on budget, resources, and capacity.
2. The executive or parliament introduces an amendment to the NHI Act.
3. Multiple litigious actions result in an outcome, forcing the Department to review and amend the Act to address the concerns in a court ruling, and thus, the Act cannot be implemented in its current state.

While also supporting the need for universal healthcare, DA leader and Minister of Agriculture John Steenhuisen said that the party hopes to iron out the flaws in the NHI through cabinet meetings instead of lengthy court battles.

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