Here is Ramaphosa’s NHI ‘health compact’ that businesses and doctors refused to sign

The Bhekisisa Centre of Health Journalism has published the highly controversial presidential health compact that businesses and doctors in South Africa refused to sign.

At a ceremony on Thursday (22 August), representatives from the government—including deputy president Paul Mashatile on behalf of President Cyril Ramaphosa—unions, and a handful of health organisations signed the second compact, which was purportedly based on the 2023 presidential health summit.

The original Presidential Health Compact was launched by Ramaphosa in 2019, which established a “framework of cooperation” between critical sectors in South Africa to significantly influence good health outcomes.

The idea behind the compact is that it brings together all sectors of society to work towards the same critical goal. The key to its success is having all stakeholders involved and willing to shift strategy to meet this.

The 2024 compact is the second iteration of the framework, and it specifically focuses on supporting health systems and strengthening and preparing them for the implementation of the National Health Insurance (NHI).

Of the 16 Articles in the compact, the NHI is mentioned in 11, where it is framed as being the baseline or foundational to the aims and goals.

It is this explicit focus on the NHI that has drawn backlash from the very stakeholders the compact aims to draw in, with business group BUSA, and healthcare professional bodies, SAMA and the SAHPC, pulling out of signing the document.

The first compact was signed by 363 partners. 48 of these were business organisations, and 76 were healthcare professional organisations.

The second compact was signed by 14 partners, with only one business representative and one health professional representative.

The signatories to the health compact are:

The numbers show very little buy-in from the private sector to Ramaphosa’s health compact, which comes even as the president and the Government of National Unity (GNU) try to push further private-public cooperation to resolve the country’s biggest crises.

The compact can be read below:

One of the biggest sticking points with the healthcare sector is that that private healthcare providers feel flatly ignored.

Ramaphosa signed the NHI Act into law two weeks before the 2024 national elections despite massive pushback from doctors, hospitals and businesses in the sector.

While all sectors align on universal healthcare in principle, the NHI has been consistently flagged over funding, coverage, implementation and administration. These concerns were raised throughout the consultation processes over the years, but the NHI was pushed through by the ANC with no changes.

Even in the era of the government of national unity, where the ANC no longer has a majority, the government is not budging.

The boycott of the signing of the compact by key groups reflects this frustration, where the organisations cited a lack of consultation over the wording of the compact and its focus on the NHI, saying that the document was “nothing more than an attempt to lock in support for the NHI Act”, while challenges are mounting.

Democratic Alliance MP tracking health, Michele Clarke, said that the boycott—and the fact that the only showing from the business sector was the Independent Community Pharmacy Association—was evidence of the opposition to the NHI, and risked breaking goodwill between business and the government.

“The fact that the Health Compact was signed despite widespread concerns and without proper engagement from the President about these concerns mimics the public participation charade in Parliament before the NHI Act was signed.

“The second Health Compact undermines the goodwill and collaboration between the government and various stakeholders, including health professionals, the business community, and labour unions, that the first Compact engendered to improve South Africa’s health sector,” she said.

Read: The end of medical aid in South Africa non-negotiable: Motsoaledi