Some Key Messages on

National Health Insurance (NHI)

Social Solidarity for quality health care for all
National Health Insurance is a way of providing good healthcare for all by sharing the money
available for healthcare among all our people. The health benefits that you receive will depend
on how sick you are, not on how wealthy you are.

Hospitals, clinics, doctors, specialists, dentists, nurses and all other health workers will also
be available to provide services to all much more equally. It all depends on our willingness to
SHARE as ONE NATION. If we can feel and act in unity about football and rugby, surely, we can
do the same when it comes to matters of life and death, health and illness. National Health
Insurance, known as NHI, is a chance for South Africans to join hands in a way that really
counts.

None of us would like a fellow human being to die, become disabled or live in pain just because
he or she could not get decent healthcare. But this is happening in our country where poor
people often have second rate healthcare while wealthier people can pay for good treatment.
South Africans from all walks of life and all parts of our country have the power to change this
tragic situation.

In summary, what is NHI?

NHI (National Health Insurance) is a health In NHI your socio-economic status will not
financing system that is designed to pool funds matter but your health needs will determine
to provide access to quality affordable what form of service you get.
personal health services for All South Africans
based on their health needs, irrespective of
their socio-economic status. What are the main objectives of the NHI?

The World Health Organisation (WHO) and the NHI aims to achieve Universal Health
United Nations call it Universal Health Coverage for all South Africans. This
Coverage (UHC) because nobody is left specifically refers to financial health coverage.
behind. UHC “is a set of objectives that health It aims to provide equity and social solidarity
systems pursue; it is not a scheme or a through pooling of risks and funds.
particular set of arrangements in the health
system. Making progress towards UHC is not It will create one public health fund with
inherently synonymous with increasing the adequate resources to plan for and effectively
percentage of the population in an explicit meet health needs of the entire population not
insurance scheme.” World Health just for a selected few.
Organization, 2013. NHI is not like a medical
scheme. NHI will be for all South Africans in Under the NHI regime, will there still be
keeping with the fact that health is a right in the private medical aid schemes?
Constitution and hence cannot be for a
selected few.

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Private Medical schemes will continue to exist, discard you and send you away after he/she
but their role will change. When the NHI is fully has exhausted all your funds.
implemented they will provide cover for
services not reimbursable by the NHI Fund. Why do we need NHI?
Medical schemes are voluntary organisation
Because our country believes that access to
and they will remain as such. healthcare is a human right.

This means every single one of us is entitled to

What about private health care providers, receive healthcare, and this should not depend on
will they continue to operate? If yes, what how rich we are or where we happen to live.
will be different? The current two-tier healthcare system has a
number of problems including inequity, hospicentric
Let me first clarify two different concepts which care, high cost, poor outcomes and inefficient. The
usually confuse many people .Private health NHI is intended to address these problems.
care has two very distinct and different arms The right to obtain healthcare is written into our
usually owned and operated by different Constitution. Government has tried its utmost since
groups: 1994 to ensure that everyone in this country has
healthcare. Our government health budget has kept
‒ One arm is called Health care funders: increasing and our network of public hospitals and
clinics has grown
These are mostly medical aid schemes, but
other funders include hospital plans, and But still there are communities in rural areas that
hospital cash plans. They pay for you when cannot easily obtain care. Many residents in our
you are sick. major cities rely on overcrowded public health
facilities with too few health professionals and poor
equipment.
‒ The other arm is called Health care
providers: These are mostly private In short, many people cannot yet get the care that
hospitals. But they also include private they need.
specialists and General Practitioners as
By changing the way our country pays for
well as allied health professionals in private healthcare, NHI will improve access to services for
practice (Optometrists, Physiotherapists, the majority of people.
Occupational Therapists, Speech
Therapist, Dental Therapists and Oral
Hygienists etc.).

They provide you with health care and the Private ambulance providers will no longer be
funder to which you belong pay for you. allowed to pick up only people who have
medical aid, credit card or cash, at the scene
The private health care providers will definitely of an accident and leave behind the poor.
continue to operate. Contrary to popular belief, Section 27(3) of the Constitution will strictly be
NHI is not going to abolish or do away with applied under NHI.
Private health providers. However, they will It simply states that nobody may be refused
operate under a completely different emergency medical treatment.
environment created by NHI.
Under NHI, private providers will no longer be
For instance, NHI will not allow them to charge allowed to charge you extra cash called co-
the exorbitant fees they are charging today, payment after NHI has paid them. Under the
especially the private hospitals. present system, a private provider may charge
you extra cash up and above what your
Certain practices will not be allowed under medical aid has paid them.
NHI. For instance, a health care provider will
not be allowed to start treating you and then

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Critics of the NHI say Government wants to aid schemes compared to private hospitals.
disrupt a private health care system that is That is not a system that can be left alone!
working well and that Government should
leave the private health care alone as this Actually the National Development Plan (NDP)
reduces the burden of providing health states that if we need to fix the health system,
care from the State. What is your we need to deal with two (2) problems. Firstly,
response? to deal with the exorbitant cost of private health
care.
It is definitely not true that the private health
care is a system that is working well. This Secondly we need to deal with the problems of
assertion is a simplification of facts. For the quality of the public health system.
starters, a system of health cannot be said to
be working well when it serves only a tiny As you can see, both systems need to be fixed
minority in the population (only 16% of South - not only the public health system.
Africans) and excludes the overwhelming
majority (84% of South Africans). It is for this reason that paragraph 2 of the NHI
policy document states: "NHI represents a
Secondly, the cost of private health care is substantial policy shift that will necessitate a
spiralling out of control with the results that the massive reorganisation of the current health
medical aid contributions (premiums) are care system, both public and private, and also
increasing more than CPIX (Consumer Price derives its mandate from the National
Index) while the benefits to patients are Development Plan (NDP) of the country".
reducing at a very fast pace. This is the only
sector in the socio-economic arena that is
behaving so. By 2030, if nothing is done to Why do we need NHI?
financially protect households, middle income Because we want a healthcare system that is fair
households are likely to spend a third of their and equal.
income on premiums for medical aid.
Government cannot simple sit by and watch While we are trying to build a more equal society,
healthcare is very unequal. The amount spent on the
this happen. healthcare of each person with medical aid is five
times the amount that is spent on each person who
Most members of medical aid schemes run out relies entirely on public health facilities.
of benefits and are no longer covered from as
early as June until the end of the year. The funding gap translates into a major gap in the
standard of healthcare available to the rich and the
poor.
You cannot therefore claim that a system is
working well when that system can take you While eight out of 10 patients depend on public clinics
out of the ICU while you are still very sick, and hospitals, the bulk of the country’s doctors,
dentists and specialists serve a small section of the
simply because your benefits have been population who can afford private healthcare. In a just
exhausted. world, the sickest people – not the richest – should
receive the largest share of healthcare. NHI will bring
Lastly, medical aid schemes are actually us closer to allocating health services according the
collapsing under the weight of the high medical real needs of our people. This is not only fair, but it will
help us build a healthier nation.
costs. In 2002 there were 141 medical aid
schemes. Today we are left with 83 and still By changing the way our country pays for healthcare,
counting down. NHI will improve access to services for the majority of
people.
General practitioners (GPs) are systematically
being taken out of practice because they are
simply not paid or are paid very little by medical

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As it is, poor people can get free medical It is only NHI that can bring this Universal
care in public hospitals. Why do you feel Health Coverage (UHC).
that we need an NHI to provide universal
health care? Universal Health Coverage is different from
Universal Health Care. Universal Health
Poor people may be getting free medical care Coverage specifically means covering each
in public hospitals. But you and I know that free and every citizen with a health financing
care is very difficult to deliver without adequate system that is equitable to all citizens, whereas
resources. Universal Health Care means providing some
form of health care to citizens without
Resources are both financial and human. The considering equity or without considering what
cream of the South African society, i.e. those type of health care all citizens are getting. You
with huge financial resources and skills, have cannot divide the Nation into free but
hived off from the rest of society to have their inadequate medical care for the poor and high
own health financing system (medical aid) and quality but highly subsidised health care for the
health provision system (private hospital). rich.
They have hived off with huge financial
resources. That is not what our Constitution meant in
Section 27 when it said that Health is a right.
Skills and professionals follow the financial
resources. Hence 80% of the specialists of the
country are in the private sector serving only It is the elephant in the room the fact that
16% of the population. The remaining 84% of public health care is collapsing due to
the population is served by only 20% of factors such as under-funding, corruption,
specialists. politics and incompetence and perhaps if
we want to ensure quality service for the
Actually our country is spending 4.4% of the poor we should deal with these problems
GDP on only 16% of the population and only and not throw the baby with the bath-
4.1% for 84% of the population. water?

The services may be free, but it is a struggle to It is true that the public health care is under-
deliver them with the meagre resources left in funded. But it is definitely not collapsing. It is
the public health sector. just dealing with a huge burden of disease and
a very huge population compared to private
Some people argue that medical aid scheme health care which is over-subsidized but has
money is private money and we have no very few people to deal with.
business to meddle in it.
As an example, let us start at the beginning of
This is a serious distortion of facts The truth is life. There are 1.2 million women who fall
that medical aid schemes are subsidized for a pregnant every year. The private health sector
whopping R46,7 billion by the fiscus of the takes care of only 140 000 of them with 80% of
country. If it was not for this very heavy subsidy the specialist doctors. The public health
from the State, medical aid schemes will have system takes care of a whopping 1,060,000
ceased to exist. People who are not on medical with only 20% of the specialists.
aid do not have access to this subsidy.
As things stand, the biggest killer of South
In the words of the Director General of the Africans is TB. There are more than 400 000
World Health Organisation (WHO), Universal South Africans being treated for TB each year.
Health Coverage is an equaliser between the All of them, regardless of their socio-economic
rich and the poor! status, are treated by the public sector. The
private sector is treating none. The TB cure

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rate used to be 67% in 2009, it is now 85% by in the world that is spending huge amounts of
2016. money on very few people. Now that is a Rolls
Royce. Rolls Royces are extremely expensive
The second biggest killer is HIV and AIDS. cars owned by very few people at the expense
There is an estimated 6 million South Africans of the majority. NHI is not designed to be a
infected by this virus. The public sector is Rolls Royce or a Toyota. It is designed to be a
treating 3.5 million of them whereas the private transport system for all South Africans, which
sector despite the huge resources at their is appropriate for all South Africans and which
command is treating only 200 000. is affordable for the country.

There used to be 70 000 babies born HIV Chapter 2.3 of the NHI White Paper shows that
positive by 2004. Because of the very highly affordability is one of the eight (8) principles of
successful PMTCT (Prevention of Mother-to- NHI. The others are social solidarity, efficiency,
Child Transmission) Programme, the figure is effectiveness etc.
now down to 6 000.
For NHI to succeed, many qualified health
How can all this be achieved by a system that professionals would be required. Given the
is collapsing? current shortage of skilled professionals
such as doctors and nurses, where will we
Corruption cannot be allowed in any system. get professionals?
We need to fight it. It is not part of NHI.
As it is at the moment, all countries in the
In the White Paper on NHI, Section 8.6.3 world, with the exception of Cuba, have a
paragraph 372-383, outlines what is being shortage of health professionals. Sub-Saharan
proposed to deal with fraud and corruption Africa has been declared a crisis point in this
under NHI. case. The Secretary General of the United
Nations has even come up with a global
We cannot then associate NHI with corruption. solution for this issue.
NHI abhors corruption because there can
never be development where there is Shortage of health workers is not a reason not
corruption. to implement Universal Health Coverage.
Actually Universal Health Coverage will help a
What do you say to people who say NHI is country like South Africa to effectively share
a Rolls Royce solution when we cannot the small pool of health professionals that we
even afford a Toyota? have. This shortage is exacerbated by not
sharing what we already have.
I will tell them that in fact a Rolls Royce is the
present system, whereby only 16% of the It is that one particular private hospital in
population spends a whopping 4.4% of the Johannesburg (name withheld) has 30
GDP on their health and leaving 84% of the Specialist Gynaecologists. Limpopo Province
population with a measly 4.1% of the GDP. has only 7 fulltime South African
Gynaecologists to serve a total of 40 hospitals
Which one is a Rolls Royce in this situation? In in the whole public sector, Mpumalanga has 6
2002 expenditure on private health care was to serve a total of 33 hospitals and North West
R41 billion but by 2014 it was already R141 has 7 to serve a total of 22 hospitals. We had
billion, but that is spent on only 16% of the to get Cuban Gynaecologists to the rescue.
population. It is for this reason that the WHO
(World Health Organisation) and the OECD
(Organisation of Economic Cooperation and
Development) has declared that South Africa
is an outlier because we are the only country

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 One of the biggest problems faced by the
Why do we need NHI? public health care system is public
Because our two-tier system of paying for servants who simply do not care about
healthcare has failed to guarantee good patients. How does the NHI propose to
quality healthcare for all. change this?
At present government pays for the health facilities
The Office of Health Standards Compliance
that assist the poor and wealthier families use private
doctors and hospitals that they pay for through (OHSC) and the Office of the Health Ombud
medical aids. This two-tier system of funding locks the (South Africa's first Health Ombud) has been
poor out of reach of a large number of health established to address these problems. We
professionals and facilities in the private sector. have even come up with a system of District
NHI will create a single pool of healthcare funding for
Specialist teams to supervise doctors and
private and public healthcare providers alike. The NHI nurses in their duties.
Fund will pay public and private healthcare providers
on exactly the same basis – and expect the same As you can see, we established all these in
standard of care from both.
preparation for NHI.
People in lower income groups will be able to consult
doctors in private practice and use private hospitals, We have developed a National Quality
because the NHI Fund will pay for this care. The Improvement Plan that will standardise service
burden of care will be spread much more equally provision in all clinics and hospitals. This will
across the public and private sectors.
facilitate accreditation of these health facilities
to meet the requirements of NHI.

As you can see, you have 98 hospitals in 3 We also need strict application of the public
provinces served by only 20 fulltime Specialist service laws and the LRA (Labour Relations
Gynaecologists while you have 1 private Act), as well as having good managers who
hospital served by 30 Specialist manage without fear or favour like the Health
Gynaecologists. Ombud!

If a teacher has got only 16 learners to teach,

and another one has got 84 learners to teach, What do you say to people who say the NHI
comparing their performances without taking is not affordable?
this into consideration, is grossly unfair, a
distortion of facts and outright unscientific. What is not affordable is the present system.
People who believe that NHI is not going to be
The solution to the gross inequalities I have affordable assume that under NHI, we are
just outlined above is NHI (Universal Health going to allow the present high health care
Coverage) whereby the whole population will costs! Both the WHO and the OECD have
also have access to all the Gynaecologists that already declared that South Africa is running
exist in our country, whether public or private. one of the most expensive health care systems
There are 3 000 Optometrists in South Africa in the world.
and only 250 of them are in the public sector.
If we share under NHI the shortage will The NHI is actually designed to fight these
somehow be mitigated. expenses. Both the WHO and OECD state that
only 10% of South Africa's population can
The NHI is not a beauty contest between the afford the present private health care cost.
public and the private health sectors, but it is a
system to make both sectors serve the whole Clearly, it is the present system that is not
population in cooperation rather than affordable, not NHI. Do you think under NHI we
competition. are going to agree to pay R7 000 to R10 000
for a simple circumcision as it is happening

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today in the present private health sector? NHI (ii) promotion of health; and
will not allow that. The problem is that people (iii) starting the entry to health care
wrongly believe that NHI is simply going to be system at the lowest level rather than
a bigger version of the present system. It is not at the highest level of specialists and
going to be. tertiary hospitals.

(d) Preparation for Purchaser-Provider split.

It has been a few years since health system This means a system whereby the
strengthening projects were launched. How purchaser of health services for the
are these going? What have been some of population (purchaser) is not the same
the lessons from these projects? as the person who actually provide the
services (provider) as it is happening
Yes, we launched pilots in order to learn what presently in the public health care
is feasible and what is not. We have learnt a system.
lot. Under the pilots, we have screened 4 (e) Completion of the NHI policy paper and
million school kids for physical impediments to promulgation of NHI Bill.
learning like eyesight, hearing and oral (f) Formation of Contracting Units for
hygiene/speech. We now know how to tackle Primary Healthcare so that they become
that. the purchasers of health for their
population from providers - both private
We have established District Specialist Teams and public.
to supervise doctors in each district. We now
know where the gaps are. We have contracted
GPs to work in public clinics and learnt that we What other countries have implemented the
also need to contract allied health care NHI? What have we learnt from these?
professionals like Physiotherapists, Speech
Therapists, Oral Hygienists, Occupational Many countries have started implementing
Therapists, Psychologists, Optometrists, etc. Universal Health Coverage even before the
United Nations adopted it as one of the 17
Primary Health worker teams have visited no Sustainable Development Goals of the world.
less than 12 million households to check their
health status. Countries call it by different names but the goal
is one, namely Universal Health Coverage
whereby every citizen in every country has
What are the critical stages for the financial coverage for their health care needs
successful implementation of NHI? instead of only a selected few as it is
happening in our country.
(a) Establishment of NHI fund including
reviewing other relevant legislations and The United Kingdom (UK) started it in 1948
inter-governmental functions and fiscal and called it NHS. Japan started in 1961.
framework that will be impacted by the Mexico started in 2001 and call it Seguro
implementation of NH Populare. Brazil has it, all the Scandinavian
(b) Reviewing all the subsidies that medical countries have very good Universal Health
scheme members receive from the fiscus. Coverage Systems.
(c) Making sure that the health care system is
re-orientated so that its heartbeat, as On the African Continent, Ghana has started.
mentioned in the White Paper on NHI, is Rwanda has also started.
Primary Health Care (PHC). In other
words, a system that is based on 3 main All 194 countries under the United Nations
pillars: have become signatories to the notion of
(i) prevention of disease;

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Universal Health Coverage - which means they when the overwhelming majority of its citizens
are preparing to implement it. are outside the major funding mechanism of
the country health system.
Actually, the list of countries that have the
system or have started is not exhausted. In September 2015, 267 eminent economists
from 44 countries signed the Economists
Budgetary constraints cannot be the reason to Declaration on Universal Health Coverage
delay the implementation of the NHI because which concluded that the economic returns on
quality health care supersedes all other investing on UHC were more than 10 times the
human needs. costs.

Can you explain what the state subsidy to

medical schemes is about?
The country has serious budgetary
constraints is it not prudent to delay the Yes. The total subsidy is actually R46,7 billion.
implementation of the NHI? One of the abnormalities in the present health
system which NHI seeks to correct, is that
The answer is no, and a big no for that matter. health is a condition of employment through
Other basic human needs such as water, medical schemes. This is wrong because
shelter, sanitation and even food, for that section 27 of the Constitution says health is a
matter, are useless if you are dead. We cannot right not a condition of employment.
postpone access to basic human needs.. The
provision of quality health care should ‒ GEMS members are subsidised for R17
supersede all other needs, because it is about billion.
sustaining life. We cannot afford to delay the ‒ Non - GEMS members are subsidised for
implementation of the NHI. R1,8 billion.
‒ SOE's members are subsidised for R7,2
In fact, when the economic situation in any billion.
country is gloomy, that is the time citizens need
access to good quality affordable healthcare Note that the subsidy of Non-GEMS members
more than ever before. NHI is intended to is for members of Parliament and Judges - very
provide just that. NHI is not a luxury that can highly paid members of society, but they are
be delayed due to economic circumstances. It heavily subsidised - R1,8 billion.
is a necessity that is needed to rescue people
especially during tough economic times. SOE's workers are the highest paid members
Otherwise, majority of people will succumb to of society. Some of SOEs top executives earn
their ailments due to their weakened economic more than five times what the President of the
status which will worsen the country's country earns, but they are also heavily
economic situation even further. subsidised for R7,2 billion.

The UK implemented it in 1948 and was driven GEMS members Such as nurses, doctors,
by the hardships brought by the Second World teachers and other senior public servants also
War which had ended 3 years earlier. Due to receive subsidies .
the World war, the British people were poor,
unemployed and sick. That is when they The total subsidy is R26,7 billion. Then come
needed it. They call it NHS. Same as the tax credits. Every single person in South Africa
Japanese who implemented it in 1961 to boost who is on a medical aid, employed in the public
economic growth also ravaged by the Second sector or private sector, is entitled to tax
World War. No economy ever grows when the credits at the end of the tax year. The total
health system is not improved for the majority credits in the last tax year was R20 billion. Add
of the people and no health system improves

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R26,7 billion to R20,0 billion and you have In re-organising the public health system, we
R46,7 billion. declared that the heartbeat of the healthcare
system under NHI will be Primary Healthcare
According to the Finance Minister, Medical (PHC). This means a health system
Tax Credit is in line for a reduction in future characterised by three main attributes:
as part of financing the NHI. What is your
understanding of this statement? ‒ Prevention of diseases
‒ Promotion of health
It has always been our position in the White ‒ Entry to the healthcare system through
paper on NHI. Paragraphs 308,309 and 400 clinics and GPs or other private primary
are making it clear that we can't continue with healthcare providers
this subsidies and tax credits. They perpetuate
inequality and deny the majority of people in It will be imperative that the clinics (PHC
our country access to good quality care and facilities) must be in pristine conditions for this
financial risk protection when they utilise health purpose. They must be efficient, effective and
services. attractive for our people.

We want to use the tax credits to establish the People must have a pleasant and
NHI fund as a transitional mechanism to start unforgettable experience after utilising
funding those who are outside the system of services in our clinics. Such clinics must have
medical aids, overwhelming majority of whom good infrastructure (physical condition and
are blacks, woman, children, adolescents, space, essential equipment, information and
people with disability, elderly, mentally ill communication tools, adequate staff,
people and school kids. These are the people adequate medicine and supplies which a
who need health care more than all other modern stock surveillance system). It uses
groups, but they are the ones who are outside applicable clinical policies, protocols and
the major healthcare financing mechanisms of guidelines as well as stakeholder support to
our country. ensure the provision of quality health services
to the community. This type of clinic is called
an Ideal Clinic.
According to Treasury, further details of
the funding model of the NHI would be
released soon. What are some of the How many clinics are classified as ideal?
proposals on the table for discussions?
Yes, at present there are 1930 clinics all over
Any government anywhere in the world fund the country that qualify as ideal clinics.
government programmes for the benefit of
citizens mainly through tax, surcharges, When we started in April 2015 not a single
special levies or special contributions from clinic, zero, qualified as ideal. In 2013 we built
certain members of the society. This will also the framework of what this ideal clinic must
be the case with NHI, as is the case with look like and tested it in 10 clinics in the NHI
Universal Health Coverage in any country. pilot districts.

We took the framework into the Operation

What is the difference between an ordinary Phakisa Ideal Clinic Lab in 2014 to develop the
clinic and the ideal clinic? roll-out plan.

Paragraph 2 of the NHI white paper states that

NHI is a significant policy shift that will
necessitate a massive re-organisation of the
healthcare system, both public and private.

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Is the private sector part of the What are the critical stages to implement
implementation of the NHI? the NHI?

The private sector has always been part of Critical stages are the following:
provision of health in our country. In NHI, we
want the citizens of South Africa to utilise The National Assembly and the National
resources in both the public and the private Council of Provinces will consult and debate
sector. NHI is a mode of cooperation and the contents of the NHI Bill.
equalisation rather than the present situation
whereby only 16% of the population can utilise The Department will begin preparing for
huge amount of resources in the private sector implementation by continuing to register
while the masses cannot. It has always been patients into a master patient register to
our intention to involve the private sector. prepare for the implementation of the NHI.

How is the NHI going to address the human The Ministry of Health will set up an NHI
capital requirements for its successful Implementation Office to prepare for the
implementation? introduction of the NHI Fund.

Let me start by pointing out that there is a huge The Presidential Health Summit Compact
shortage of human resources for health all signed by the President and stakeholders will
over the world, with sub-Saharan Africa be incrementally implemented. Some of the
branded a crisis region in this regard. We have key interventions include filling of vacant posts
tried to resolve this in several ways: for health personnel, improving and
maintaining hospital and clinic infrastructure,
‒ We have expanded the Cuban training improving access to medicines, equipment and
programme from 80 students per annum medical products.
to about700 students per annum over a
three years’ period.. The Office of Health Standards Compliance
‒ We have asked the Universities to try will certify health facilities that will become part
their best to admit as many medical of the NHI.
students as they possibly can. Wits
University started in 2011 by taking 40 The National Quality Improvement Plan will be
extra students Other Universities have implemented in preparation for accreditation of
followed. We have even opened the 9th providers and establishments to provide NHI
medical school of the country, which is services.
under the University of Limpopo.

Together with the private sector in health, we

have established a Public Health
Enhancement Fund and through it we have
now 70 medical students from the poorest
areas of the country who are pursuing their
studies paid for by this money contributed by
the private sector.

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