Almost all respondents had concerns regarding the implementation of NHI.

Poor quality public sector health services

The current public sector health system was seen as ailing (shortages of health professionals, poor infrastructure, financial constraints, inadequate equipment) and struggling to provide an acceptable standard of care, both in terms of fulfilling the requirements for NHI accreditation, as well as the expectations of an expanded pool of users under NHI, who would previously have had medical aid. 

Managerial capability

Members were concerned at a lack of leadership and managerial capability in the public sector that would impede the implementation of NHI. Managers might be appointed for their political connections, rather than competency. Respondents felt that gross mismanagement has plagued healthcare in many provinces and this might carry over to poor management of NHI.

Possibility of corruption and poor governance

A widely expressed concern was the possibility of corruption, given the history of state-capture and corruption in other state owned enterprises and provinces. Corruption might lead to the misappropriation of funds at different levels in the NHI system.

Members were concerned that the Minister of Health had too much personal and political control over the appointment of NHI governance structures and that there was too little oversight of this power. This leads to a future risk for a lack of accountability as well as patronage and corruption. 

Insufficient funds

Members were concerned that the relatively small tax base to fund NHI would not be sufficient to pay for a comprehensive package of care for all in the South African context. Government entities such as NHI would find it difficult to borrow money and would be dependent on tax funded government bail outs should shortfalls arise. No provision is made for a pool of reserves. Limited funds might then lead to restrictions on what services were covered. Tax payers would then have to pay for NHI, but all might receive a less comprehensive package of care than what is currently available. 

Financial planning

There was concern that no detailed costing of the NHI model had been published and that this represents a lack of due diligence on the part of those planning to implement the model.

Administrative capacity

Members were concerned that inefficient public sector administration and bureaucracy would impede the implementation of NHI. 

The concept of “timely” remuneration is not defined in the Bill, which leaves the payment of providers open ended. There should be a legal requirement to pay within 30 days.

Timeframe

Several respondents felt that the time frame was unrealistic and implementation too fast given the many issues that need to be solved to make it a success.

Effect on health professionals

Uncertainty and fears that remuneration may decrease and workload increase in the private sector may prompt some doctors to emigrate. Fears that NHI will lead to increased workload and reduced quality of life for practitioners.

There is uncertainty about the place for other members of the multidisciplinary team in the services funded by NHI –e.g. mid-level workers, pharmacists, therapists.

The possibility to earn extra income in the private sector may be reduced.

Outcomes for patients

Several respondents saw NHI as benefiting people from lower socio-economic groups, while a few believed that they might even be worse off.

There was a concern that many patients would experience a decline in their quality of care with longer waiting times and waiting lists.

There was some comment that NHI erodes ones autonomy to freely choose one’s own service providers and one’s rights as a consumer.

Employed people currently on medical insurance may be expected to pay for NHI, receive a lower standard of care and in addition pay for additional medical insurance for what is not covered by NHI.

Legal framework and definitions in the Bill

Many aspects of the NHI Bill contradict existing legislation and this may take time to address properly.
The role of provinces seems to be minimised in the Bill and changes in their role may lead to legal or constitutional challenges.

The concept of “appropriated resources” in the Bill needs to be explained or defined and is a worrying possibility.

The dominance of the NHI Bill over other legislation such as Children’s Act, POPI, Consumer Protection, Health Professions Act, may erode consumer rights and ethical medical practice.

Excluding NHI transactions from the Competition Law could lead to higher prices with less competition, allow suppliers to collude on higher prices or threaten withdrawal of services if tariffs do not suit them. 

The requirements to record information in practices that opt out of NHI may conflict with the autonomy of patients to not provide this information.

Illegal foreigners will find it difficult to access health care under NHI and having different tiers of access (they will be able to access care for notifiable conditions) will be administratively complicated. There may also be a contradiction between the constitution, which speaks of the right to health care for everyone, and the NHI Bill which restricts health care for certain groups. 

How will the state determine what are “reasonable” or “unreasonable” grounds to deny people health care as stated in the Bill.

The administrative requirements to fulfil 6(b) and communicate to all citizens might be beyond capacity to deliver.

It is not clear if the military who are excluded from NHI will still have to fund NHI through taxation.

It is not clear whether NHI will contract with health care service providers, who are juristic persons, or with public entities such as hospitals and clinics. Hospitals and clinics cannot contract with the NHI currently as they are not juristic persons and would have to go through a process of being registered as per the legal requirements. The employment status of the employees of these hospitals and clinics might then need to change.

The Bill implies that it may negotiate prices for health services (11.2e), while elsewhere implying that NHI will set prices for capitation and services.

The Bill says nothing about traditional practitioners.

The Bill appears to provide loopholes for medical schemes to offer the same services to patients who skip the referral chain, who consult non-contracted healthcare professionals or to foreigners who are not covered.

The Bill appears to place the responsibility on practices to transfer patients to another facility if they cannot provide the care needed – who will pay for this? This needs to be clarified.

What benchmark will be used to determine a reasonable waiting time for services and what recourse will people have if this is not met. This should be defined.