A coherent, achievable path to universal health coverage now imperative

Wednesday, 29 November 2023, Glaring voids highlighted in submissions on the National Health Insurance (NHI) Bill threaten South Africa’s path to equitable healthcare access for all, cautions the Health Funders Association (HFA). The organisation has voiced its profound concern, emphasising the disconcerting sway of politics over the bedrock mission of prioritising the well-being of our nation within this critical healthcare deliberation.

“The practical barriers to successfully executing NHI as it is laid out in the Bill are hard to ignore, and yet the numerous concerns and suggestions raised in the consultation process have not been considered or implemented,” says Craig Comrie, chairperson of the National Health Funders Association (HFA).

“The clear shortcomings of the NHI Bill in terms of practical funding mechanisms and lack of collaboration with experienced health funders, among other aspects, have been overlooked for the most part, with only the Western Cape so far rejecting the Bill in its current form.”

The National Council of Provinces (NCOP) Committee on Health’s approval of the NHI Bill with insignificant edits does not address the numerous concerns raised in submissions made by the public and informed stakeholders, including the HFA, on behalf of its members.

The HFA is a professional body representing medical schemes and half of South Africa’s medical aid membership.

“There are constructive solutions to address the problems identified in the NHI Bill effectively, and it is not too late to fix the legislation. While the Bill is rushing towards the President’s pen to be enacted, the HFA respectfully appeals to the President to reconsider the wisdom of signing into law a Bill that has no workable funding mechanism while disregarding solutions proposed by private health funders, leading organisations, businesses and other key constituents,” Comrie says.

“We anticipate considerable resistance to the NHI Bill on Constitutional grounds, and as the HFA, we will continue to advocate for a more achievable approach to fulfilling universal health coverage aims.

“The timing of the recent flurry of activity in moving the Bill through the necessary hoops ahead of next year’s election invites the notion of a blunt instrument, an unrealistic election promise rather than a pragmatic solution for the highly complex health challenges South Africa faces,” he says.

Health Funders Association members, including leading lights in the industry such as Bankmed, CAMAF Medical Scheme, Discovery Health Medical Scheme, Fedhealth, Glencore Medical Scheme, Momentum Medical Scheme, Profmed and PPS Healthcare Administrators, to mention but a few, are ready to work with government to develop evidence-based solutions that will help secure access to quality healthcare for all South Africans.

“There is so much opportunity to make the NHI work. Private public partnerships and collaboration have achieved so much good for the benefit of South Africans in other sectors, and there is much our industry can contribute to help make quality healthcare more accessible and sustainable for all,” Comrie concludes.

HFA Opinion pieces

Protect SA’s rights and health assets for all.

By Craig Comrie, chairperson of the Health Funders Association (HFA).

Tuesday, 23 January 2024, in a resounding declaration at the ANC’s 112th-anniversary rally, President Cyril Ramaphosa recently proclaimed that the National Health Insurance (NHI) Bill is destined for enactment, a fait accompli that leaves no room for dissent.

Should the current iteration of the NHI Bill be signed into law, citizens face a stark reality: a healthcare system tied to the bureaucracy of unfriendly processes to access care listed as NHI services. This process devoid of choices of where and how to access healthcare is going to be the biggest compromise for a healthcare consumer who has no alternative care and is effectively tethering their fate to the State’s monolithic singe-funder structure.

As the Bill stands, it would signal a profound seismic shift in the very fabric of South Africa's healthcare dynamics. Exactly how this will work in practice appears deliberately unclear, with crucial details around funding and the list of services that will be available if the NHI is not yet defined nor budgeted for.

Quality healthcare should be available to everyone, irrespective of the capacity to pay for it. There is more than one path to Universal Health Coverage (UHC), and there are quicker and more effective ways than the NHI Bill to bring our current two-tiered health system into closer alignment with its stated objectives. It is possible to work towards the aims of UHC while protecting and building South Africa’s health assets and protecting constitutional rights.

As the Bill stands, any procedure or service listed as being covered by the NHI, cannot be paid for privately or with medical scheme cover. Everyone will be at the mercy of a single state funding system for these services, and this greatly diminishes the right to freedom of choice in how and where a person can access healthcare in South Africa.

Consider that under the proposed NHI model, patients requiring standard procedures such as tonsillectomies and hip and knee replacements, among others, would have no option but to live in discomfort until their turn comes up on the NHI’s waiting lists.

If we look at the United Kingdom’s comparatively well-funded National Health Service (NHS), which has been held up as a model for SA’s NHI, procedures such as these typically have significant waiting lists often longer than a year, while patients receive ongoing pain management treatment. Then again, UK patients still retain the right to go the private route to access life enhancing procedures sooner outside the public health system. Many other European countries struggle with the same issue of growing costs and where national budgets aren’t able to keep up, queuing becomes a national pastime.

At this juncture, it is worth pointing out that the UK’s GDP per capita to support the NHS is $46 510 USD, compared with South Africa’s being a mere $7 055. The public health system of Denmark, which has a GDP per capita of some $68 007, is another country that has been held as an example of what South Africa’s NHI aspires to achieve.    

We have to be realistic about how we get closer to Universal Health Coverage as a society, and we cannot afford to put all our eggs in one untested basket and hope for the best. Bringing the public health system closer to the private system to improve access to quality healthcare for everyone while maintaining the option for additional funding mechanisms would advance the aims of UHC more speedily.

Medical schemes are non-profit funds established to fund private healthcare and remove the pressure on public health services thereby reducing queues and government funding. Currently, people who belong to medical schemes are removing the obligation from the State for funding their healthcare needs, while still contributing tax to sustain public health services.

Nationalising healthcare funding as proposed under the NHI Bill is a risky step, as removing private funding diminishes opportunities for the retention of specialist skills, general infrastructure investment and the development and long-term management of health resources.

Alternative models have been discussed that would allow the improvement of public health facilities with combined public and private funding and proposals of partnerships to improve the quality of the public health system while reducing costs to those with medical scheme membership.

A single, centralised funder model is not essential for speeding up progress towards the goals of UHC, it is possible to get there without incurring the constitutional pitfalls of the NHI Bill as it stands now.

HFA outlines presidential petition to prevent decimation of the SA healthcare system

Monday, 18 December 2023,The NHI Bill presented to President Cyril Ramaphosa cannot be permitted, as in its current form, it will infringe the rights of all South Africans by destroying the South African healthcare system. The Health Funders Association (HFA) has petitioned the President to withhold assent of the Bill on constitutional and procedural grounds and intends to take the matter as far as necessary and to the Constitutional Court if need be.

“We have taken a strong stand by respectfully urging the President to withhold assent of the Bill, citing constitutional and procedural concerns that pose a significant threat to the integrity of the country’s healthcare system," remarks HFA Chairperson Craig Comrie.

“Should the need arise, the HFA is prepared to escalate the matter to the courts. Our goal is to meticulously align the legislation with the authentic objectives of Universal Health Coverage and the principles enshrined in the South African Constitution.

"Our action in opposing the NHI Bill being signed into law protects the interests of ALL South Africans who will require healthcare in future, including the people we are duty-bound to safeguard through the medical schemes and healthcare administrators we represent,” Comrie says.

While expressing unwavering support for achieving Universal Health Coverage (UHC) in South Africa, the HFA questions Parliament's endorsement of a bill that raises significant constitutional and procedural concerns and fundamentally cannot achieve a sustainable system of UHC.

Some of the primary concerns outlined in the letter include:

• Constitutional concerns: The NHI Bill's clear infringement on constitutional rights, particularly the right to access healthcare and freedom of choice for South Africans, and by implication, the right to life. The Bill is seriously flawed in that regard, undermining the rule of law.
• Procedural concerns: Questioning the extent and effectiveness of public consultation during the drafting and review of the NHI Bill, where thousands of submissions resulted in no meaningful changes to the Bill, the HFA advocates for a more inclusive and consultative approach.

The letter implores President Ramaphosa to exercise the powers granted by the Constitution to refer the NHI Bill back to Parliament for review.

“In addition to petitioning the President directly as guardian of the Constitution, the HFA will oppose the NHI Bill in its current form through every possible avenue, including approaching the courts to set aside the Bill on constitutional and procedural grounds.

“The HFA will also seek a High Court interdict against implementation of the NHI Act until the merits of our case have been heard and ruled upon by the High Court.

Craig Comrie concludes, "It is with a heavy heart that we make this plea, urging the President to secure the rights and wellbeing of our people. We will persist to ensure that what is right triumphs in our nation. South Africa deserves leadership that prioritises the welfare of all of its citizens, above all."

Multiple roads to Universal Health Coverage based on social solidarity

Thursday 16 May 2024: The process towards fulfilling the promises of the National Health Insurance (NHI) will be a complex and unprecedented process that will necessitate extensive reorganisation of the healthcare sector. As such the experience for most South Africans will not meaningfully change for years to come with hopes having been raised of achieving Universal Health Coverage (UHC) through the NHI Act.

“There are various paths towards Universal Health Coverage [UHC], and collaboration with private healthcare funders can bring the benefits of more equitable access to quality healthcare to millions more South Africans,” says Craig Comrie, Chairperson of the HFA.

“The signing of the National Health Insurance (NHI) Bill into law by President Cyril Ramaphosa will shape South Africa's healthcare future, yet at present there is no threat to medical scheme members’ benefits as the implementation of the NHI Act will be constrained by significant financial and structural constraints and complexities, not to mention legal challenges.

“Until the NHI Fund and public healthcare system are ready to support quality, dignity-affirming healthcare, private health cover could offer an effective means of elevating the standards of care and extending access to millions more South Africans. With the finalisation of long-awaited regulations such as those pertaining to Low Cost Benefit Options (LCBOs) and regular Prescribed Minimum Benefit reviews, real and lasting progress towards the goals of UHC could be made,” Comrie says.

“We remain concerned about the long-term implications of certain sections of the NHI Act and its ramifications for the quality of healthcare for all South Africans, the sustainability of the healthcare system, and by extension, the rights of patients to quality care.

“What is needed is for all in the healthcare sector to unite our efforts to build a workable integrated funding system incorporating multiple funding streams and collaborative engagement to benefit everyone in South Africa. There are workable alternative approaches which can achieve universal healthcare without compromising the freedom of individuals to choose how to fund their healthcare needs,” he notes.

“Where constitutional and other legal issues exist, we will take the necessary action to protect the constitutional rights of individuals and their medical scheme benefits,” Comrie says.

“The NHI Act in its current form will not achieve equity in healthcare and there are better ways to achieve the genuine objectives of Universal Health Coverage. We take the duty to protect access to quality healthcare in line with citizens' constitutional rights very seriously and will not be deterred.”

Health Funders Association to petition President Ramaphosa

The National Assembly and National Council of Provinces’ adoption of the National Health Insurance (NHI) Bill is a disservice to South Africa and its citizens, and the Health Funders Association (HFA) is petitioning the President to reconsider certain aspects of the proposed legislation.

“In adopting the NHI Bill in its current form, Parliament has failed to take proper cognisance of the implications for citizens’ constitutional rights, healthcare as a whole, and the South African economy. In short, it has failed South Africa and its citizens,” says Craig Comrie, chairperson of the HFA.

“This is too important to let pass without every effort being made to ensure the President, as guardian of the Constitution, is fully aware of the unintended, yet completely foreseeable, consequences signing the NHI Bill into law in its current form would have for South Africa.

“There is still time to make the required changes to the bill that would help to make the goals of Universal Health Coverage achievable and sustainable in South Africa. “The Health Funders Association is therefore petitioning the President to send the draft legislation back to Parliament for the necessary amendments to ensure it is aligned with the true aims of Universal Health Coverage, and our Constitution, to serve South Africa better,” Comrie concluded.