By Johann Serfontein

There has recently been an upswing in pro-NHI rhetoric from government circles and affirmation that the consulting processes continue. The Parliamentary Portfolio Committee on Health has started giving initial feedback on the received NHI submissions. It is going to be a mammoth task to work through these, and if past government consideration of submissions is anything to go by, we might as well have a little bonfire with the paperwork. Even the Davis Tax Commission (DTC) recommendations presented in their 2017 report to parliament were ignored. At that stage, the DTC stated that “the proposed NHI, in its current format, is unlikely to be sustainable unless there is sustained economic growth.” That was before the economy shrunk by 16% last quarter.

Government also seems resolute to avoid meaningful contact with healthcare professionals and their representative bodies in the approach to NHI. In COVID, tariffs for doctors were determined without even speaking to them. Doctors in the frontline trenches were simply informed of the fee. Take it or leave it. How the government thinks it can establish a new healthcare system on the ruins of the old one, without involving doctors in the process, boggles the mind. SAMA is, unfortunately, currently so pre-occupied with not being liquidated, that one wonders whether they will add any value to the upcoming consultation process in the Portfolio Committee on Health. This is the final opportunity for government to listen to those delivering services on the ground. Government hospitals are not the backbone of the health system, as the previous Minister of Health indicated, healthcare professionals are. The healthcare system is kept afloat by the efforts of healthcare professionals, who risked their lives during COVID to care for the ill, while being deprived of PPEs by the politically connected. They deserve to be heard on NHI, and government ignores them at its own peril. 

The Davis Tax Commission also further stated that “The magnitudes of the proposed NHI fiscal requirement are so large that they might require trade-offs with other laudable NDP programmes such as expansion of access to post school education or social security reform.” South Africa has, in the interim, introduced free higher education and there is now talk of a universal income subsidy. The NHI money has therefore effectively already been used to fund free higher education. When one considers that an income subsidy in itself will also improve the health status of many South Africans by giving them access to nutrition and water, it would probably still rank higher in importance than NHI. The DTC report preceded the current COVID epidemic, which has put the South African economy back 10 years. With a R300 billion government funding shortfall forecast for 2020, which is more than the proposed NHI budget, and skyrocketing debt levels, there simply is no money for a fully tax funded healthcare system. Not by 2025, and probably not by 2035.

But next year is a local election year, so it is time for the faithful “Free healthcare for all” policy to be taken of the shelf and dusted off for electioneering purposes. A decade after its inception, we still have no indication what services it may offer, or what it may cost. But government remains adamant we can afford to implement it. How government can, with certainty, state that something is affordable when they do not know what it will cost, is a total conundrum. The government is also sitting with the dilemma of what can be done to draw attention away from the corruption cesspool that undermined the COVID efforts. NHI serves that purpose adequately. The arguments that COVID could have been better handled under NHI is proposed as the main reasoning. The National Health Insurance Fund will be a very large healthcare purchaser. Run by the state. The amount of contracting and procurement that has to be done by the NHI Fund makes it twice the size of Eskom, financially speaking. Failure of South Africa’s COVID efforts lay in failure of control processes of contracting, allowing rampant corruption to syphon off billions of rand that was supposed to be spent on protecting South Africans from COVID. The NHI Fund is all about contracting. Purchasing of services, PPEs, and medication all lying in a central body. Corruption Central, one might call it.

International evidence on universal healthcare models does not put a single payer as a pre-requisite. It also does not state complete tax funding as a pre-requisite. The decision for a single payer tax funded system in South Africa was made in 2009, at the absolute height of state capture. If COVID corruption has shown us anything, it is that the selection of the NHI model was not made on best international evidence, but on ease of access to a centralised pile of funding money by those participating in corruption. One can only hope that in the next 10 years, as the economy recovers, a sensible approach can be taken to achieve universal health coverage. An approach that does not involve having to trust government officials in the NHI Fund with the entire South African healthcare budget.

Dr Johann Serfontein is healthcare consultant and external lecturer at the University of Stellenbosch Business School. He is also a published novelist under the pseudonym, Jean Cerfontaine.