Section 33 of the National Health Insurance (NHI) Act — the part that says medical aids in their current form will be scrapped, as they won’t be allowed to cover the same services as the NHI — is staying as is, even if it costs South Africa its Government of National Unity (GNU), Health Minister Aaron Motsoaledi told Bhekisisa.
“You can’t come and tell me ‘I support this universal coverage, but it (section 33) must go.’ It’s like supporting a house, but the foundation must go. Don’t you know it’s going to collapse?” Motsoaledi said in an interview for Health Beat, Bhekisisa’s TV show.
https://youtu.be/rNyUj4-NiAA?si=lTsFbbUHve23gmF7
Once the NHI, which aims to give rich and poor the same health services, is fully rolled out, medical aids will only be allowed to cover top-up services that the NHI doesn’t pay for. The logic behind it is for the total amount of money that South Africa spends on health — 8.24% of GDP — to be more equitably distributed: about half of the funds are spent on the benefits of patients with medical aid cover (15%) and the other half on the remaining 85% who rely on government hospitals and clinics.
But it’s one of the issues that parties in the GNU who don’t support the NHI in its current form — only four of the 10 parties do — are most concerned about. They view it as a potentially unconstitutional condition, because it deprives the medical aid industry of the right to trade, and takes away consumers’ choice to buy health cover from a preferred source. They also fear such a move will destroy the private healthcare industry.
For the DA, the GNU’s second largest party, section 33 is a dealbreaker; in fact, expanded access to private medical aids forms the backbone of the party’s health plan included in its 2024 election manifesto. And, in its submission before the parliamentary portfolio committee on health in 2022, the DA said: “The NHI Bill completely removes the choice for South Africans to choose where to get their healthcare and could effectively outlaw medical aids.”
https://www.youtube.com/watch?v=NsBxWA82J_Q
The DA’s spokesperson, Matt Cuthbert, told Bhekisisa “it was clear in the negotiation (process) with the GNU that a relook at the problematic clauses (of the NHI Act) would be essential to the GNU formation and its sustainability”. Cuthbert says that in Cabinet discussions “it was agreed that a subcommittee would be established to process the views and alternatives”.
But Motsoaledi stands firm: “We (the ANC) are not in an alliance with the DA; we just went into the GNU because the situation demanded it… If anyone believes because of this misunderstanding the GNU should collapse, that will be very unfortunate.
“But what can we do, that will have been their choice?”
Should government and business talk more?
The future of medical schemes and also how the private healthcare industry will be used to give all South Africans good care, regardless of whether they can pay for it, were some of the reasons Business Unity South Africa (Busa) and the South African Medical Association refused to sign the country’s second presidential health compact on Thursday.
The South African Medical Association has about 12,000 doctors as members and Business Unity South Africa is the country’s largest federation of business organisations.
A health compact is an agreement among sectors — for example, business, government, labour, patient groups, civil society, health professions organisations, statutory bodies and academia — to work towards a common goal, and sets out what each industry has to bring.
The country’s first health compact, of which the goal was to better equip “the South African health system towards an integrated and unified health system”, was signed in 2019, and had remarkable cooperation from many sectors outside the government.
Of the 363 partners, only 16 were state departments. Organisations such as Business Unity South Africa, the South African Medical Association and the Progressive Health Forum served on the steering committee, and they helped to lobby other organisations in their fields to participate, too.
For example, Business Unity South Africa got 48 business organisations to commit to the agreement and coordinated the private sector’s contributions. The South African Medical Association, in turn, got 76 health professional organisations involved and managed input relating to primary healthcare services.
‘The NHI was pushed down our throats’
But this time around, only 13 partners signed the compact, of which three were the president, health minister and minister of science and innovation, because organisations such as the South African Medical Association and Business Unity South Africa argued that the NHI, in its current form, was essentially pushed down their throats.
Where references to the NHI in the first compact were few — the agreement had nine pillars and the NHI is mentioned in three, and only in relation to future implementation — the draft document that was circulated for input last week has 16 sections, called articles, and the NHI, as a clear policy to which all signatories commit, is mentioned in 12. For instance, the NHI is referred to as “a lodestar” for the “voyage” towards universal health coverage.
Ultimately, those who didn’t sign, felt excluded.
“It (the compact document) has been unilaterally amended by the government, transforming its original intent and objectives into an explicit pledge of support for the NHI Act. These changes to the health compact were made without consultation,” Business Unity South Africa said in a press release.
The implication is that there are fewer partners to formally work together to improve the country’s health system. As Olive Shisana, the president’s social policy special advisor, put it in her closing speech entitled “Why we need the second presidential health compact”, at the 2019 event: “The state, as the main provider of healthcare services, cannot address all the health challenges on its own, and it needs the support of other stakeholders… A health compact can help to establish a shared vision and goals for the health system and provide a framework for collaboration.”
Although the media was invited to the signing event, copies of the final document hadn’t been made available at the time of publication. Read the draft copy that was circulated here.
One of the solutions to the medical aid issue, suggested by the country’s largest private scheme, Discovery Health, would be amending section 33 to say “that the role of medical schemes will be determined at a later time through a collaborative and a consultative process”.
Discovery CEO Ryan Noach told Health Beat in July 2023: “That kind of amendment is only a few words in the act — but … would lead to (the act) being much more feasible and much easier to implement.”
ARVs for asylum seekers and undocumented migrants?
Motsoaledi says although he’s not prepared to negotiate on section 33, there are other parts of the NHI Act, such as the one about who will have access to HIV treatment, that could potentially change.
Section 4 of the act says asylum seekers (people who have applied for refugee status but are still awaiting the outcome of the government’s decision) and “illegal foreigners” (undocumented migrants) can only get treatment for emergencies or notifiable diseases. A notifiable disease is an illness that can lead to an epidemic-like outbreak and cause many deaths, thereby posing a threat to the health of everyone in a country, like Covid-19 or Ebola.
This section of the Act has previously caused outrage among health activists, because HIV is not a notifiable disease in South Africa and asylum seekers and undocumented migrants with HIV will therefore not be able to access antiretroviral treatment.
Not treating everyone with HIV in a country doesn’t make sense, research has shown, because antiretrovirals, when used correctly, bring down the levels of HIV in an infected person’s body to such low levels that it becomes scientifically impossible for them to transmit the virus during sex. Treatment, therefore, not only keeps people healthy, but also slows down the spread of the virus.
With this strategy, Motsoaledi says, he agrees, and if “there’s a mistake in the NHI Act about that, it needs to be corrected”.
“If you refuse people with highly infectious diseases, like HIV, treatment, it’s going to spread around. Then you’re working in reverse. Because otherwise (without offering treatment), I don’t think we’d be able to defeat the disease.”
In fact, Motsoaledi says, laws are often amended. But in the case of the NHI, he will only sit down to listen to those who are open to change, and who have constructive suggestions.
“I’ve been in government for ages now. I’ve never seen an act on Earth that is never amended,” he says. “But I’ve learned, from home affairs, everything people don’t like, just by not liking it, they’ve given it a new name: unconstitutional.” DM
Watch the full Aaron Motsoaledi interview on Health Beat on eNCA on Sunday, 25 August at 5.30pm or from Monday, 26 August on Bhekisisa’s YouTube channel.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
