How the NHI will work over time
One of SA's most anticipated pieces of legislation, the National Health Insurance (NHI) Bill, was tabled more than two weeks ago but instead of providing relief it has caused confusion and speculation about the future of health care in the country.
NHI's aim is to provide universal access to quality personal health-care services purchased through the National Health Insurance Fund once it is fully implemented in 2026, but there are concerns about how it will be implemented.
At the top of the list of concerns is the future of medical aid schemes, potential job losses in the private sector and just how much NHI will cost South Africans.
On Wednesday, the health department's deputy director-general for NHI, Anban Pillay, said the situation was not as dire as it seemed. He responded to some of the issues.
"They [medical schemes] will always be there, even when there is full implementation of the NHI. Only at that point of full implementation [will] they take a complementary role. From now on until full implementation, schemes will continue as they are currently," Pillay said.
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After the NHI Bill was tabled, SA's private medical scheme companies' share prices took a knock, with the bill cited as one of the reasons.
The bill states that medical schemes will provide complementary care services that the government will not provide.
Pillay said the uncertainty for medical schemes comes mainly from them not knowing what kind of complementary cover they will provide.
"I think the main issue about certainty is they [medical schemes] are not sure about the complementary cover and they don't understand how the complementary cover will be implemented."
He said the cover the government will provide will be determined by the economy, which dictates what the state can afford.
"So when the economy does badly, this would affect the budget allocation, which may impact on the services that will be covered. This will then impact on the services that schemes will cover as complementary cover," he said.
The initial focus of NHI is primary care, which includes services such as general practitioners, medicines, optometrists and laboratory services.
However, this will change with every medium-term expenditure framework, depending on how big the budget is for health care, said Pillay.
The department has been criticised for not having a funding model and costing for NHI, apart from pricing it at R256bn, which was calculated on 2010 prices.
Pillay said the Treasury is working on a new costing model, which will be released in the next few weeks.
This model will be based on SA's economic growth expectations when NHI is implemented, the burden of disease, health-seeking behaviour and the cost of treatment.
He cautioned against focusing on the cost of NHI, saying: "People keep saying, 'how much will NHI cost?' And we keep having to explain that it's the wrong question, because NHI can cost as much as we want it to cost.
"You could take the entire budget of any country and spend everything on health care if you wanted to - not that any country will do so.
"The question is not how much NHI will cost but rather how much of funding is available and how will these funds be efficiently used to deliver a set of services."
He said the question to ask is how much the Treasury has available to allocate to the NHI Fund.
"So as the money from Treasury increases, the package will also increase, so it doesn't matter how much the total cost is because that is an academic question - the more important question is how much of money is available," he said.
Like the public sector, the changing packages mean that medical aids will have to change their complementary care packages with every medium-term budget statement.
As for worries that some private-sector staff will lose their jobs once NHI is implemented, Pillay said the opposite will happen.
There are 8.8-million members of medical aid schemes at the moment. Pillay said that with more people having access to health care at the level that the NHI is promising, and the private sector contracting to the government by providing services, the health sector will have to employ more people.
When the NHI Bill was tabled, the DA said it will be used to nationalise health care, establish a new state-owned enterprise and be an additional tax burden.
Pillay disputed that.
He said the National Health Act currently gives provinces autonomy over certain functions such as providing specialised hospital services and planning the development of public and private hospitals, other health establishments and health agencies.
This has left the health minister with little power over what happens at provincial health departments.
Pillay said this will soon change as the National Health Act is being revised to give the minister more power
"It's not nationalisation, the minister is accountable for the health system but he currently doesn't have powers to manage the entire health system so we are correcting this misalignment where a minister has responsibilities but no powers to intervene," he said.