Court-ordered NHI pause opens door to policy rethink

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JEREMY MAGGS: A court-ordered pause on the implementation of the National Health Insurance (NHI) Act has effectively, as far as I understand it, frozen government’s rollout plans after the president (Cyril Ramaphosa) undertook not to proclaim any provisions and the minister of health (Aaron Motsoaledi) then agreeing to halt implementation, pending Constitutional Court hearings in May.

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Supporters say this creates space for meaningful reform. But critics are arguing the act in its current form risks destabilising the healthcare system.

It’s an important issue, and I’m going to talk now to the chief executive officer of the Health Funders Association, Thoneshan Naidoo, a very warm welcome to you. Let me start simply then, does this pause fundamentally change the trajectory of NHI or is it just delaying the inevitable?

THONESHAN NAIDOO: I’m very optimistic. I believe this pause has come about to reflect and engage. It’s a positive move. I see this came forward from the president and the minister, one, to not proclaim the act and two, not to implement the act.

We’ve been in court because we’ve said the act is unworkable, financially not sound, and will create havoc.

Now, during this pause, what we would like to do is reset this framework. Let us sit around the table, let us focus on what are the opportunities.

We can collectively as public and private, work on enhancing health care for all 63 million South Africans, and that’s why we welcome it.

JEREMY MAGGS: Let me pick you up on resetting the framework, if I can. As far as I understand it, your association supports universal health coverage, but as you’ve suggested, opposes the current model. Just remind me again quickly what in the act makes it, in your words, irrational or unworkable?

THONESHAN NAIDOO: As the first point of call, but not the only one, it’s financially impossible to achieve.

It would mean basically that members would have to increase what they’re currently paying in taxes, and it would require our current bill going to almost R1 billion. It’s basically impossible. So that’s financially.

Secondly, it says that what is then prescribed or offered from NHI can no longer be offered by medical schemes. So you’re actually taking away access from it.

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Then the third thing is about actual capabilities. For NHI to be able to do what it needs to do and be equivalent to medical schemes, you need to triple the number of doctors, you need to triple the number of healthcare resources, and we simply are not on that trajectory.

We are literally setting ourselves up for failure because none of the planning, none of the implementation, infrastructure systems are there.

What we are about is we are for universal health coverage. We want equity in the country. But the trajectory of this is going to destroy healthcare for all of us.

JEREMY MAGGS: In fact, Thoneshan, you go further than that, you also say the act, and I quote, would undermine and collapse the healthcare system as it exists right now. That’s strong language, what’s the single biggest systemic risk then that you see?

THONESHAN NAIDOO: One, I don’t want to say it’s one, but I think it is financials. We simply cannot afford this. Then two, the consequence of that is the healthcare professionals simply are mobile.

We are in so much demand globally and we will see all the nurses, the doctors, literally emigrate out of here, further collapsing the system. I think those are probably two key things that we see as an issue.

JEREMY MAGGS: On the flip side, your critics say that private funders are simply protecting commercial interests. So how do you convince us that this is about sustainability and preservation and not just about profit?

THONESHAN NAIDOO: Firstly, medical schemes are not-for-profit organisations, and we are actually owned by members. The whole intention is not about protecting the private sector, it is about equity.

We want to make sure that healthcare, as a constitutional right, is actually accessible by everyone. It does not protect (private) interests.

Then, quite importantly, there’s a misnomer that medical schemes are all about the elite, when we know that up to 88% of people in medical schemes actually earn less than R40 000 and in fact, 40% earn less than R16 000.

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These are your teachers, your nurses, your working middle class, the engine of South Africa who actually carry the financial burden.

There are about seven million taxpayers. A large portion of those are medical scheme members who fund the taxes for South Africa.

It is not a case of protecting private interest. The interest is in protecting healthcare in South Africa and protecting the country.

JEREMY MAGGS: Let me come back to you and say that you present a very eloquent argument. But I would contend that the vast swathe of South Africans have no access at all to private healthcare and funding.

THONESHAN NAIDOO: I think, firstly, there’s a misnomer, we believe that only nine million South Africans who belong to medical schemes access it.

But our studies, there are a number of studies that actually say that up to 40% of South Africans access private healthcare. Now, the problem or challenge is many of South Africans do so out of cash.

We actually have put on the table an alternative solution for what we call primary healthcare. At R400 per month, we can get access to GPs (general practitioners) and to private primary healthcare.

So we put solutions on the table, and we continue to (provide solutions) that increase access. What we do need, and hopefully in this reset, government can look at the issues and the policies and start unblocking those.

Then we can collaborate around making a system, because once we enable this efficiency system, the public sector, which is under so much strain, those can be unblocked to make sure the vulnerable who can’t afford it can get the right access to the right quality without queuing and so on.

JEREMY MAGGS: All right. If this pause, then, as you’ve told me, is a window for collaboration, is there a measurable compromise that you’re prepared to make to meet government halfway?

THONESHAN NAIDOO: Firstly, the legal route we’ve taken has always been our last resort.

To be honest, if we go down the legal route, in five years, the biggest losers will be South Africans.

So we will always be willing to sit at the table, to negotiate, to engage and say, we want to make this country work, here are solutions.

We’ve got a private healthcare system that is world class, probably in the top five. We have the skills, the knowledge, the IT. We are willing to roll up our sleeves and help increase the standard of the public sector.

So definitely, without a doubt, we are willing to be at the table to negotiate.

JEREMY MAGGS: You’ll need to give me a quick answer here. The Constitutional Court challenge, as I understand it, focuses on public participation, not substance. If the court then rules that parliament followed proper process. Would you be prepared to accept the act as it is?

THONESHAN NAIDOO: No. So once that is accepted that that is all good, then we will continue possibly with our case moving forward regarding the substance of that, because the substance of that is still unconstitutional.

JEREMY MAGGS: Thoneshan Naidoo, thank you very much indeed, chief executive officer of the Health Funders Association.

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