The NHI: The IRR's analysis

Anthea Jeffery says despite its basic unaffordability govt is pressing ahead with the scheme


There is still no clarity on what the proposed National Health Insurance (NHI) system will cost, how it will be financed, how the supply of health services can be ramped up to match increased demand, how the enormous administrative burden will be met, or how the corruption the new system will foster can be curbed. In March 2017 the Davis Tax Committee also warned (in a report which it finally made public last week) that the NHI was ‘unlikely to be sustainable unless there was sustained economic growth’. The government is nevertheless busily pressing ahead with NHI implementation.

A revised NHI White Paper

A revised White Paper on the NHI was gazetted by the health minister, Dr Aaron Motsoaledi, on 30th June 2017. This revised document is much the same as a draft white paper, published in December 2015, which was widely criticised by experts for the many weaknesses in what it proposed.

NHI benefits

The White Paper gives a long list of the services the NHI is to provide free of charge to all South Africans. These range from cardiology, dermatology, and neurology to oncology and cancer treatments, psychiatry, obstetrics, gynaecology, paediatrics, orthopaedics, and surgery (including organ transplants of various kinds). At the primary health care level, the services to be provided will include ‘sexual and reproductive’ health care, along with optometry, ‘oral health rehabilitation’, and a comprehensive range of remedies for mental disorders and disability needs. Treatment for ‘rare diseases’ and ‘dread diseases’ will also be provided, along with comprehensive radiology services, including ‘nuclear medicine and radiation oncology’.1

NHI costs

The White Paper again fudges the key question of what the NHI is likely to cost. Instead of trying to provide any realistic estimate, the document simply repeats the figures provided in the December 2015 draft. It thus puts ‘projected NHI expenditure’ in 2025/26 (when the new system is supposed to be fully operative) at R256bn in 2010 prices.

However, if both public and private spending on health care in the current financial year is taken as the starting point and the health inflation rate is estimated at 6% a year, then the NHI will cost R665bn in 2025, rising to R890bn in 2030, R1 190bn in 2035, and R1 260bn in 2040.

But health inflation is in fact higher than 6%. In nominal terms, expenditure on public health care has gone up by roughly 45% over the past five years or by 9% a year on average. Spending on private health care has gone up by much the same proportion over this time.2

If health spending keeps increasing at 9% a year – and the NHI proposal offers no meaningful way of bringing it down – then NHI costs are likely to rise from R665bn in 2025 (13% of GDP) to R965bn in 2030, R1 400bn in 2035, and R2 030bn (equivalent to roughly 30% of likely GDP) in 2040. Spending of this magnitude on health care within a scant 15 years of the system’s introduction is completely unaffordable. 

NHI financing

Like its predecessor, the White Paper presumes that only R72bn in additional revenue will be needed to fund the NHI. It also claims that this sum could be raised through a 4% surcharge on taxable income.  However, actual costs are likely to be far higher, which means that the tax increases required will be much larger too.

At the same time, the White Paper overlooks the small size of South Africa’s tax base. Though some 18 million employees were registered for personal income tax in 2015, most had earnings below the tax payment threshold. Hence, 62% of all personal income tax that year was paid by some 560 000 people with annual taxable income of R500 000 or more. If increased taxes and reduced health services were to encourage 250 000 of these individuals to emigrate, the personal income tax that could be collected would be reduced by more than a quarter.3 This would make it all the more difficult to sustain social grants and free services for the poor.

In addition – and even without the NHI – the fiscus faces a revenue shortfall of R51bn in the current financial year, rising to a cumulative R209bn over the next three years (as the October 2017 medium-term budget policy statement has acknowledged). Public debt will soon more than quintuple, rising from R630bn in 2008/09 to R3.4 trillion in 2021/22. Interest payments – even without the further ratings downgrades that surely lie ahead – will then amount to R223bn, or some R610m a day.

The NHI Fund

The White Paper claims that the NHI will significantly reduce healthcare costs by introducing ‘a single-payer and single-purchaser fund’, which will ‘leverage its monopsony power’a to ‘strategically’ purchase services and achieve major ‘economies of scale’.4

However, monopsony power will be less important than state regulation, for the NHI will also give the Department of Health control over all prices, ranging from the cost of aspirin and rubber gloves to the fees payable to surgeons and GPs. The document assumes that these controls will be effective in cutting costs and enhancing quality. But the more likely outcome is that many valuable therapies, health technologies, and diagnostic tests will be ruled out as too costly.

In addition, no amount of ‘strategic’ purchasing by a centralised fund will address the major drivers of health care costs. These are increasing utilisation rates resulting from an ageing population, high levels of chronic disease, and the rising costs of new medicines and technologies, compounded by the falling value of the rand.

The bureaucratic burden of the NHI

The NHI Fund will be buttressed by 12 ‘specific technical functional units’, ranging from ‘a Planning and Forecasting Unit’ to ‘a Procurement Unit’, a ‘Provider Payment Unit’ and a ‘Risk and Fraud Prevention Unit’. A host of other committees, at both national and district levels, will also be required to oversee and co-ordinate the system.

The White Paper, like its 2015 predecessor, makes no attempt to quantify the costs of this bureaucracy. Its estimate of the R256bn the NHI will cost in 2025 also overlooks these expenses. Yet all these new administrative entities will have to be suitably staffed, remunerated, equipped, and provided with appropriate office or other working space.5

Fraud and corruption

The lodging of fraudulent claims against medical schemes is already a major problem costing the industry some R22bn a year. According to the Board of Healthcare Funders, ‘at least 7% of all medical claims in South Africa are fraudulent and the figure could be as high as 15%’. Under the NHI, South Africa is likely to lose very much larger sums to fraudulent claims unless effective steps are taken to prevent this.6

Fraud and inflated pricing in public procurement are also already rife. As Kenneth Brown, chief procurement officer at the National Treasury, warned in October 2016, some 40% of the government’s R600bn budget for goods and services – amounting to roughly R240bn a year – is currently tainted by ‘inflated prices and fraud’.7 Unless this trend can be reversed, the hundreds of billions of rand in the procurement budget of the NHI Fund are likely to be similarly compromised.

Major inefficiency within the NHI Fund

Even if fraud and corruption can be countered, the problem of inefficiency is likely to remain. If the NHI Fund is anything like other state monopolies – Eskom, Transnet, Prasa, Portnet, and the South African Post Office – its administration will be grossly flawed and ineffective.

The example of the (workmen’s) Compensation Fund is also relevant here.  The Fund receives some R11bn a year in mandatory contributions and pays some 900 000 claims a year to doctors for treating people injured at work. Often, however, doctors have to wait a year or more to be paid.

In 2015 a survey carried out by the South African Medical Association (SAMA) among medical practitioners in Gauteng found that 65% of them had been adversely affected by the Fund’s failure to pay their claims. The average amount outstanding was R895 000 per doctor, said SAMA. The DA commented that ‘these figures were astronomical and could easily result in small medical practices having to shut their doors’.

Similar problems are evident at the Compensation Commission for Occupational Diseases, which is supposed to provide compensation to mineworkers suffering from lung diseases contracted on the job.  In July 2017 the Commission had an estimated backlog of some 700 000 unpaid claims, including some 94 000 claims which had already been approved for payment by the Medical Bureau for Occupational Diseases.

A similar story is evident at the Road Accident Fund (RAF), which is funded by the fuel levy and is supposed to pay the claims of people injured in road accidents. The RAF receives a monthly income of about R3bn and makes some 30 000 payments a month. But the RAF also has a backlog of roughly 5 600 claims, cumulatively worth around R8.4bn. Court-ordered deadlines for payment are so often ignored that ‘more than 1 000 warrants of execution are received from sheriffs every month...and it is common for RAF assets to be attached, removed, and sold,’ as the organisation acknowledged in February 2017.8

The gross inefficiencies at the Fund, the Commission, and the RAF provide some indication of the problems likely to arise under the NHI. Those problems are likely to loom even larger, as the NHI Fund will have a budget of at least R256bn a year, compared to R11bn for the Fund and R36bn for the RAF. Moreover, instead of having to deal with only small groups of South Africans, the NHI Fund will be responsible for all the health services provided by all accredited hospitals, clinics, doctors, specialists, nurses, and other health providers to some 56.6 million South Africans.

It will also have to take charge of all the medicines, medical devices, diagnostic tests, consumables, and other relevant goods and services that may be supplied to the population in any given year. The three funds earlier described have failed to deal effectively with a far smaller number of claims. Imagine, then, the inefficiency and inordinate delays that are likely to arise once the NHI Fund has to start overseeing and paying out on hundreds of millions of claims each year.

Certification and accreditation for NHI participation

All health providers and facilities, whether public or private, that wish to participate in the NHI will first have to be assessed and certified by the Office of Health Standards Compliance (OHSC). Once OHSC certification has been obtained, the Accreditation Unit of the NHI Fund will decide whether accreditation should follow.

How many health providers or facilities will qualify for certification by the OHSC remains uncertain. At present, however, most public clinics and hospitals would not be able to take part in the NHI as their compliance with core norms and standards is too low. In 2014/15, for example, the OHSC inspected 417 out of roughly 3 900 state facilities and found that only 3% of them were ‘compliant’. Another 13% were compliant ‘with requirements’ or were ‘conditionally compliant’. The remaining 84% were non-compliant, of which 16% were ‘conditionally compliant with serious concerns’, 28% were ‘non-compliant’ and 40% were ‘critically non-compliant’.9

Compliance standards have generally deteriorated since then, especially at the primary level which will be crucial to the NHI. Between 2012 and 2016, compliance among the clinics and community health centres assessed edged up by a single percentage point in two provinces: in Mpumalanga (where it rose from 47% to 48%) and in the Northern Cape (where it went up from 40% to 41%). But compliance diminished in all other provinces, including Gauteng and the Western Cape. Moreover, whereas in 2012 four provinces had compliance scores above 50%, in 2016 only Gauteng came in above the 50% level with a score of 55% (down from 69% in 2012).10

The role of medical schemes

South Africa has a world-class system of private health care, to which some 30% of its population on average, or roughly 17 million people, have access through their medical schemes, health insurance policies, or out-of-pocket payments. In the 2017/18 financial year, spending on private health care is expected to amount to R213bn, of which 83% (R177bn) will go to medical schemes, while R29bn will be spent on out-of-pocket expenses, and R5bn will go to health insurance. South Africa’s 82 medical schemes are thus vital in providing access to private health care.11

The number of people belonging to medical schemes has risen from 6.9 million in 1997 to 8.9m in 2016.  However, because the South African population has also increased over this period, medical scheme membership as a proportion of the total population has remained much the same, at around 16%. The demographic representation of medical schemes members has nevertheless changed substantially over the years, for 49% of members are now black Africans, while 10% are coloured, 7% are Indian and the remaining 34% are white.12

Despite this major shift, the government plans to use the NHI to put an end to almost all medical schemes. According to the White Paper, ‘individuals will not be allowed to opt out of making the mandatory prepayment towards NHI, though they may choose not to utilise NHI healthcare services.’13 This in itself could bring about the demise of most medical schemes, as most medical scheme members will battle to afford both their medical aid contributions and the additional taxes required to fund the NHI.

Medical schemes will also be confined to ‘offering complementary cover to fill gaps in the service coverage offered by the NHI’. Restricting medical schemes in this way is likely to sound their death knell.  A medical scheme could still cover a rare disease such as haemophilia (uncontrollable bleeding), if this was excluded from the NHI package. But the pool of potential members wanting cover of this kind would be very small. Premiums would thus have to be set so high that only the very rich could afford them.14

Few, if any, medical schemes will survive in these circumstances. The main source of funding for private health care will thus mostly come to an end. Some private practices might still be able to continue on a cash basis, but most will struggle to survive – especially as many of their potential patients will also be paying high payroll and income taxes to help fund the NHI.15

Pushing ahead with implementation

New committees being established

On 7th July 2017, a scant week after the gazetting of the White Paper, the Department of Health gazetted details of the ‘institutions, bodies and commissions’ that must be established to help implement the NHI.16

All these new institutions are to be established under Section 91(1) of the National Health Act of 2003, which empowers the minister to establish such ‘advisory and technical committees as may be necessary to achieve the objects’ of the statute. However, these objects make no mention of the NHI.  The establishment of the proposed bodies is thus ultra vires the Act (beyond the powers conferred by the statute) and prima facie unlawful.17

The new committees will be responsible, among other things, for developing clinical guidelines and ‘rationing criteria’ for tertiary care; recommending the fees to be paid to doctors, specialists, and hospitals; and establishing an agency to decide on the health technologies to be allowed under the NHI. One committee has also been instructed to consider the introduction of mandatory medical scheme membership for employees. However, if this is in fact permitted – which seems unlikely – it will be nothing more than ‘an interim measure on the path to the NHI’, says the Department of Health.18

The NHI Fund

Legislation to establish the NHI Fund is currently being developed. The present tax credit for medical scheme membership may also be reduced (as described below) to help finance the NHI Fund. The Fund will start by focusing on maternal health care and the provision of spectacles and hearing aids to school pupils, among other things.

Further interventions against private health care

Earlier interventions

Government regulation has already greatly pushed up the costs of medical scheme membership through arbitrary reserve requirements (set at 25% of annual contributions); an insistence on open enrolment and community rating, which makes it hard to attract the young and healthy; the introduction of some 300 ‘prescribed minimum benefits’ (PMBs) which have to be paid for ‘in full’; and a prohibition on low-cost medical schemes that might otherwise have extended medical scheme membership to some 15 million more people.

Current moves against medical schemes

Ending the tax credit

According to the White Paper, current tax credits for medical scheme membership are to be removed and used to fund the NHI. At present, the tax credit reduces the amount of personal income tax that taxpayers belonging to medical schemes must pay. It results in the revenue service collecting some R20bn a year less than it might otherwise do.19

The rationale for the tax credit is that it encourages people to join medical schemes, so increasing the use of private health care and reducing the burden on over-stretched public facilities. But Dr Motsoaledi claims that the tax credit is illegitimate because ‘the money…is sent to people who are already rich, [when it should be used] to help those who are poor’.20

However, the National Treasury has since found that these tax credits are ‘well-targeted to lower- and middle-income taxpayers’, as finance minister Malusi Gigaba noted in his recent medium-term budget policy statement. In the 2014/15 tax year, for instance, more than half (56%) of the total credits claimed went to 1.9 million taxpayers with annual taxable incomes below R300 000. Removing the tax credit would make it difficult for these households to retain their medical scheme membership – which is why the Treasury now wants to give the matter more thought.

Removing public sector subsidies

The health minister is also intent on removing the subsidies the government currently provides to millions of public servants to help them pay their medical scheme contributions. Most public servants belong to state schemes, such as the Government Employees Medical Scheme (GEMS), but some also belong to private schemes. Overall, these subsidies cost the fiscus an estimated R27bn a year.21

However, public sector unions have campaigned long and hard for these subsidies, while their removal would reduce the benefits provided to public servants by between R24 200 and R61 000 a year.22 In practice, union members may thus object to the termination of these subsidies, irrespective of what their leaders might say.

One benefit option only

In 2016, open medical schemes had an average of 6.5 benefit options per scheme, while restricted schemes (where membership is confined to employees, for instance) generally had two. Now, however, medical schemes are to be confined to offering only a single benefit option.

The White Paper provides no clarity as to what this single option should cover. The director general of health, Dr Precious Matsoso, has said that ‘the prescribed minimum benefits (PMBs) are to be replaced with a comprehensive set of services’, to which all medical scheme members will be entitled. But medical schemes may battle to provide this comprehensive single package if their membership numbers start to dwindle as current tax credits and state subsidies are removed. The proposal also ignores the extent to which the low-income plans currently offered by many open medical schemes are subsidised by mid- to high-end plans.23

Consolidation of medical schemes

According to the White Paper, the government will identify all the funding for medical schemes which it currently provides and then ‘consolidate’ this into the NHI Fund. More recently, however, the minister has indicated that a different kind of consolidation is also envisaged. Smaller state medical schemes will be ‘consolidated’ into GEMS, while smaller private medical schemes will be ‘folded’ into larger ones. However, it remains unclear how this is to be achieved, or what the legal and constitutional ramifications of these changes might be.24

Dr Motsoaledi remains adamant that all medical schemes will ‘eventually be gone’, once the NHI is in operation.  ‘This will be a process that takes years and, in the transition, there will be consolidation’, he says. Once the NHI has been rolled out, the medical schemes that remain will ‘all be collapsed into a single state-run medical aid plan’, he states.25 But ordinary public servants are worried about this idea, a spokesman for the Public Servants’ Association saying that officials ‘don’t want to find themselves in a situation where the NHI is the only option.’26

Curtailing health insurance

On 23rd December 2016, in the midst of South Africa’s festive season, the Department of Health and the National Treasury gazetted regulations aimed at limiting access to health insurance products of various kinds. These regulations are known as ‘demarcation’ regulations because they demarcate or identify health insurance products which the government wants to have treated as medical schemes. The demarcation regulations generally took effect on 1st April 2017.27

The demarcation regulations have particular impact on primary health care policies. In return for premiums ranging from R90 to R300 a month, these policies generally entitle people to a limited number of GP consultations, some acute and chronic medication benefits, and basic radiology, dentistry, pathology, and optometry benefits. These policies are particularly popular with lower-income households unable to afford the high costs of medical schemes.

Under the demarcation regulations, however, new primary health care policies have been prohibited since 1st April 2017, while existing policies may be exempted until April 2019. By then, low-cost medical scheme options are supposed to have been developed, but it remains doubtful whether this will be done.28 

The principal effect of the demarcation regulations, once they come fully into effect, will be to deprive some 2 million people with primary insurance policies of access to private health care. In the words of Richard Blackman, CEO of Day1 Health: ‘People take up primary health care insurance because they want to access private health care but can’t afford the conventional medical aid premiums... Now, the government is taking that right away from them and forcing them either to pay for medical aids or use the public health care sector. What is tragic is that the cheapest medical scheme options cost [at least] three times as much as what primary health care insurance policies cost.’29

Stigmatising private health care

The ANC is ideologically hostile to business and has long demonstrated a deep suspicion of the ‘profit’ motive in private health care. Both for this reason – and to help pave the way for its damaging regulatory interventions – it has repeatedly stigmatised the private health care system as costly, selfish, and uncaring in its constant drive to put ‘profits before people’.

Stigmatisation has continued in 2017, with the minister constantly repeating the same unfounded accusations against the private healthcare system. According to the minister, the private system has been ‘systematically stripping’ the public healthcare sector of key resources. The private system also devotes a massive 4.4% of GDP to meeting the health needs of a mere 16% of South Africans. At the same time, he claims, the private sector lures specialists away from the public service, with the result that only ‘20% of all specialists are left to serve 84% of South Africans’.30

However, there are many fallacies in the minister’s analysis. As earlier noted, some 62% of personal income tax is paid by some 560 000 people, most of whom get little back from the fiscus. Private health care is funded from people’s after-tax salaries and does not infringe on the resources available to the public sector. Those resources amount to 4% of GDP, which compares well with other emerging markets. The key problem, however, is that available tax revenues are often badly used because of limited skills, poor management, and widespread financial irregularities in the public healthcare sector.31

It is also inaccurate to assert that the private health system serves only 16% of the population, when some 30% of South Africans on average rely on private practitioners: 16% of them through their medical schemes and 13% by making out-of-pocket payments as the need arises. In addition, more detailed utilisation figures show that 62% of South Africans rely on public sector nurses, while 38% rely on private sector ones. Similarly, 63% of the population consult public service GPs, while 37% use those in the private sector.32

Alternatives to the NHI proposal

In the past year, Dr Motsoaledi has frequently accused critics of the NHI of wanting to retain an unfair system and deprive South Africans of the benefits of universal health care (UHC). This accusation is false. It is not the UHC goal that critics oppose, but rather the inability of the NHI to achieve it. Critics also point to the folly of insisting on the NHI as the only way to proceed when better alternatives are readily available.

Concrete proposals for a new UHC system – that would be fully in line with what the World Health Organisation (WHO) recommends – have been developed by the South African Private Practitioners’ Forum (an organisation representing private specialists), the Democratic Alliance, the Free Market Foundation, and the IRR, among others.

All agree that the most important need is to give the poor increased access to South Africa’s world-class system of private health care. Such access should be financed by the government, either through state-funded vouchers or by some variant of these. Affordability should be increased by allowing low-cost medical schemes and primary health insurance products, and by either returning to risk rating (the most cost-effective option for most people) or introducing risk equalisation between medical schemes. Medical scheme membership and/or health insurance cover should be mandatory for all employees, with premiums for lower-paid employees buttressed by employer contributions for which businesses should garner tax credits.  Once millions of South Africans are empowered in this way, medical schemes and health insurers will have to compete for their custom, helping to encourage innovation and contain costs.

All these organisations also urge that the efficiency of public hospitals and clinics be greatly enhanced. This requires merit-based appointments, strong internal discipline and accountability for performance, and effective action against corruption and inflated pricing. In the short term, it also requires sound public-private partnerships, with the administration of health facilities contracted out to private firms through open and competitive tendering processes. 

The proposals also concur in stressing that the supply of health facilities and health providers must be significantly increased. Current regulatory constraints must be removed so that the private sector can more easily establish day hospitals and other health facilities. Private institutions could then also start training the doctors, nurses, specialists, and other providers the country so badly needs.

A warning from the Davis Tax Committee

In March 2017 the Davis Tax Committee, in a report on the financing of the NHI, warned that ‘substantial increases’ in VAT or personal income tax, or the introduction of a new social security tax, would be needed to fund the NHI. It also said (emphasis as in the original) that ‘the proposed NHI, in its current format, is unlikely to be sustainable unless there is sustained economic growth’. It further cautioned that ‘the magnitudes of the proposed NHI fiscal requirements are so large that they might require trade-offs with [ie reductions in] in other laudable programmes’, such as increased funding for post-school education or ‘social security reform’.  Yet the comprehensive benefits promised by the NHI were unlikely to be achieved, as a 2015 World Bank report on universal health coverage in 24 developing countries had found that there was generally ‘a gap between the free comprehensive benefit package promised...and the de facto actual benefits’.33

Time for an affordable, constitutional, and workable alternative

The true objectives behind the NHI are not to improve access to health care but rather to increase the power and control of the ruling ANC. Part of the aim is to push the private sector out of a key sphere and increase dependency on the state. This will also weaken the middle class, as many wealthier South Africans may choose to emigrate rather than be forced to rely on the inefficient health services that will remain. The more the middle class erodes, the more this will strengthen the ANC’s hold on power, as middle-class voters are the ones most likely to shift to rival parties. Giving a greatly expanded army of bureaucrats ever more control over the pricing and provision of health care will also increase the ANC’s powers of patronage, while generating many opportunities for individual enrichment too.

A critical part of the ANC’s objective is to use the NHI to advance the national democratic revolution (NDR). Both the ANC and its communist allies have been committed to the NDR since the 1960s, for they see it as offering an incremental but ‘direct’ way to take South Africa from a predominantly capitalist economy to a socialist and then communist one. Putting an end to private health care and vastly empowering the state will, of course, serve this ideological aim. But empowering the state in this way will also open up many opportunities for self-enrichment for a small political elite, who are becoming increasingly aware of how NDR goals can be harnessed to their own kleptocratic and selfish ends.

If South Africa is to attain the benefits of economic growth, rising employment and expanding prosperity, the ANC’s outdated and damaging NDR ideology must be jettisoned. So long as the ruling party remains intent on pursuing a socialist and communist future, investment will be muted, growth limited, and unemployment high. This dismal situation is also precisely where South Africa now finds itself, as Mr Gigaba’s medium-term budget policy statement has so graphically shown. 

However, even in its current straitened circumstances, the country could still implement a new UHC system which would be affordable, constitutional, and effective in meeting health needs. At the same time, if this initial UHC system is to keep improving the benefits it offers to a growing population, the annual growth rate must rise to at least 5% of GDP a year so that millions more jobs are generated and the tax base can expand.

All these gains can yet be achieved. However, they will become increasingly unattainable if the ANC continues to propel the country down the NDR path. This outdated ideology – which even its Soviet authors have long since abandoned – must thus be jettisoned, along with the NHI proposal it has helped to spawn.


 1 Department of Health, ‘National Health Act, National Health Insurance Policy: Towards Universal Health Coverage’, (White Paper), 28 June 2017, p3, para 1; p24, Figure 4 and paras 108, 109; p25, para 112; p27, paras 128-131 

 2 Ibid, p42, Table 2

 3 Anthea Jeffery, ‘The NHI Proposal: Risking Lives For No Good Reason’, @Liberty, IRR, Issue 29, December 2016,  p45

 4 White Paper, pp49-50, para 253

 5 Jeffery, ‘The NHI Proposal’, p39

 6, 18 July 2017

 7 Business Day 13 October 2016

 8 Paul Harris and Julia Price, ‘Discussion Paper on Access to Healthcare in South Africa and the Proposed National Health Insurance Plan’, prepared for the High Level Panel of Parliament, 26 June 2017, p8; The Star 4 February, The Times 16 February, Business Day 2 June 2017

 9 Dr Johann Serfontein, Presentation to the Free Market Foundation, 20 April 2016

10 Dr Johann Serfontein, Briefing to the Free Market Foundation, 19 July 2017, slide 27; Office of Health Standards Compliance, Annual Inspection Report 2015/2016, p27; Health-e, ‘Grim findings after health facilities inspected’, Daily Maverick, 18 April 2017

11 Serfontein, FMF briefing, 19 July 2017, slide 10;  White Paper, p42, Table 2;  Council for Medical Schemes, ‘The Medical Schemes Industry in 2016’, Annual Report 2016/17, p128

12 IRR, 2017 South Africa Survey, p586; Council for Medical Schemes, Annual Report 2016/2017, p130; ‘Medical aid coverage by population group and sex’, Table 4.2, in Statistics South Africa, General Household Survey, 2016, P0318

13 White Paper, p58, para 305

14 Serfontein, FMF presentation, 20 April 2016

15 Serfontein, FMF briefing, 19 July 2017

16 Department of Health, ‘NHI Implementation: Institutions, bodies and commissions that must be established’, Government Gazette No 40969, 7 July 2017; Mail & Guardian 25 August 2017

17 Department of Health, ‘NHI Implementation’, Government Gazette No 40969, 7 July 2017; Mail & Guardian 25 August 2017; Sections 2, 91(1), National Health Act of 2003; Neil Kirby, Briefing to the Free Market Foundation, 1 August 2017

18 Sunday Times 23 July 2017

19 Mail & Guardian 30 June 2017, The Times 28 August 2017; ‘Media Release: Removing medical tax credits is yet another blow for tax payers’, Free Market Foundation, 24 October 2017; Business Day 15 May 2017

20 Business Day 18 May 2017, Mail & Guardian 30 June 2017, Business Day 13 July 2013

21 White Paper, p59, para 308; The Star 7 March, Business Day 15 May 2017

22 Business Day 18 May, Legalbrief 21 September 2017

23 Harris and Price, ‘Discussion paper on Access to Healthcare in South Africa’, p14

24 White Paper, p59, para 308; Daily Maverick 19 July 2017

25 Business Day 15 May, The Times 11 May 2017

26 The Herald 20 September, Legalbrief 21 September 2017

27 City Press 15 January, Business Day 17 March 2017; Money Marketing 31 March 2017; Business Day 18 January 2017

28 National Treasury, Media Statement, ‘Health Insurance Policies to Complement Medical Schemes through an Enabling Regulatory Framework, Release of Final Demarcation Regulations’, 23 December 2016; Business Day 12 January 2017, Sunday Times 23 July 2017

29 Business Day 24 January 2017, Moneyweb 21 February 2017, City Press 15 January 2017

30 Sunday Times 16 July 2017

31 The Times 26 June 2015

32 Serfontein, FMF briefing, 19 July 2017

33 The Davis Tax Committee, ‘Report on Financing a National Health Insurance for South Africa’, March 2017, pp44, 21