NHI: A deadly cure

William Saunderson-Meyer writes on Ramaphosa's signing the NHI Act into law


On Wednesday, after sitting on it for six months, Cyril Ramaphosa signed into law the National Health Insurance Bill.

It’s the president’s final roll of the election dice in the hope of double sixes. In other words, a gamble — statistically possible but unlikely to pay off.

On Thursday, in response to Ramaphosa, came a remarkable initiative to hasten the implementation of the NHI. All public servants, union officials, African National Congress office bearers and MPs, deployed cadres, and tripartite alliance supporters previously covered by medical aid schemes, pledged that they would immediately use only State medical facilities. No more medical aid-funded private health care for them. 

That’s called practising what they preach. In other words, it didn’t and won’t happen.

With the signing, there’s a lot of cynicism in play on the part of Ramaphosa. Also, some astute politicking.

Put aside the fact that the NHI is uncosted by the Treasury and unaffordable according to most experts, including Ramaphosa, who a few years back publicly expressed doubts that the money could be found. Never mind that the NHI’s intention is not to supplement South Africa’s world-class private healthcare sector but to dismantle it. And never mind that the NHI’s actual implementation will take not years but decades

All that matters to the Ramaphosa at the moment is weathering the 29 May electoral test. Fortunately for the ANC, one of the advantages of incumbency is being able to schedule state initiatives to best benefit the party. Hence the recent rash of public announcements of new government initiatives, most of which have been old initiatives dressed up in a new bonnet.

And hence the presidential playacting around the NHI. The slow tease started in February, during Ramaphosa’s State of the Nation address, when he joked that what was delaying matters was the lack of a writing instrument: “The Bill has arrived on my desk. I am going through the Bill. I am looking for a pen.”

Consummate actor that the president is, the build continued during his election-trail walkabouts. “There is a Bill, I am going to sign it.” That he eventually did exactly that, just two weeks before voting opened, is then hardly the “surprise” that Daily Maverick described it as.

The eventual theatrical reveal at the signing ceremony came not only with a flourish but a taunt. Those opposed to the NHI, declared Ramaphosa, are “fearful whites” and “well-to-do, rich people … [who] don’t want the have-nots to benefit from what they have been having”. 

Of course, whether the drama that Ramaphosa is starring in is a farce or tragedy will only be revealed in the fullness of time. However, he did fluff his performance somewhat when in the denouement he tried to compare the NHI bounty that the ANC was promising with the economic bounty the party had already delivered. 

Fearful whites had been so afraid of blacks having the right to vote that they had hoarded tinned food to prepare for calamity, said Ramaphosa. Contrary to their expectations, “only progress” happened. They had been scared also of the right to strike but these turned out to be just “feared ghosts”. Instead, the economy has grown “almost threefold since the days of Apartheid”. 

The same was happening with the right to universal health care (UHC). Those who were fearful should simply remind themselves of the ANC’s “commitment to build a sustainable, growing nation,” declaimed Ramaphosa.

This is a jarringly dishonest and divisive narrative from a president who is consistently portrayed as the great conciliator. 

Firstly, Ramaphosa is overstating the ANC’s economic achievements. As Daily Investor has pointed out, in reality, South Africa’s Gross Domestic Product growth measured in US$ is up 175% since 1994. That’s not only substantially lower than fellow BRICS members Brazil, Russia, India and China, but also than our African neighbours. Zimbabwe is up 317%, Mozambique 538%, and Angola 1,655%.

Secondly, opposition to the NHI has never been selfish, racist or frivolous. One of the remarkable and cheering aspects of this protracted debate has been the unanimous commitment across South African society, including on the part of the medical scheme companies, to a sustainable and implementable system of UHC. 

With this shared objective in mind, throughout the legislative process — green papers, white papers, public and professional consultative forums, parliamentary committee scrutiny, public debate, and the eventual release of the Bill for input and objections — there have been scores of stakeholder proposals that genuinely tried to address the NHI’s disastrous combination of unsustainable costs, lack of professional and administrative capacity, as well as the ANC’s record in state-owned entities of poor management, and rampant corruption. None of these modifications was adopted. 

That’s just another reminder of one of the most destructive aspects of ANC governance. Whenever faced with a choice between ideological purity and pragmatic compromise, it invariably plumps for the former over the latter. 

The NHI will now be challenged in the courts. Arraigned against it are all the major opposition parties and civil society organisations. 

The Democratic Alliance, civil rights group AfriForum, Solidarity trade union, the SA Health Funders Association, the SA Medical Association, the SA Health Professionals Collaboration (SAHPC), and the two biggest business organisations – Business Unity SA and Business Leadership SA (BLSA) – are just some of the bodies that have indicated they will approach the courts. Others opposing the Act include the Private Practitioners Forum, the Hospital Association, the Helen Suzman Foundation, the Institute of Race Relations, and the public interest law organisation Section 27.

SAHPC, which claims to represent more than 25,000 medical, dental, private and public sector health workers, says its members’ inputs, starting as far back as 2011, had been “systematically ignored”, raising serious questions about the fairness and effectiveness of the democratic process. BLSA CEO Busisiwe Mavuso says that public consultation could not just be a matter of procedure: “It is hard to believe that there has been proper consideration when draft legislation is finalised without change.”

However, Professor Pierre de Vos of the University of Cape Town scoffs at any constitutional challenge. Echoing the sentiments of the president, De Vos says the Act is the result of a proper democratic process and those who oppose it do so not because of any specific infringement of rights, “but merely because they do not like [it] or fear it would disadvantage them”. In contrast, the Parliamentary Legal Advisor previously warned that several sections of the Bill were constitutionally dubious. 

Aside from pinning their hopes on a successful Constitutional Court challenge, the NHI’s opponents comfort themselves with predictions that it will take a long time to implement. The government says four years, the sceptics predict at least a decade, given that it will require annually at least another R200 billion of taxpayer money.

Theirs is a false security. The NHI has been wreaking damage on the country’s health sector long before this week’s signing. 

In anticipation of the NHI’s promulgation, the exodus of doctors, nurses and other medical professionals has been growing for at least half a dozen years. With NHI implementation now on the horizon, that will accelerate.

So, too, will the exodus of the middle- and upper-income bracket taxpayers upon which such grand social engineering projects depend. Continued access to top-flight private medical care is non-negotiable to those who have the option to emigrate. 

There is danger also in raising expectations that cannot be met. On the campaign trail, ANC Gauteng Premier Panyaza Lesufi has been promising, “After 29 May, any citizen can go to any hospital, private or public, to receive the best treatment and that afterwards government will pick up the bill”.

One wonders whether it has yet dawned on the members of the NHI-supporting trade unions — especially those working in the public service — that they are set to lose their access to private hospitals and private practitioners. While their political masters will be jetting to China, Russia and the United Kingdom for the kind of medical care that today is the norm for every South African medical scheme member — they will now be queueing from dawn to dusk to access the already overburdened facilities of the State.

When that happens, the anger of this very large ANC-voting constituency is going to be something to behold.

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