The NHI is enacted: Five things you need to know

The National Health Insurance (NHI) was signed into law by President Cyril Ramaphosa on 15 May, 2024, at the Union Buildings in Pretoria. In the presence of other members of government, the MECs of health from different provinces, as well as civil society representatives, Ramaphosa expressed excitement over turning the bill into an act that will ensure the state-funded provision of quality healthcare services for all.

He described the NHI as fulfilling a commitment by the government to put an end to the vast inequalities that have determined who receives adequate healthcare and who suffers from neglect based on one’s race, location, and economic status. “By putting in place a system that ensures equal access to healthcare regardless of a person’s social and economic circumstances, the NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention.”

The president noted the major gaps in equality of access to healthcare for citizens in the country as an important backdrop to the support of the NHI. He emphasised the importance of dismantling the barriers that hinder and cause difficulties in accessing healthcare. “The rising cost of healthcare makes families poorer. The NHI is an important instrument to tackle poverty because it will free up resources in poor families for other essential needs. This will produce better health outcomes and prevent avoidable deaths,” said Ramaphosa.

For many South Africans, the passing of the NHI into law is a promise that they will have better access to quality healthcare services and their right to health will be adequately realised. Here’s what you need to know about accessing healthcare services in the country.

When will the NHI kick off?

According to the Department of Health (DoH), the implementation of the NHI is set to begin in 2030. Government will be phasing in the various systems that will enable the smooth transition from a two-tier health system to a single-payer one. Minister of Health, Dr Joe Phaahla, explained that the implementation of the NHI will be done step by step. “The first phase will be from 2023 to 2026; this will deal with the establishment of the institutions, funding pathways, accelerating and strengthening all basic instruments in providing healthcare, as well as, the quality improvement of facilities. Many of these have already started in the provinces all over the country,” said Phaahla at the podium.

Phaahla described the second phase, from 2027 to 2030, as focusing on implementation programmes in terms of contracting and procurement of services. This means that it will take years before citizens can access healthcare services under the NHI.

How the NHI will affect working conditions for healthcare workers, who last year went on a bitter wage strike, is not spelled out in the NHI Act. File Photo by Mzi Velapi

What health services will the NHI cover? ﻿ ﻿

The NHI service package will offer care at all levels, from primary healthcare, to specialised secondary care, and highly specialised tertiary and quaternary levels of care. The cover includes hospital visits – inpatient and outpatient, rehabilitation and mental health services as well as emergency medical services. The comprehensive personal health service benefits will be purchased from contracted public and private health facilities.

However, even though there will be free medical services at clinics and community health centres, Phaahla said that there are still a lot of primary health services that will not be covered by the NHI package. According to him, the country does not have enough specialists like physiotherapists, audiologists, and dentists who can provide key services.

How will the government fund the NHI?

Based on the NHI Act, the NHI will be funded through general revenue allocations, supplemented by a payroll tax payable by employers and employees and an increased charge on individuals’ taxable income. The government will pool funds gathered through taxes and allocated to the fund by parliament for the national treasury to then determine the funding for the NHI, which will thereafter have to be approved by the cabinet.

“We are committed to making sure that there will be various accountability systems we will have in place, including the transparent governing system of the board. It is also open for members of the public to report any suspicious behaviour to the department,” said Phaahla in response to concerns about looting of funds in the department through the NHI.

4. How are public health facilities preparing for the NHI?

Before health facilities and healthcare providers can provide services to patients under the NHI, they will have to undergo quality evaluation, check, and approval by the Office of Health Standards Compliance. The tools for healthcare provider compliance have been developed but the NHI Fund accreditation and contracting requirements are still being developed. “We have already begun implementing a national quality improvement plan in public and private healthcare facilities and are now seeing a vast improvement,” said Ramaphosa.

Phaahla added that there are currently various improvements being rolled out in primary healthcare services such as acquiring new equipment like digital x-ray machines in hospitals. “We will be consulting further with the treasury to look at further acceleration. We have agreed that we are also going to have to look at other measures in terms of funding models through which we can improve infrastructure and purchase equipment to adequately accelerate the standard of public health facilities,” he said.

How are doctors in the private health sector affected?

According to the DoH, the participation of doctors in the NHI is a matter of choice of an individual health provider. If they choose to participate, they need to meet certain requirements that will be set out under the NHI policy. Such requirements will include acceptance of a capped limit on the fee for service, which will be aligned and appropriate to the pricing mechanism of the NHI.