The NHI is a proposed public fund that the National Department of Health intends will purchase all healthcare services from accredited healthcare providers and suppliers for all South Africans. Thus, the fund is intended to be the single purchaser of all the healthcare needs of all South Africans.

The Government believes that pooling all money spent on healthcare provision in the private and public sectors for healthcare centrally will address inequalities in the system and achieve universal health care.

People requiring care will follow a set out treatment pathway that includes accredited public and private sector facilities and practitioners, extending from primary healthcare provision and culminating, if necessary, in hospital. The intention, says the Health Ministry, is to reverse a hospital-centric current system. Throughout, patients will not need to pay for treatment at the point of service as the NHI will make these payments. Unsurprisingly, this framework will require an extensive re-organisation of the healthcare system. It is not yet clear where the funds required for this proposed system will come from, nor what the amount required will be.

This is not yet fully known. The exact list of services to be covered by the NHI is still to be finalised with discussions including how these services can be provided in a country with critical human resource shortages.

The NHI stipulates that private medical aid will “complement” the NHI, though what this means in practicality is not yet clear.

The objectives of the NHI are noble -accessible, high-quality, universal care for all South Africans is to be supported. However, we do not believe the NHI Fund, as envisaged by the Health Ministry, is affordable, achievable, and constitutional.

Some of the main concerns raised in court papers relate to:

• Uncertainty about NHI funding sources.
• Lack of clarity on benefits and provider roles.
• Potential curtailment of choice and autonomy.
• Concerns about governance and corruption control.
• Concern about centralisation of influence and power.
• Lack of necessary infrastructure and human resources.

Only certified providers (facilities certified by the Office of Healthcare Standards Compliance) will be eligible for NHI Fund accreditation. Only a small fraction of existing public facilities would currently be certified by the OHSC and accredited by the NHI Fund.

The Minister of Health is on record saying private healthcare will not be destroyed. However, under the NHI as it stands, medical aid schemes will shift from comprehensive funding of medical needs of members to covering only services not covered by the NHI Fund. Service providers not contracted to the NHI or accredited by the fund will be excluded from its payment system. Prices and benefits offered will be determined by the NHI structures. There are therefore several risks pertaining to the private sector.

No. Reserves belong to members, and the NHI Fund cannot appropriate them.

All public funds are audited by the Auditor-General and are governed by the Public Finance Management Act (PFMA). The NHI CEO is tasked with establishing a risk management and fraud prevention investigation unit within the organisation. However, given the extensive corruption of various public funds that share the same operating principles and governance framework, there is grave concern that this largest-of-all public funds will not be kept safe.

It is impossible to say when exactly, but Government officials are on record saying it will take at least 10-15 years. According to the Government, it will be phased in over several years (current roadmap: 2 phases running from 2023–2028), beginning with strengthening public infrastructure, piloting services for vulnerable groups, and building digital and administrative capacity. It is our view that any subsequent stage in implementing the reforms will occur only when agreed-upon signposts have been reached. We should not attempt to apply a timeline.

Stakeholders have recommended:

• Completing stalled private sector reforms (e.g., mandatory membership and risk equalisation funds) to lower the costs of medical aid cover.
• Numerous commissions, committees, and associations have proposed reverting to compulsory medical aid membership for the formally employed and their families to initiate better cross-subsidisation in medical aids, thereby lowering premiums for those who are members, and reducing the population dependent on the public sector. This would allow for the freeing up of funds for investment in the public sector, since a greater portion of the population will assume responsibility for funding their healthcare.
• Fixing public healthcare infrastructure and initiating a drive to overcome shortages in human resources and skilled medical staff.
• Building a more robust primary care system, particularly in rural areas.
• Finding ways for the public and private sectors to collaborate more widely and more often to deliver healthcare services to the entire population.
• Strengthening public health sector governance and leadership to begin to eliminate corruption and prioritise the provision of quality healthcare for the most vulnerable populations.