South Africans have a scant week left to say their first resounding ‘No’ to a National Health Insurance (NHI) proposal likely to capsize the economy even as it destabilises the healthcare system and destroys its most effective elements.

Written submissions on the NHI Bill are due by 29 November, while the public hearings already in progress will continue until February 2020. However, the public hearings offer little opportunity to oppose the NHI. Rather, they seem to be part of a massive propaganda campaign being mounted by the ANC to counter rational argument against the NHI and build up an unwarranted support for the Bill.

According to Dr Sibongiseni Dhlomo, chairperson of the portfolio committee on health (and until recently the controversial MEC for health in KwaZulu-Natal): ‘The Department of Health has released about a million pamphlets in all 11 languages for people to read about [the NHI]… It has also been placing newspaper adverts. They have been in the media. They have been on radio.’

The message being conveyed is not that the NHI is ‘unaffordable’ and ‘unsustainable’ – as both the National Treasury and the Davis Tax Committee have warned – but rather that the new system will ‘benefit and uplift the poor’. It will help ‘the sick and the old, like my grandmother, my grandfather, and the uncle of my father’, as Dr Dhlomo puts it.

Dr Dhlomo further emphasises that the Bill is vital to ‘social solidarity’. Hence, people are also being asked if they are ‘ready and available’ for the ‘young to carry the old’, the ‘healthy to carry the sick’, and the ‘wealthy to carry the poor’. 

Individuals unable to address the public hearings, he adds, are being encouraged to write down messages in which, for example, they say, ‘I like the NHI because it has a capacity to assist my mother’, or ‘I don’t like it because I do not think I’ll benefit’. But they are also being told that the only people opposed to the Bill are those who want to ‘push aside other South Africans to make themselves benefit’.  

The public hearings seem tainted in other ways as well. At the initial hearings in Mpumalanga, says DA shadow health minister Siviwe Gwarube, ‘the ANC packed the halls with party supporters – an act which is not only wrong but completely distorts the findings of the process’.

Sfiso Nkala, a representative of civil society organisation Section27, attended the Ermelo (Mpumalanga) event and writes that it was ‘like an ANC rally, not a public hearing. About 90% of the people were wearing ANC regalia; you can’t help thinking that these people came from the branches and from the ANC alliance partners’.

People queuing up to speak were told that they must say that ‘they endorsed the NHI’. Overall, he adds, ‘it was like they wanted to make sure that it looked like the NHI Bill had everyone’s approval. It was just a sham’.

Public hearings of this kind make a mockery of the constitutional obligation to facilitate public involvement in the legislative process. They also seem intended to counter and override the impact of the written submissions, at least 100 000 of which have already been sent in.

These documents are probably replete with reasoned objections to the NHI, based on factors such as:

  • its enormous and still unquantified costs, estimated by Fitch at R450bn a year within two years of the system’s becoming fully operative in 2026;
  • the size of the (expensive) bureaucracy needed to draw up, implement, monitor, and revise its comprehensive controls on fees, prices, and permitted medicines, devices, and diagnostic tests;
  • the extent to which these top-down controls will drive out innovation and competition, while promoting inefficiency and corruption;
  • the sheer folly of insisting on a ‘single-payer’ system in which the NHI Fund will have to pay, among other things, for all the medicines, consumables, equipment, machinery, maintenance, and other goods and services needed to treat some 60 million people every year;
  • the extent of the medicine ‘stock-outs’ and other shortages likely to result when NHI bureaucrats, like their counterparts in many other state entities, fail to pay suppliers for weeks, months, or even years on end. (In Gauteng, for example, 987 health suppliers have been owed some R1.7bn for more than a year, while 236 have been owed R1.3bn for more than three years);
  • the number of health professionals who may decide to emigrate rather than subject themselves to persistent bureaucratic inefficiency and stifling state control. (A recent survey of radiologists showed 20% are planning to leave and 60% are ‘considering’  doing the same);
  • the extent to which the skilled and taxpaying middle class will emigrate too as the tax burden goes up and health services decline; and
  • how badly the NHI will damage the economy when the gap between revenue and state spending is widening so rapidly that public debt – even without the NHI – is expected to rise to an untenable 80% of GDP by 2027.

Many doctors are also opposed to the NHI. In a survey carried out in October 2017 by Solidarity, a trade union, 85% of the doctors canvassed warned that the NHI could ‘destabilise’ healthcare. Only 15% thought it could be implemented successfully.

In interviews with the Financial Mail, moreover, one doctor queried how much of the health care system would be ‘destroyed’ in the government’s ‘transparent bid to grab private healthcare users’ money’. Another commented that the NHI ‘will be like Eskom, SAA and the SABC combined, except that many people will die’.

This last is the essential point, of course. The NHI will give the state a monopoly over healthcare similar to its monopoly over electricity. Eskom failures mean load-shedding, with all its heavy costs and many inconveniences. NHI failures will mean life-shedding.

However, given the false promises and emotional blackmail being used to whip up an artificial support for the NHI, only a massive public outcry will shift the ‘balance of forces’ sufficiently to make the ANC draw back.

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Dr Anthea Jeffery holds law degrees from Wits, Cambridge and London universities, and is the Head of Policy Research at the IRR. She has authored 12 books, including Countdown to Socialism - The National Democratic Revolution in South Africa since 1994, People’s War: New Light on the Struggle for South Africa and BEE: Helping or Hurting? She has also written extensively on property rights, land reform, the mining sector, the proposed National Health Insurance (NHI) system, and a growth-focused alternative to BEE.