Ramaphosa seems to think it funny to sign the NHI Bill. The people of South Africa will be the butt of his joke.

‘I have found my pen,’ quipped president Cyril Ramaphosa, continuing a joke he started during the State of the Nation Address (SONA) back in February.

He was speaking at an ostentatious public ceremony in which he signed the National Health Insurance (NHI) Bill into law.

Given that the Bill was already on his desk at the time of the SONA on 8 February, and that he already indicated his intention to sign it, the more than three-month delay to a date exactly two weeks before the National and Provincial Elections was an obvious ploy; it was an obvious abuse of state power to advance a partisan party-political agenda.

But then, we don’t expect honest dealing from Ramaphosa.

False pretences

What is now the National Health Insurance Act has been sold to South Africa under false pretences.

In the ANC’s manifesto, it promises to, ‘Implement the National Health Insurance to reduce the cost of medical care, especially for the poor.’

In his signing speech, Ramaphosa said: ‘The NHI takes a bold step and a stride towards a society where no individual must bear an untenable financial burden while seeking medical attention.’

But the unaffordability of healthcare for the poor was never the problem. Public healthcare facilities have always offered highly subsidised or free care to the poor.

What the NHI does is the exact opposite: it promises free care to the rich.

Looting and mismanagement

Said Ramaphosa: ‘In its essence the National Health Insurance is a commitment to eradicate the stark inequalities that have long determined who in our country receives adequate health care and who suffers from neglect, by putting in place a system that ensures equal access to health care regardless of a person’s social and economic standing and circumstances.’

The public healthcare system was already supposed to ensure that, but it has (in ANC-run provinces, at least) been run into the ground by mismanagement and looting – that is, by government failure.

Now, instead of improving the quality of public healthcare, the NHI proposes to combine the resources of the public and private sector, as if the government has a rightful claim on the after-tax income of private individuals.

It does so in the belief that the government will, out of the blue, be able to manage a very large central fund that isn’t looted or mismanaged.

And I say ‘out of the blue’, because the government had a perfect opportunity to demonstrate its ability to run a major health-related project in its response to Covid-19. Instead, it proved to be authoritarian, arbitrary, and wide open to billions of rands of corruption.

The NHI is much, much bigger. All that means is that there will be more corruption, more looting, and more whistleblowers to assassinate.

NHI will not improve the healthcare available to those who, hitherto, have relied on public healthcare services. It will make all healthcare – even if provided by nominally ‘private’ entities – publicly funded.

So, in order to offer free healthcare to people who currently choose to pay – above and beyond their taxes – for private care, the NHI will reduce the quality of their healthcare to the same level currently available to those who are now dependent upon a dysfunctional state.

In fact, public healthcare will likely become even worse than it is now, for various reasons.

Burden on the state

The new public healthcare system, instead of providing for only some of the population, will now be required to provide for all the population, including for people who can afford to look after their own healthcare and therefore needn’t be a burden on the state and its limited fiscal resources.

Thousands of healthcare professionals have already signalled their intent to flee the country if the NHI is implemented. They have no desire to be subject to central planning bureaucrats in Pretoria who will control everything from what tests they may order to what drugs they may prescribe to what procedures they may conduct to what they may charge.

State monopsony

A non-competitive, centrally planned funding system is inherently far less efficient than a competitive private industry. Only competition can continually put downward pressure on prices, and continually drive improvements in quality.

The NHI will establish a monopsony, which is like a monopoly except it refers to a sole buyer, instead of a sole seller.

Without the pressures of competition, neither monopolies nor monopsonies have any incentive to be efficient. Indeed, virtually every state monopoly and monopsony in South Africa is ineffective, inefficient, and unsustainable.

With the elimination of a private market in healthcare, the government will have no price mechanism against which to benchmark its own expenditures.

If someone offers a particular procedure for a particular fee, or a particular drug at a particular price, bureaucrats will have no way of knowing whether they’re being charged fairly or whether they’re being taken for a ride.

Remember the price gouging on masks, gloves, and hand sanitiser during the Covid-19 pandemic? Or the R117 million wasted on unnecessary ‘fogging’? Or the R26 single-ply toilet roll, the R51 black refuse bag, the R238 000 mop, and the R80,000 knee pads?

That will be standard operating procedure once government is the only customer for medical products. Healthcare won’t become cheaper. It will become far more expensive.


That means that any additional money the government manages to raise to pay for it – the Act is silent on how the NHI will be funded – will quickly be redistributed to profiteering middlemen.

That, in turn, will mean that healthcare will become more scarce, and will become rationed.

More life-saving drugs will be perpetually out of stock. Queues will become longer. So will waiting lists for surgery, cancer treatments, or other procedures. More people will die in ambulances, waiting for emergency room beds to open up, if ambulances even turn up on time at all.

These are all problems plaguing Britain’s National Health Service (NHS), despite the fact that it serves not many more people but has a budget at least eight times the most optimistic amount that the South African government could devote to the NHI.

‘What we are trying to build is a Rolls-Royce system of healthcare for all South Africans,’ said Ramaphosa, to scattered applause from some grinning idiots in the audience. Yet all we can afford is a Trabant system of healthcare.

The whole thing is a joke, and South Africans are the butt of the joke.

Sheer genius

At an ideological level, the NHI has only one purpose: to advance the National Democratic Revolution (as I wrote last year).

As an election ploy, appealing to the masses at an emotional level, it is sheer genius, however.

Because on one hand the poor have both a limited voice and a limited grasp of the nuances of healthcare policy, and on the other hand opposition to the NHI has been expressed by business associations, healthcare professional associations, opposition parties and media commentators, Ramaphosa has claimed that the opposition ‘is coming from well-to-do, rich people’.

He even had the temerity to accuse the ‘haves’ of not wanting ‘the have-nots to benefit from what they have been having’.

This is an outrageous insult, since the ‘haves’ – medical schemes, academic experts and commentators – have been agitating for low-cost medical insurance plans since 2001, while a government agency, the Council for Medical Schemes, has kept low-cost health insurance for the poor illegal all that time.

Ramaphosa goes on: ‘We cannot, and must not, go on with the new South Africa when we still have inequality in some areas of life – and healthcare, which is the most important area of life for anyone, is one area where we need equality.’

Of course, he doesn’t concede that the lack of equality is entirely due to the ANC government, which has made it illegal for the private sector to insure poor people for health expenses, and then ran their only alternative, the public healthcare system, into the ground.

‘And, believe you me, we are going to have equality, whether people like it or not,’ he added.

Crass populism

This is the sort of crass, hateful populism, that often resonates with the poor and the downtrodden. They love seeing a revolutionary leader – even if he is one of the richest men in South Africa – promise to take the rich down a peg, to make them suffer the same indignities the poor have to suffer.

The masses don’t realise that they suffer these indignities not because they’re poor, but because of inept government. But like Ramaphosa, they delight in the idea that everyone else will be made equally miserable.

That’s always been the promise of socialism: instead of a society in which some are rich and some are relatively worse off, it seeks to establish a society where everyone is equally immiserated.

Ramaphosa is cynically playing the poor like a violin. They don’t know yet that the rich will not be the only ones to suffer once the government eventually tries to implement the NHI.

The rich can always leave, and many of them will. Politicians can always get their healthcare in Dubai or Moscow, as many of them do.

The poor, however, have nowhere to go. They are stuck here, doomed to suffer the consequences of ill-conceived election ploys like the NHI.

The views of the writer are not necessarily the views of the Daily Friend or the IRR.

If you like what you have just read, support the Daily Friend

Image: President Cyril Ramaphosa makes promises he can’t keep, at the signing ceremony of the National Health Insurance Act. Video still from SABC broadcast, 15 May 2024.


Ivo Vegter is a freelance journalist, columnist and speaker who loves debunking myths and misconceptions, and addresses topics from the perspective of individual liberty and free markets.