This article was first published by Business Day on 24 February 2025
There was much interest on the reported deal between DA leader John Steenhuisen and monitoring, planning and evaluation minister Maropene Ramokgopa, regarding the removal of National Health Insurance (NHI) from the five-year medium-term development plan.
The deal apparently included the axing of section 33 of the NHI Act, which prohibits medical schemes from covering NHI services. Yet the proverbial ink was barely dry on the page when both health minister Aaron Motsoaledi and the presidency rubbished the claim, stating they knew nothing of the deal.
Motsoaledi went further, trotting out his usual tirade attacking the private sector and medical schemes and adding a new accusation that medical schemes refuse to cover TB patients. This completely disregarded the fact that TB is a prescribed minimum benefit (PMB), meaning medical schemes are compelled by law to cover it. But for the vain belief in a brief reprieve, it seems NHI will stay as is for now.
The real tragedy around all of this posturing and rhetoric in support of NHI is the grim impact on the poor. The ANC’s uncaring and incessant focus on its hopelessly unimplementable NHI policy means the public health sector is left unattended, continuing its slow but steady self-destruction under the burdensome malfeasance of corruption, mismanagement and incompetence.
Instead of implementing workable reforms in the public health sector and weeding out the obvious governance and management issues, notions of NHI fantasies continue to be indulged by the ANC, leaving the majority of South Africans at the mercy of sub-standard public healthcare that is costing lives.
Counting the cost
SA’s infant mortality rate now stands out as the worst among its upper middle income (UMI) peer countries. A similar review of five-year mortality rates exhibits an equally dismal performance. Both mortality measures are standard metrics in health outcomes performance and SA’s poor performance is made even worse by the fact that our per capita public health budget is the 10th highest among 41 UMI peer countries.
The only province in SA to achieve infant and 5-year mortality rates in line with our better performing country peers is the Western Cape. And that is not attributable to more funding flowing to the province, since the Treasury’s provincial equitable share allocates provincial health budgets on an equal per capita calculation based on population size.
The Western Cape’s substantially improved performance is rather attributable to its better governance and management capacity. This better quality of care is also corroborated by the Western Cape’s negligible medical malpractice claims – at less than 0.1% of its 2023/24 budget – versus a total liability for the other eight provinces equal to 25% of their combined budgets.
The latest 2023/24 provincial health reports show unauthorised, irregular, fruitless and wasteful expenditure – a gauge of corruption and mismanagement – at a combined 15% of noncompensation expenditure for the eight ANC controlled provinces. The same measure for the Western Cape is 0.02%.
It is abundantly clear that good governance and competent management matter enormously in achieving better health outcomes.
Health sector resources
In contrast to the perpetual state propaganda that the public sector’s problems are caused by resource deficiencies, human resources have grown substantially over the past two decades. Of all the major medical disciplines, the growth in public sector medical personnel has outstripped population growth in all but one.
Besides the delusion that the institutional design of the NHI can be implemented, the ANC also believes it can strip citizens of the right to purchase their own private healthcare (section 33) and, simultaneously, impose onerous new NHI taxes on the same citizens.
It further dreams that the substantial number of private sector medical practitioners – all of whom are also high-income taxpayers – are readily going to give up their private practices to become servants of the state under NHI.
SA’s total tax burden for 2023 was 26% of GDP, making it the second most taxed major upper middle-income country – and the NHI proposes to add taxes of a further 3% of GDP onto that. Combine this with the denial of the right to access private healthcare, and you have an economic implosion brewing, as the shrinking of the tax base will accelerate and desperately needed investment will all but evaporate.
NHI and the GNU
The DA has rightly and repeatedly stated that NHI is a red line it will not accept. However, the GNU coalition is a tough space in which to operate, especially given the ideological chasm that exists between the DA and the ANC, and the harrowing prospect of the ANC allying with either the MK party or EFF should the DA withdraw from the GNU.
Nonetheless, the contradictions from high-ranking ANC ministers tell us that the ANC is likely to be divided on NHI. Let’s hope the DA is not divided too – and that it can sway health policy in a better direction for the country. SA desperately needs it.
