The analyses and debates about the National Health Insurance (NHI) Bill rage on following its introduction to Parliament early August. The tabling of the Bill was long in coming as the mooting of ideas to reform healthcare financing in South Africa are not new and date as far back as the late 1920s. In the infographic below, we trace the historical timeline of the Bill (only looking at the democratic dispensation) and highlight key dates and events, from when healthcare financing proposals were initially put forward, to date.
1994: Healthcare Finance Committee
In the early 1990s, the spotlight turned to the possibility of introducing some form of mandatory health insurance and after the 1994 elections; there were several policy initiatives that considered either social or national health insurance. The Healthcare Finance Committee of 1994 recommended that all formally employed individuals and their immediate dependents should initially form the core membership of social health insurance arrangements with a view to expanding coverage to other groups over time.
1995: Commission of Inquiry on National Health Insurance
The 1995 Commission of Inquiry on National Health Insurance fully supported the recommendations of the 1994 Committee. A strong case was made for primary healthcare services by its commissioners but is unclear whether their recommendations were taken forward fully at that time.
1997: The Social Health Insurance Working Group
In 1997, the Social Health Insurance Working Group developed the regulatory framework that resulted in the enactment of the Medical Schemes Act in 1998. This Act was meant to regulate private health insurance as well as entrench the principles of open enrolment, community rating, prescribed minimum benefits and better governance of medical schemes. However, despite the introduction of the Act and the supporting principles the level of coverage for the national population has remained below 16 percent.
1998: Big Pharma versus Nelson Mandela
In February 1998, the South African Pharmaceutical Manufacturers Association and 39 mostly multinational pharmaceutical companies took the Government of South Africa to court, saying that its attempts to increase the availability of affordable medicines violated both the South African Constitution and the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement. Following international public outrage over the companies’ legal challenge, the case was unconditionally dropped in early 2001.
2002: Committee of Inquiry into a Comprehensive Social Security for South Africa
In 2002, the Department of Social Development set up the Committee of Inquiry into a Comprehensive Social Security for South Africa. The Commission recommended that there be mandatory cover for all those in the formal sector earning above a given tax threshold and that contributions should be income-related and collected as a dedicated tax for health. The Committee also recommended that the State should create a national health fund through which resources should be channelled to public facilities through the government budget processes.
2002: Ministerial Task Team on Social Health Insurance
To implement the recommendations of the aforesaid Committee, the Department of Health established the Ministerial Task Team on Social Health Insurance. The Task Team’s primary mandate was to draft an implementation plan with concrete proposals on how to move towards social health insurance and to create supporting legislative and create supporting legislation and institutional mechanisms that will in the long term result in the realisation of National Health Insurance in South Africa. However, the path to achieving universal coverage through a social health insurance model was not widely supported and the implementation of the supporting proposals thus stalled.
2009: Advisory Committee on National Health Insurance
In August 2009, the Ministerial Advisory Committee was established and tasked with providing the Minister and Department of Health with recommendations regarding the relevant health system reforms and matters relating to the design and roll-out of National Health Insurance. This was to carry forward the Resolution passed at the ruling ANC’s Polokwane Conference in 2007.
2011: Department of Health Policy Paper
In mid-2011, the Department of Health released a policy paper titled “NHI in South Africa” for public consultation. The paper proclaimed that “South Africa is in the process of introducing an innovative system of healthcare financing with far-reaching consequences on the health of South Africans.” The National Health Insurance was to ensure that everyone has access to appropriate, efficient and quality health services.
2012-2017: NHI pilot projects rollout
Following release of the 2011 policy paper, implementation phase commenced in 2012, with its overarching focus being the piloting of health system strengthening (HSS) initiatives; the establishment of the NHI Fund and key institutions; and the moving of central hospitals to the national sphere. According to then Minister of Health, Dr Aaron Motsoaledi, the transition was expected to take about 15 years in three phases.
2015: Department of Health White Paper
In 2015, the Department of Health released a white paper titled ‘National Health Insurance for South Africa: Towards universal health coverage.’ It “laid the foundation for moving South Africa towards universal health coverage (UHC) through the implementation of National Health Insurance (NHI) and establishment of a unified health system.” The Department pointed out that implementation of NHI will require amendments to related existing legislation and enactment of new laws to ensure that there is not only legislative alignment but also policy consistency across government departments and spheres of government. The paper would serve as the precursor to the drafting and subsequent introduction of NHI Bill.
2018: National Health Insurance draft Bill
In June 2018, the Department of Health invited written comments from the public on the proposed draft NHI Bill. The draft Bill’s aim was “to provide mandatory prepayment health care services in the Republic in pursuance of section 27 of the Constitution; to establish a National Health Insurance Fund and to set out its powers, functions and governance structures; to provide a framework for the active purchasing of health care services by the Fund on behalf of users; to create mechanisms for the equitable, effective and efficient utilisation of the resources of the Fund to meet the health needs of users; to preclude or limit undesirable, unethical and unlawful practices in relation to the Fund and its users; and to provide for matters connected herewith.”
2019: Introduction of NHI Bill before Parliament
In August 2019, the NHI Bill was introduced to Parliament and is currently under consideration by the National Assembly’s Portfolio Committee on Health. The Bill will have to go through the stipulated parliamentary processes, which will include a public participation period, which might inform some amendments to the Bill, before it is put before the National Assembly for a vote. The Portfolio Committee has invited stakeholders and interested parties to submit written submissions on the Bill. You can find the full details and a guide on how to write a submission by following the links. This is an opportunity for all South Africans to have their voices heard and give meaningful input to legislative processes.
On the 30th of August 2019, the Portfolio Committee on Health put out a call for comments on the NHI Bill. The deadline for submissions is 29 Novermber 2019.
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