Panel Discussion: Making the NHI Work for All South Africans - Can It be Achieved?

8 Aug 2013

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On 2 August 2013, SACSIS and the Friedrich Ebert Foundation (FES) co-hosted a panel discussion on the theme, "Making the National Health Insurance Scheme (NHI) Work for All South Africans - Can It Be Achieved?"

Our government’s NHI scheme presents an important opportunity to develop a better healthcare system that works for all South Africans. It is a once in a lifetime opportunity to close the gap between public and private healthcare and develop a unified world-class healthcare system that all South Africans could have confidence in -- but how do we achieve this goal? 

The questions we put to our panelists were: How does our government intend to develop a unified healthcare system that all South Africans feel is safe and affordable to use? What are the responsibilities of the state, the medical fraternity and the public in general towards developing such a system? Most importantly, how can we use the NHI as an opportunity to build greater social cohesion, in South Africa, around the delivery of an important social good that all South Africans can share in equally?

Our panelists made outstanding presentations that contribute enormously to developing a better understanding of what good healthcare should be.

Prof. Robert Van Niekerk of Rhodes University argued that the process of establishing the NHI is part of a bigger project about building "a new kind of South African society".

He argued, "Very deeply implicated in the idea of establishing a new kind of society, which can bring classes together across the social divide, is the idea of the kind of society we want to create in South Africa. The debate about establishing a new kind of healthcare system needs to be coupled to the idea of what kind of society do we want to live in as South Africans, and not externalise the problem as something about how do we create access for poor people to healthcare, but also talk about how we contribute as citizens who are more privileged from the middle classes, largely, in terms of being part of the political elite, the policy elite and other professional sectors, about what choices are we wanting to make to create a new kind of South African society."

But, as all speakers noted, the challenges are huge, not least due to the uneven distribution of resources and capacity in the healthcare sector. Prof. David Sanders, Director of the School of Public Health at the University of the Western Cape, who talked about the challenges we face within the healthcare sector, reported that 70% of specialists and 50% of doctors are in the private sector serving just 16% of the population.

An interesting observation that he made is that, as result of our society's huge inequality, even for better off South Africans, health indicators are poor. For example, for White South Africans whose lifestyles can be equated to those in the global north, infant mortality is three times higher than the average in the global north.

Inequality is bad for everyone, not just for the poor, he argued.

Louis Reynolds, a lecturer at the Education Development Unit, University of Cape Town, reinforced the point by arguing that inequality is a source of major stress in society. "Everyone suffers he said. Poverty is bad for health, but the gains in wealth you get from increasing wealth only last up to a certain degree, if there is also growing inequality," he argued.

Is the NHI a solution?

It presents a wonderful opportunity to build a more cohesive society, but as Reynolds argued, "The NHI is a bit of a black hole at the moment. None of us know what's going on. It's happening behind closed doors." He believes that the secrecy surrounding the release of the white paper, which has been delayed, is linked to the fact that there might be "a fight going on behind closed doors between people with vested interests who are benefitting from the current inequitable system."

Mark Heywood, executive director of public interest NGO, Section 27, who was the last speaker of the day said that the contest being referred to by Reynolds was one within government, "in particular between the treasury and the ministry of health about how NHI should be funded and whether there should be co-payments as a part of access to health services."

Another vested interest that Heywood referred to was the private healthcare sector. He argued, "Nobody is proposing to do away with the medical aid schemes. But an efficiently, properly instituted system of national health insurance would make those things redundant and would give cause for them to wither away and that is what they (the private sector) understand."

Heywood said that people leak him lots of documents, so he has seen what Netcare and Medicare are saying. All of them are "lawyered up", he reported. "They have made their submissions on the green paper. Their submissions have veiled lawyerly - in between the lines - hints of litigation, if the NHI system is not the type of NHI system that they will be satisfied with -- and that partially explains the delay that we have between the green paper and the white paper," he said.

Healthcare has unfortunately become a commodity in South Africa, despite the fact that access to healthcare is enshrined in our Constitution.

Heywood argued that "bad public health is good private business." Over R20 billion is spent annually out of pocket on expensive private healthcare services, which, in his view, are not world class.

"The other problem with the growth of the private healthcare sector - the unregulated, uncontrolled growth - is that even those people who think they are purchasing some sort of security through medical aid schemes, discover that they're not," Heywood argued.

He illustrated this by talking about "gap plans". "A gap plan is the insurance that you take out above your medical insurance for costs that you may incur when your medical insurance has run out. In the last five years, there has been a five-fold increase in the number of gap plans people can buy. And there are today 250,000 different gap plan policies that are in existence to help you top up on your top up."

"Some of the strongest opponents of NHI will be hospital groups like Netcare, Mediclinic and so on. Netcare's return on capital employed in its hospitals has risen to 25% by 2011 from about 7% 10 years ago. Mediclinic's return on capital employed has risen to 27.3%," Heywood argued.

He also said that there will be no NHI in South Africa, if there is not a movement for a national health system. At the moment there is not a health movement in South Africa.

Watch the clip above for more details from our panelists, as well as introductory remarks from Axel Schmidt, country representative of FES and Fazila Farouk, executive director of SACSIS. You can also listen to the whole event, including the Q&A session by clicking on the "Play Podcast" button above. Finally, you can also listen to podcasts of the individual inputs of all our speakers separately, as well as watch them on You Tube, by clicking on the links below.


Prof. Robert Van Niekerk, Director and Professor of Social Policy at the Institute of Social and Economic Research (ISER) at Rhodes University. Listen to a podcast of Robert Van Niekerk's presentation. Watch Robert Van Niekerk's presenation on the SACSIS You Tube Channel.

Prof. David Sanders, Emeritus Professor and founding Director of the School of Public Health at the University of the Western Cape. Listen to a podcast of David Sander's presentation. Watch David Sander's presentation  on the SACSIS You Tube Channel.

Prof. Louis George Reynolds, Lecturer, Education Development Unit, University of Cape Town, Faculty of Health Sciences and formerly of the Red Cross Children’s Hospital. Listen to a podcast of Louis Reynold's presentation. Watch Louis Reynold's presenation on the SACSIS You Tube Channel.

Mark Heywood, Executive Director, Section 27. Listen to a podcast of Mark Heywood's presentation. Watch Mark Heywood's presenation on the SACSIS You Tube Channel.

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