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NHI framework fatally flawed

18 July 2023 Gareth Stokes

If you do not support South Africa’s National Health Insurance (NHI) Bill, then you are anti-poor or worse! Yes, dear reader, rather than respond to balanced and justified criticism levelled at the proposed state-run scheme, its disciples choose to deflect from rational, objective facts with wild accusations and petty slander. Thankfully, today’s hogwash opening line is easily dismissed as a ‘straw man’ argument, as it was during a recent NHI Insights panel discussion hosted by diversified financial services provider, Alexforbes.

A logical fallacy distorting valid argument

A ‘straw man argument’, with reserved apologies to the gender equality fanatics among you, is described by Grammarly.com as “the logical fallacy of distorting an opposing position into an extreme version of itself, and then arguing against that extreme version”. 

So, for example, if you argue that the NHI is doomed to fail due to 50 objective facts, the pro-NHI advocates you present them to will turn things around by saying that your hatred for the scheme derives from your privileged participation in the private sector, and is an indication that you do not believe in equal access to health coverage. You end up being labelled as someone who does no support universal health coverage (UHC) rather than someone who has a rational, reasoned objection to an ill-thought policy. 

Panel facilitator, Michael Avery, dismissed the anti-poor misdirect as inappropriate “given that those who are fortunate to be employed are already paying tax to fund the public health system [as well as] providing for their own after-tax health care expenditure”. His somewhat antagonistic view was tempered by the now familiar ‘soft touch’ approach of the private sector panel participants. “The principle of UHC cannot be quibbled with, but there are some key constitutional concerns that need to be aired,” said Avery, turning to the legal expert on the panel to expand on the matter. 

The access and association quandary

Neil Kirby, a director at law firm Werksmans, said that most of the current concerns over the NHI Bill could be traced back to the constitutional rights of ‘access to health care’ and association. “There is an array of arguments that lie around how the SA Constitution is going to apply [with reference to the Bill], and those arguments implicate other pieces of legislation as well,” he said. On the access to health care matter, Kirby said it remained unclear what the Constitution meant by ‘access’. He then singled out the Consumer Protection Act (CPA) as just one item of legislation that enshrined certain constitutional consumer rights that could, potentially, be overridden by the NHI Bill as currently framed. PS, this is the writer’s interpretation of the panellist’s response. 

One of the major issues with the NHI Bill process is that government, in formulating the Bill, has flat-out ignored suggestions from citizens and concerned private sector health care providers to make changes to it. “There has been commentary from many quarters [and] we still believe there is an opportunity to put forth our comments,” said Dr Katlego Mothudi, MD of the Board of Healthcare Funders (BHF), as the Bill moved to the National Council of Provinces (NCOP) for the near final stage of its approval. 

Unfortunately, government does not seem to be listening. It is estimated that around 135000 public submissions were made on the Bill, with at least 117 oral presentations to the relevant parliamentary portfolio committee. Around 45% of these submissions raised concerns about governance and leadership, and 11-12% were worried about technical issues. And yet, new iterations of the Bill remain unchanged. 

Even experienced state lawmakers disagree

Dr Mothudi observed that there was room for legal challenge in terms of the impact of the NHI on medical schemes. “There was even disagreement between the parliamentary legal adviser and the state law advisor in terms of how the NHI Bill is structured; and that was not taken into consideration,” he said. 

Another staggering shortcoming of the decades-long NHI process is that government has still not completed a costing: nobody knows what services the NHI will eventually provide, nor how much individual taxpayers will have to contribute to the fund. The result: industry stakeholders are repeatedly asked for their views and opinions on a proverbial ‘sea of unknowns’. 

Butsi Tladi, Executive: Consulting at Alexforbes, was asked how much of the unknown cost of NHI might be raised via a new payroll tax. Talk about a hospital pass! “The quantum of [NHI costs] are still not clear, nor is its structure,” she said, before adding that there would still be a need for additional cover, whether that be through medical schemes or health insurance. What? This comment really got under the writer’s skin: industry seems to be admitting it does not know how much NHI will cost, nor what health services it will provide; but they are already confident that Jane and Joe Average will have to take out additional health insurance to get by. The more we listen and read, the more the UHC dream we are being ‘sold’ comes across as a total con. 

Avery then steered the discussion to the potential impact of NHI on health care goods and services in a post-NHI world. The first concern was with the likelihood that most public health care facilities would fail the envisioned Office of Health Standards Compliance (OHSC) ‘test’ to participate in the NHI. “In order to be accredited as a provider under the Bill, you would need to be able to provide a quality service in accordance with the recommendations and approval of the OHSC,” noted Kirby. The consequence could be a significant rush on private clinics, hospitals and GPs. 

Health care professionals will leave…

Coupled with this, there are many commentators who suggest NHI will result in thousands of health care professionals abandoning ship. Dr Mothudi rushed through a number of issues with the accreditation and contracting proposals contained in the Bill, with the now mandatory ‘too much uncertainty’ disclaimer. Offering anecdotal evidence from other countries where state-run health systems were in force, he said: “Medical practitioners in those countries [complain that] if they rely on the government for more than 30% of their income, they find that their practices become unsustainable…” Of greater concern is that South Africa already struggles with a shortage of skilled health care professionals, especially in rural areas and smaller towns. The key point here: government cannot ignore the myriad concerns that doctors have raised, because they can and do leave. 

Tladi was put on the spot again to hypothesise over the future of the country’s many healthcare brokers. “The need for advice will remain; we do not envisage the system becoming any simpler, despite the huge effort that went into in the recent Health Market Inquiry,” she said, before adding that many things would have to happen before South Africa boasted a fully-fledged NHI. The question should have been what happens to brokers if medical schemes cease to exist? 

When asked for his view on medical schemes’ future, Kirby offered an optimistic and pessimistic ‘skew’. “If you are an optimist, then there will be a place for medical schemes to provide those services that are reimbursable by the NHI fund,” he said. For the pessimists: “If you assume that NHI starts with a primary health care ‘sweep’ of what currently exists under a medical scheme, then you must consider what that does to the medical scheme’s viability”. The impact of the Bill on schemes’ solvency was among the many factors contributing to Kirby’s opinion that the NHI Bill, as currently framed, could never work. 

50 Reasons to question your blind loyalty to this Bill

The 30-minute discussion did not allow enough time to go into all the concerns over NHI. Readers who want to unpack the matter might consider a thought-provoking statemented issued by the opposition Democratic Alliance titled ‘50 Reasons why the NHI will never work’. My challenge to you, dear reader, is that before you dismiss the DA as anti-poor or worse, you take a moment to scroll through that list. Failure to address just one of those points could render the entire scheme unworkable. 

Finally, it behoves us to consider the latest ‘straw man’ argument that dismisses all objections to NHI by saying: “look, this is a process that will take 10 or 15 years to finalise, so do not stress”. Here follows an analogy to illustrate. Imagine, dear reader, that NHI is a homemade soap-box waiting at the starting line atop a steep, windy road. You, the long-suffering taxpayer, are sitting behind the wheel; the Department of Health and National Treasury are standing behind you, ready to push you on your way. 

You look up at them, nervously, and say: “Hey guys, there are no brakes on this buggy, and the steering is looking a bit wobbly”. Their response: “Do not worry bro, it’s a 15-minute journey to the bottom … you can figure these things out on the way down”. 

Writer’s thoughts:
The argument that South African citizens should support the NHI in its current form because “it will take 15-years or longer to bed down” is ludicrous. Are you prepared to blindly back a policy when its costs and outcomes will only become clear five- or 10-years down the line? Please comment below, interact with us on Twitter at @fanews_online or email us your thoughts editor@fanews.co.za.

Comments

Added by STEPHEN ROBERT POVERELLO, 18 Jul 2023
Humphrey, I agree with you 100%, excellent summarizing of the current situation! I will probably be pushing up daisies before this neanderthal project starts!
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Added by Gareth Stokes, 18 Jul 2023
Thanks for sharing @Humphrey. No surprise that the likes of DM and JZ jet off to Russia whenever they need 'medical' assistance... Plus, I just read an opinion piece by Magnus Heystek who suggests 'medical expense trusts' in Mauritius as a possible NHI foil...
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Added by Humphrey, 18 Jul 2023
I was never one to pay much attention to history - in school I dropped the subject as soon as I could. Today, a little older and a little wiser, I understand the valuable role history has to play, the future can in many ways be predicted by past events.

Historically just about everything the ANC and like-minded parties have historically touched they have broken. They simply cannot make a success of anything - this is for 2 reasons: 1) they are simply incapable and 2) they do not want anything to succeed where they cannot steal from it (and once you start stealing from it, it breaks).

One thing is for sure, the ANC and other like-minded parties do not care about the people (the general public) - this is clear from lack of electricity, lack of quality schooling, lack of clean water, lack of good roads and transport systems, current lack of public healthcare (billions of our tax money already go into this dismal failure of a system - NHI is not going to change that), lack of safety and security.

They simply do not care - they care only about themselves.

So why would they listen to all the valid arguments and suggestions on this topic - well they simply do not care. You, me and our offspring (or those that stay in the country) will suffer under NHI - the ANC elite will simply go overseas for critical medical treatment - AT TAXPAYERS MONEY.
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Added by Gareth Stokes, 18 Jul 2023
It is worrying that the Bill is pushing ahead without taking onboard the many comments from private citizens / firms ... and it is insane that the simple process of fixing the public sector was not adopted as a first step. Imagine the health outcomes miracle had government made annual improvements in that 'space' over 20-30 years???
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Added by Gareth Stokes, 18 Jul 2023
Very painful indeed, @Dermot. 'Delusion' works perfectly in the NHI context.
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Added by David Thomson, 18 Jul 2023
Is there any point in commenting further? Seems not. A commie- driven agenda by the cadres. Once again govt. tries to 'fix' things that are not broken because they are apparently too thick & lazy to fix what is actually broken?
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Added by dermot quinn, 18 Jul 2023
The delusion of our leadership is very painful to watch.
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