The National Health Insurance Scheme (NHIS) – the
first implementation phase of which is supposedly set to begin in
2012 – will make scheme membership compulsory for all
However it remains to be seen to what extent current policy
thinking and target dates will be modified in the release of the
eagerly-awaited Government White Paper on the NHIS, now expected
around September this year at the earliest, according to healthcare
Payment for the NHIS will come from a levy or tax deducted from
the salaries of formal sector employees, and by the State for the
Says Neil Kirby, director and Health, Pharmaceutical & Life
Sciences Practice Area head at Werksmans Attorneys: "The NHI
concept is nothing new in larger, wealthier democracies. The
question is whether such a system is a good fit for South
He points out that the Obama administration in the US and the
South African government are currently proceeding down similar
paths in terms of proposed healthcare reform.
"The big difference between the US and SA on this is that
the American legislation made it mandatory for all US citizens to
purchase private health insurance, whereas in South Africa, there
is no such obligation to join a medical scheme."
Within SA, says Kirby, much of what constitutes the NHI scheme
is already in place and, "it's just a matter of connecting
the dots". The basic concept is that all South Africans, rich
and poor, are entitled access to healthcare services. This
principle is also enshrined in the South African Bill of
Over the past decade a raft of often inter-twining legislative
amendments touching on all aspects of healthcare access have been
made, Kirby adds. Amendments to the 1967 Medical Schemes Act, for
example, were aimed at removing risk-rating and providing more
equitable entry criteria for medical scheme admission, so
increasing the accessibility of private healthcare benefits.
Among other important changes were amendments to pharmacy
legislation designed to provide healthcare services in areas
under-serviced by pharmaceutical services. In tandem with this was
the admission of corporate ownership for pharmacies, to allow
larger corporations to enter the pharmaceutical industry.
"In theory," says Kirby, "this would have enabled
them to use their economic muscle to provide cheaper pharmacy
services through an established network of retail outlets, thus
reducing overhead costs and making pharmaceutical products cheaper
and more accessible." However, as healthcare analysts have
observed, the debate around affordable medicine and the
availability and advisability of generic alternatives still rages
Kirby says one of the pillars of the NHIS is the National Health
Act of 2003, which will introduce the concept of accreditation of
healthcare providers, with healthcare services being available only
from specifically accredited providers.
Also introduced was the national health reference price list
– a list of prices that was supposed to be used to
establish charges for all healthcare services – which in
effect, says Kirby, was a definitive list of what healthcare
services should cost. However, this list failed as the
legislation underlying it was found wanting by the North Gauteng
High Court in Pretoria.
In essence, Kirby suggests, "the NHIS is basically a large
medical scheme - to be governed by a board of trustees in the form
of an authority to be created by legislation - and making available
only a prescribed set of benefits. These will be provided by a
prescribed but legally-accredited set of healthcare providers,
including doctors and hospitals for a cost negotiated between the
State and the healthcare providers."
This formula is already in place, in a micro-cosmism form, in
the substance of the Government Employees Medical Scheme (GEMS)
which, due to its membership and affiliation to the public service,
is "a model of the NHIS," says Kirby. He describes the
present NHIS concept as, "the tin man without a heart...it
promises access, but access to what?
"Providing universal access is laudable and is a
constitutional directive, but we must be certain that we have our
eyes fixed on the goal - efficacious and quality healthcare - and
not just the promise of it.
"Hopefully the eagerly-awaited Government White Paper on
healthcare reform will provide us with some much-needed specifics
on planned NHIS implementation," Kirby says.
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