South Africa will see an "exodus" of doctors, while the country’s struggling poor and middle-class will suffer through higher taxes if President Cyril Ramaphosa signs the 'unconstitutional' National Health Insurance (NHI) Bill into law in its current form, numerous healthcare associations say.

The National Council of Provinces (NCOP) voted on Wednesday in favour of the bill, which aims to establish universal healthcare for all South Africans by abolishing the "two-tier" system, in which the bulk of healthcare spending is made in the private sector for the benefit of the few, while the mass of the population is relegated to the "underfunded" public sector.

While the South African Medical Association (SAMA), the Board of Healthcare Funders (BHF) and the Hospital Association of South Africa (HASA), all expressed their commitment to universal health coverage, they said the legislation suffers from fundamental problems, including a lack of input or participation from the industry during the process.

SAMA, which represents nearly 13 000 doctors in both the public and private sectors, specifically warned of an exodus of skilled professionals.

"SAMA notes with concern the exclusion of medical doctors and other healthcare professionals from significant contributions to the practical aspects of the NHI Bill. The absence of their input in decision-making processes, including the composition of the NHI board, poses a risk of a healthcare workforce exodus. In order to ensure the success of the NHI, it is imperative to include healthcare professionals in all relevant boards and decision-making processes," the association said.

"The exclusion of healthcare practitioners, particularly medical doctors, from significant contributions to the practical aspects of the NHI Bill poses a dual challenge. Not only does it risk a potential exodus of healthcare professionals, but it also limits the co-creation of the healthcare system."

Dr Katlego Mothudi, CEO of BHF, an association representing medical schemes and their administrators, said the bill was "unconstitutional" and that recommendations were "ignored", with the bill being passed by the NCOP effectively unchanged from its originally drafted form.

"We have consistently given input into this proposed law and are disappointed that our concerns and those of other stakeholders appear not to have been considered or even tested."

HASA echoed the same comments, saying the NCOP passed the bill "without engaging with the many constructive suggestions and proposals that we, business representative organisations, and many other healthcare stakeholders have tabled".

Funding concerns

Numerous concerns were also raised about the financial feasibility of the NHI system.

"SAMA cautions that the current funding mechanism, relying heavily on general tax revenue, payroll tax, and surcharges on personal income tax, may lead to financial hardships, particularly for the poor and middle-class citizens. The small tax base and existing economic challenges in South Africa may limit the affordability of the proposed funding model," SAMA said.

Mothudi said the current version of NHI "has the potential for a wider negative economic impact".

"There is still uncertainty around how the NHI will be funded, but it will very likely be through additional taxation, something that will unavoidably have a detrimental effect on the economy at large – companies, individual employees and the general public – in the form of job losses."

Finance Minister Enoch Godongwana said at News24’s On the Record event at the end of August that "there are lot of missing things in" the NHI Bill, including around how it will be funded.

The state of SA healthcare

BHF and SAMA also shared a litany of other problems with the bill. 

SAMA said the current healthcare system is not adequately prepared for the implementation of the NHI.

"The Office of Healthcare Standards and Compliance (OHSC) report indicates significant compliance challenges in public healthcare facilities, highlighting issues such as understaffing, limited resources, poor leadership/management, and poor infrastructure. The readiness of healthcare facilities, both public and private, is a critical factor for the successful implementation of the NHI." 

Mothudi said the BHF was also concerned that the bill may prejudice the rights of women.

"The proposed amendments to the Medical Schemes Act exclude access to pregnancy-related healthcare services for women who are medical scheme members. This means that these women would have to access reproductive healthcare from the public sector at their own cost, which is in conflict with the provisions of the National Health Act."

Meanwhile, ANC members of the NCOP described the passage of the bill as "an unstoppable train" and warned that the NHI would be implemented "whether people like it or not".