Medical professionals and business organisations reacted immediately to the passage of the National Health Insurance (NHI) Bill through the National Council of Provinces (NCOP) on Wednesday afternoon, saying they would petition President Cyril Ramaphosa to return it to Parliament. 

While African National Congress (ANC) members of the NCOP celebrated and Minister of Health Joe Phaahla acclaimed the day as "historic", the Western Cape stood apart as the only province that did not support the bill.

Phaahla and numerous other speakers from the ANC underlined popular support for the bill, which they had encountered in public hearings around the country. This was to counter claims from business and medical professionals that they had failed to consider their views.

The bill passed through the NCOP without a single amendment. 

Said Phaahla: 

It is a historic day and a historic act… I can tell you without a shadow of a doubt that the majority of people supported the bill. They were not misled.

'Like it or not'

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

The bill 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 a few, while the mass of the population is relegated to the "underfunded" public sector. 

A single NHI Fund managed by the state will buy healthcare services from the public and private sectors, with all services free to the public at the point of delivery. Once a service becomes available under the NHI, medical schemes will no longer be allowed to cover it, implying the ultimate phasing out of private medical insurance. 

It is this provision – Section 33, which will limit the role of medical schemes – that has proved the most controversial. Also very uncertain is the funding of the NHI, which will require large tax increases. 

Business Unity SA (BUSA) and Business4SA (B4SA) said on Wednesday evening they were "preparing to submit a formal petition to President Ramaphosa, requesting that he refer the NHI Bill back to the National Assembly for amendment. We believe that the bill, in its current format, is not only unworkable, unimplementable, and unaffordable, but also unconstitutional, both on substantive and procedural grounds."

The signing of the bill by Ramaphosa is the last and final step in its passage into law. Ramaphosa can only return a bill to the National Assembly if he believes it to be unconstitutional. 

BUSA and B4SA argue that the bill is unconstitutional on procedural grounds because: 

• Public participation inputs were not adequately considered;
• The NCOP process was rushed and failed to deal with reports from the provinces;
• The NCOP failed to incorporate amendments, provincial public submissions and technical flaws noted by several provinces and even by the Department of Health itself. 

They say that the bill also falls short on substantive constitutional grounds because: 

• Unfettered power is granted to the Minister of Health to restrict the role of medical schemes. This will damage the private sector and impact people's ability to seek private healthcare;
• The processes for accessing healthcare will frustrate or even deny the right to access healthcare.

The SA Health Professionals Collaboration (SAHPC), which represents 25 000 medical professionals in nine professional organisations, also called on Ramaphosa to refer the bill back to Parliament for reconsideration.  

"This is on the basis that it lacks clarity on key elements, and if implemented in its current form, will have a devastating impact on the country’s ability to deliver quality healthcare," said the SAHPC.  

The group said it shared the view that the bill was unconstitutional and unworkable: 

For this reason, we urge the president to return it to Parliament for reconsideration. We recognise that health reform is necessary, both in the public and private sectors, and that the country needs an appropriately funded, managed, and delivered healthcare system for the benefit of all. Section 33 of the bill, which limits the role of medical schemes, and therefore the funding for the entire private healthcare sector, undermines the country’s ability to achieve these objectives, and therefore should be removed.

At a press briefing after the sitting, Phaahla said the government wanted to continue engaging with all stakeholders as the NHI was rolled out. He said it was not accurate that all medical professionals opposed the bill. Some, such as the Family Medical Practitioners' Association, supported it.

The SA Medical Association had also, at some point, supported it, but had now changed its position after a change in leadership, he said.

Phaahla said he understood why business organisations had concerns, as some practitioners and insurers believed their businesses would be threatened. But the NHI would be introduced gradually, he said, and the fears that health practitioners would leave the country were exaggerated. 

"It is a fear of the unknown. I don’t deny there will be disruption because the current situation is unsustainable. But our point is that healthcare should be a public good."