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The Citizen
5 days ago
- Health
- The Citizen
Reality check for the working class: who really pays for NHI?
Both the poor and the wealthy will have to pay for NHI. It will not be as free as government makes it out to be. Do you think the working class will not pay for the National Health Insurance (NHI)? As government presses ahead with implementing the controversial fund, a difficult question needs to be asked: who will pay the real price? Contrary to popular belief, it is not the wealthy elite who will be hardest hit but South Africa's working class, Thoneshan Naidoo CEO of the Health Funders Association (HFA), warns. 'Medical scheme members are often painted as a privileged minority but the truth is very different. Of the 9.1 million South Africans on medical schemes, more than 6 million (68%) are black and up to 83% of employed members earn under R37 500 per month. 'They are teachers, nurses, police officers, civil servants and union members, the engine of South Africa's economy. These South Africans make extraordinary sacrifices to secure access to healthcare. Medical schemes are not luxury products and working families are stretching their disposable income to protect themselves and their families. 'Of the 9.1 million beneficiaries, 4.1 million are employed and form a critical part of the country's taxpayer base. In fact, medical scheme members pay an estimated 74% of South Africa's personal income tax, amounting to nearly R443 billion in government revenue. These same members also contribute significantly to VAT and other taxes.' ALSO READ: Experts warn NHI is economic suicide Free NHI at the point of service, but who pays? Government promises that the NHI will provide comprehensive, high-quality care for all – free at the point of service. But at what cost? According to an economic feasibility study by Genesis Analytics, achieving this vision would require personal income taxes to more than double. Taxes would have to increase to 2.2 times the current average rate and healthcare would consume 33% of the national budget. In less efficient scenarios this could mean tripling taxes and health expenditure consuming up to 44% of the budget. Naidoo says this is based on the unrealistic assumption that tax increases would be entirely directed to healthcare and that there would be no additional allocations for other urgent social needs such as education, social grants and service delivery. Even under a shared resources scenario, Naidoo warns that where total healthcare spending remains at today's R532 billion, personal income taxes would still have to increase by almost 50%, while taxpayers would receive substantially less. Benefit levels would be 43% to 65% lower than the promised comprehensive scenario, he says. 'In short, taxpayers would pay more and get less – less than they currently receive if they are medical scheme members and much less than what has been promised for the scope of NHI services.' ALSO READ: Health funders also heading to court about NHI Act What about section 33 of the NHI Act that prohibits medical aid? A lot has been said about section 33 of the NHI Act that the president signed last year. This section prohibits medical schemes from covering any service that the NHI claims to offer. Naidoo says this means that even if you have the means and willingness to buy private cover, you will be barred from doing so if the service is theoretically offered by the NHI. 'Rather than universal access, this is universal restriction and the result is likely to be delays, rationing and deteriorating health outcomes, with no alternative safety net.' And who will bear the brunt? The working class, Naidoo says. He warns that the NHI Act risks collapsing the very system that currently supports our healthcare infrastructure. 'For the 3.4 million low and middle-income medical scheme members, the impact will be devastating. The NHI Act's funding model is built on their shoulders through higher taxes, the removal of the medical tax credit and reduced access to care.' Healthcare cannot be viewed in isolation from the broader economy, Naidoo says. 'Draining all available funding into a single centralised system without the infrastructure or capacity to deliver, jeopardises not only health outcomes but also jobs, investment and growth.' ALSO READ: NHI regulations 'prematurely' published with legislation not proclaimed yet 43% reduction in medical care for scheme members under NHI He points out that even in the best case shared resources scenario modelled by Genesis, medical scheme beneficiaries would see a 43% reduction in access to care. 'Combined with the ban on supplementary cover, the state will actively prevent people from protecting their own families.' Naidoo cautions that healthcare rationing will become the norm. 'This is not speculation. It is already happening. Public hospitals face routine medicine stockouts, long surgery waitlists and severe staff shortages. In Gauteng, thousands of cancer patients were denied timely radiation therapy, with devastating consequences. When care is rationed, lives are lost.' Section 33 of the NHI Act risks deepening these crises, he says. 'It removes a vital layer of protection for millions. Blocking people from using their own resources to access care is not equity, but rather forced dependency.' However, there is a better way: reform, not ruin, Naidoo says. 'South Africa's constitution guarantees everyone the right to access healthcare. Our courts have recognised the vital role medical schemes play in realising this right. That does not mean collapsing what works, it means improving what does not.' ALSO READ: DTIC plan to implement only some Health Market Inquiry recommendations 'illegal'? Health Market Inquiry Medical schemes are not perfect and reform is essential. Fortunately, Naidoo says, the blueprint exists. The Health Market Inquiry, initiated by the Competition Commission, laid out clear steps to improve affordability, transparency and efficiency in the private sector that include: A supply side (healthcare providers and facilities) regulator for health to oversee negotiated fair reimbursement levels; A risk adjustment mechanism, where medical schemes with higher-than-average risk profiles receive funds through an appropriate mechanism from those with lower-than-average risk profiles, to level the playing field; Standardised benefit packages; Better governance structures to ensure efficient use of resources. ALSO READ: Implementing recommendations of Health Market Inquiry good idea – experts These steps will ensure more and better medical care for all Implementing these reforms in a holistic and integrated manner would strengthen the role of medical schemes in a fairer, more accountable health system without tearing down what is working for millions, Naidoo says. 'Most importantly, these improvements could be implemented now, without the massive fiscal burden of a centralised NHI that requires impossible tax increases. The Health Funders Association proposed an alternative, a hybrid multi-fund model that preserves the public private mix, ensures income cross subsidisation and gradually expands coverage. 'This model is based on the NHI Fund working with medical schemes to expand access to healthcare and incorporates key Competition Commission recommendations and would protect the vulnerable while preserving choice and quality. 'South Africa can achieve universal health coverage without banning the opportunity to purchase supplementary cover, overtaxing workers or dismantling functioning systems. The working class has more than paid its share. The question South Africa must ask now is whether government will listen and build a better system or press ahead regardless of the cost.'
eNCA
06-06-2025
- Health
- eNCA
Health Funders Association challenges NHI Act over cost and constitutionality
JOHANNESBURG – The Health Funders Association (HFA) is mounting a legal challenge against key aspects of the newly signed National Health Insurance (NHI) Act, citing serious constitutional and economic concerns. HFA CEO Thoneshan Naidoo says while the organisation supports the goal of universal healthcare, the current NHI framework is fundamentally flawed. 'The debate around national health insurance has been ongoing for years,' said Naidoo. 'Unfortunately, despite consistently raising our concerns, we've now been forced to take legal action.' The HFA commissioned an independent expert to assess the economic impact of implementing the NHI as it currently stands. The findings are stark: For South Africa to provide the same level of care promised under the NHI -- equivalent to what private medical schemes currently offer -- it would require the country's 7.4 million taxpayers to double their current tax contributions , a cost Naidoo says is simply unaffordable. In addition to the financial strain, Naidoo highlighted a massive shortfall in human resources. 'To provide the same level of care across the population, we would need an additional 286,000 healthcare professionals, which the country currently does not have,' he added. Naidoo maintains the Act, in its current form, is economically unsustainable and constitutionally questionable, and does not align with the realities of South Africa's healthcare infrastructure. The legal challenge is expected to intensify debate around the future of healthcare reform in the country.
The Citizen
06-06-2025
- Health
- The Citizen
Experts warn NHI is economic suicide
Lower earners could face marginal tax rates of 41%, sparking concern that NHI funding will punish the most vulnerable. Research just released by the Health Funders Association (HFA) is the most-stark warning yet that the ANC's push to implement the National Health Insurance (NHI) is not only doomed to failure, it is going to drag down our economy with it. The HFA commissioned Genesis Analytics – an independent economic consultancy with experience in over 115 countries – to build a financial and economic model to test the viability of NHI and to compare the system with those in similar, middle-income countries. The analysis was that, for NHI to fund a level of care equivalent to what medical scheme members now receive, personal income tax would have to increase by 2.2 times (a 115% increase in tax) from the current average rate of 21% to an average of 46% of income. This would push marginal tax rates in the lowest income bracket from 18% to 41% and in the highest bracket from 45% to 68%. ALSO READ: Health funders also heading to court about NHI Act HFA estimated that were VAT used, it would have to increase from 15% to 36%. Even a hybrid public-private system would require personal income tax to increase by 47%. HFA is going to court to fight the proposals – and they aren't the only ones. This is simply financial madness. NOW READ: Health minister defends nearly R10 million legal spend on NHI court battles
Mail & Guardian
05-06-2025
- Business
- Mail & Guardian
Health association takes legal action against NHI Act
File photo by James Oatway The Health Funders Association this week launched a legal challenge against the President Cyril Ramaphosa The ANC, which governed the country solely until being forced into a national coalition after the polls, says the NHI is intended to provide universal and comprehensive health coverage to all South Africans. But it has faced fierce criticism from the private healthcare sector and parties such as the Health Funders Association chief executive Thoneshan Naidoo acknowledged this week that 'South Africa needs a healthcare system that delivers equitable, quality care to all [and] we fully support that vision.' But he added: 'In its current form, and without private sector collaboration, the NHI Act is fiscally impossible and operationally unworkable, and threatens the stability of the economy and health system, impacting everyone in South Africa.' The association filed its application at the Pretoria high court, joining five other medical entities that are fighting the law. The It argued that the framework in its current form was not fiscally feasible and would also have adverse effects on South Africa's healthcare and economic outcomes. 'The steep tax increases required to fund the NHI will reduce disposable income, curb consumer spending across all sectors of the economy and may well trigger an exodus of high-income taxpayers,' it said. 'At the same time, destabilising the private healthcare sector will deter investment, put jobs at risk, and slow The association's position is premised on a report by Genesis Analytics, published this week, which showed that the 'NHI Act requires unsustainable tax increases while reducing healthcare access for medical scheme members'. It said the analysis also revealed South Africa's racially diverse medical scheme membership, in which more than 68% of members are black, Indian or coloured, and up to 83% earn less than R37 500 a month. 'The proposed NHI would, therefore, disproportionately impact working-class households who currently rely on medical schemes for quality care.' Modelling by Genesis Analysis showed that it would be impossible to raise the funds required for NHI, 'even under the most optimistic assumptions'. 'For NHI to fund a level of care equivalent to what medical scheme members currently receive, as government has indicated is the intention, the Genesis model shows that personal income tax would need to increase by 2.2 times (a 115% increase in tax) from the current average rate of 21% to an average of 46% of income.' This, it said, would push marginal tax rates in the lowest income bracket from 18% to 41%, and in the highest bracket from 45% to 68%. Building its case, the association said the Genesis model projected that more than 286 000 additional healthcare professionals would be required to fulfil the NHI vision. This is more than twice the number of general practitioners, nurses and pharmacists and three times the number of specialists. 'NHI will therefore place significant pressure on healthcare workers and addressing these capacity gaps will require significant time and investment,' the association said. Naidoo added that South Africa does not have enough skilled workers to deliver the NHI's mandate. 'By driving down service tariffs, the NHI risks accelerating the emigration or exit of healthcare professionals from the sector altogether.' The country is already facing a medical professional 'brain drain'. A survey conducted last year by the South Africa Medical Association, which represents approximately 17 000 doctors across South Africa, showed that as many as 38% of its members intended to leave the country in response to the implementation of the NHI scheme. Last month, Ramaphosa defended the Act after the Board of Healthcare Funders, which represents most private medical schemes, said he flouted his constitutional duty by failing to scrutinise its constitutionality when he signed the NHI into law. It added that the president ignored submissions that pointed to the patent constitutional defects in the legislation. The Pretoria High Court ruled in favour of the board. Ramaphosa launched an appeal, arguing that the court lacked jurisdiction in the matter and erred in finding that his decision to sign the new law was reviewable. The court found no merit in his argument on the separation of powers and said the step of assenting to a Bill was but part of a lawmaking process that was a reviewable exercise in public power.
Daily Maverick
05-06-2025
- Health
- Daily Maverick
Health Funders Association launches latest legal challenge to NHI Act, calling legislation ‘unworkable'
The Health Funders Association is the sixth organisation to launch a legal challenge to the NHI Act, describing it as 'unaffordable, unworkable and unconstitutional'. The Health Funders Association (HFA), a nonprofit representing 20 medical schemes and three administrators in South Africa's private healthcare funding sector, has become the latest organisation to launch a legal challenge to the National Health Insurance Act. On Thursday, 5 June the HFA announced the challenge, which has been lodged in the Gauteng Division of the High Court in Pretoria. The organisation has said that while it supports the 'goal of universal health coverage', it considers the NHI Act to be 'unaffordable, unworkable and unconstitutional'. 'Litigation is not our preferred route but it is, under these circumstances, the responsible one to protect our economy and the future of healthcare in our country,' said NFA chief executive Thoneshan Naidoo. Unconstitutional and invalid In its legal challenge, the HFA argues that the NHI Act is procedurally and substantively flawed and will cause irreparable harm to the health system economy. It also seeks to show that: Section 33 of the NHI Act, which limits the role of medical schemes to providing complementary cover, infringes on section 27 of the Constitution regarding the right to access healthcare; The Act is not a 'reasonable measure' under section 27(2) of the Constitution, which stipulates that the government must take progressive, reasonable steps to realise access to care; and The Act unconstitutionally delegates legislative authority to the minister of health. Naidoo said that the relief sought by the HFA in the high court was for 'certain sections of the NHI Act be declared unconstitutional and invalid. Alternatively, the Act, in its entirety, to be declared unconstitutional and invalid.' There are already five legal challenges to the Act playing out in South Africa's courts, led by the South African Medical Association, the Board of Healthcare Funders, the Hospital Association of South Africa, the South African Private Practitioners Forum and the trade union Solidarity. 'With our knowledge, skills and experience of the funding industry… we bring an understanding of what the flaws are [in the NHI Act], what path we're on and alternative solutions. We don't view ourselves in opposition, but as part of completing the solution,' Naidoo told Daily Maverick. He noted that the HFA had engaged with the NHI through public participation processes before it was signed into law, in an attempt to work collaboratively with stakeholders. 'We are a part of Busa [Business Unity South Africa]… and while we go ahead with this legal challenge, we are hoping that through Busa… and that ongoing engagement with the president, it can lead to some amicable solution,' Naidoo said. Health Department spokesperson Foster Mohale said the department would study the HFA's application once it had received it and 'respond accordingly through the legal channels'. Independent study Part of the reason the HFA's legal challenge was launched more than a year after the NHI Act was signed into law was to allow time to research the potential impact of the legislation, said Naidoo. The organisation commissioned an independent economic analysis by consultancy firm Genesis Analytics. 'The Genesis analysis assesses various potential efficiency savings under NHI compared to the current system. For modelling purposes, savings are assumed to be as high as 45% of private sector cost levels. The report demonstrates that even under the most optimistic assumptions, it is not possible to raise the funds required for NHI,' the HFA said. 'For NHI to fund a level of care equivalent to what medical scheme members currently receive, as government has indicated is the intention, the Genesis model shows that personal income tax would need to increase by 2.2 times (a 115% increase in tax) from the current average rate of 21% to an average of 46% of income.' The Genensis model considered a scenario of pooling existing healthcare expenditure in the private and public sectors to support NHI. Its finding was that to enable this, personal income tax would need to increase by 1.5 times its current rate (a 47% increase in tax), from its average of 21% to 31%, according to the HFA. The report stated that medical scheme members would face a 43% reduction in the level of healthcare services relative to what they currently receive. When breaking down who would be affected by the potential decline in services under the NHI, Naidoo said the Genesis analysis showed that more than 68% of medical scheme members were black, Indian or coloured, with up to 83% earning less than R37,500 per month. 'There's often a misconception that medical schemes are for the wealthy and the elite. But if 83% are earning less than R40,000, it means this is actually your economic engine of South Africa. This is your workforce,' Naidoo said. Another finding of the study was that an additional 282,000 healthcare professionals would be needed to achieve the same level of care and access under the NHI than is currently experienced through medical schemes. 'Every year, we only get about 3,600 new medical graduates. Qualifications take between nine to 13 years… so the targets are decades away,' Naidoo said. Pursuing meaningful reform Naidoo said the HFA was not seeking to preserve the status quo, since it believed meaningful reform was essential to improve affordability, quality and access in healthcare. 'We remain committed to working with government and stakeholders to design a more inclusive, financially viable and constitutionally sound [system],' he said. 'Almost all successful [universal healthcare coverage] models, whether it's in high-income, middle-income or even low-income countries, involve strong public-private sector collaboration… Rather than sidelining the private sector, these systems leverage its capacity, innovation and infrastructure to expand access, improve efficiency and enhance quality of care.' The HFA has proposed a 'hybrid funding model' that involves the NHI fund and medical schemes operating 'in tandem'. It argues that this system would preserve individuals' 'freedom to choose supplementary private cover'. 'Public resources are focused on those most in need, while regulated competition supports innovation, efficiency and cost control,' it said. 'The proposed model offers a common benefit package with built-in cross-subsidisation to ensure equitable access for vulnerable populations. Grounded in a strong primary healthcare foundation, the model reflects international best practice and is especially relevant for middle-income countries like South Africa.' Other organisations have proposed alternative models to the NHI fund, including the Universal Healthcare Access Coalition, made up of the South African Medical Association, the Progressive Health Forum and the South African Private Practitioners Forum. Naidoo noted that a 'common thread' in many of these healthcare reform proposals was the emphasis placed on 'multifund, multipayer systems' rather than a single-fund monopoly. DM
