The South African government is pursuing a policy of National Health Insurance (NHI) that is expected to have far reaching implications for how the country’s population accesses healthcare in future.
The NHI Benefits Advisory Committee will decide for which healthcare services the fund will pay, where you should access those services and the standard treatment guidelines, medicines and devices, required for those health services.
The current NHI Act provides that you will be able to access any healthcare services but the NHI Fund will decide which will be paid for by the NHI Fund.
All NHI users have to register with the fund and then enrol with a primary healthcare practitioner – a general practitioner (GP) or clinic of your choice who is registered with 
the Fund.
NHI users will not be able to access other professionals, such as specialists, have medical tests or scans, or obtain medicines that are paid for by the fund unless their GP has referred them, recommended the test or prescribed the medicine and this referral or test is part of the standard treatment guidelines or the medicine is on the NHI fund’s formulary.
Section 33 of the NHI Act states that once NHI has been “fully implemented”, medical schemes will only be allowed to provide complementary cover.
The
Act does not define what “fully implemented” means – the Minister of Health will have the discretion to decide when NHI is fully implemented.
It is generally understood that this means that medical scheme members will be obliged to contribute an amount similar to their current medical scheme contributions to taxes that will pay for the NHI Fund. The Fund will then pay the primary providers accredited by the fund - and any higher providers accredited by the fund to whom those practitioners refer you - for the NHI benefits you access.
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HEALTHCARE COVER TIP Full implementation of the NHI Act is still many years away. |
The NHI Act does not define the complementary cover that medical schemes will be able to provide, but when NHI is “fully implemented” members will be able to choose to buy cover from schemes for benefits for which the NHI Fund does not pay. It is expected that the Medical Schemes Act will remain in place and will still govern schemes. It is likely that there will be far fewer schemes than there are currently.
The reserves that medical schemes currently hold have not been addressed, but the courts have previously ruled on members’ rights to this money.
The government currently provides money to the provinces to provide healthcare services and each province has its own budget. There are also separate allocations for correctional services and the South African National Defence Force.
The NHI Act states that these provincial and other state entities’ healthcare budgets will be re-allocated to the NHI Fund.
It also states that Minister of Health may designate provincial tertiary and regional hospitals or groups of hospitals as autonomous legal entities accountable to the Minister through regulation. Ten central hospitals responsible for training specialists have been identified to become semi-autonomous.
The Act also empowers the Minister to delegate the provinces to manage health care services by contracting with provincial tertiary, regional and emergency medical services.
Public healthcare facilities will be required to meet the Office of Health Standards Compliance standards and be accredited, or conditionally accredited, before they can contract with the NHI. Many of the public health facilities and some private facilities inspected so far have failed to achieve accreditation.
Private healthcare providers will need to meet the Office of Health Standards Compliance standards and be accredited before they can contract with the NHI to be paid for providing NHI services.
They will have to agree to be paid the rates the fund will pay, to adhere to the fund’s treatment protocols and to refer patients for other healthcare services in line with the fund’s referral pathways.
If your provider fails to contract with the NHI or your primary care provider fails to refer you to your specialist, you will not be able to obtain NHI-funded services from that provider.
The fund will provide health care to all South African citizens, permanent residents and their dependents, as well as to prisoners and refugees.
Asylum seekers and illegal immigrants will only be given access to emergency services and services for notifiable diseases, such as cholera, tuberculosis, measles and listeriosis.
Visiting foreigners will only be entitled to emergency services and anything their travel insurance covers.
Currently, everyone has access to free primary care at state clinics, irrespective of their citizenship or financial status.
This article was reviewed by Professor Nicholas Crisp, deputy director general for National Health Insurance at the National Department of Health and Elsabe Klinck, managing director of Klinck & Samuels
Medical scheme members should therefore continue their membership for now to ensure they have access to private healthcare services.