NHI Built on a Foundation of Deceit

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National Health Insurance

This article was first published in Afrikaans on Maroela Media

Impact studies are an important characteristic of well-considered public policy. In their absence, government conduct might be whimsical and have no relation to reality. But impact studies themselves can be used to deceive, especially when they are intellectually dishonest and partial. This is exactly what the National Health Insurance Bill, and the policy underlying it, is based on: A poorly drafted impact study tainted by bias, replete with uncited assertions, and glaring omissions. With such a shaky foundation, the National Health Insurance scheme is clearly not supported by reason or evidence and should ideally be set aside.

Both the Constitution, in various provisions, and the Department of Planning, Monitoring, and Evaluation (DPME) recognise that new public policy interventions must be based on a solid foundation of reasoned arguments and evidence. Public policy must not be whimsical, or enacted for expedient political purposes like satisfying passing populist demands. These reasoned arguments and evidence must be manifested through impartial and intellectually honest impact studies, known in South Africa as a socio-economic impact assessment (SEIA). 

The flagship SEIA upon which the National Health Insurance (NHI) is based, was conducted in 2017 on the NHI White Paper. The Department of Health, despite being required to do so, did not publicise a SEIA on the recently published NHI Bill.

The SEIA is flawed in many respects and has few redeeming qualities. 

The first, and probably most relevant flaw, that permeates and arguably causes all its other problems, is that the assessment is not impartial. It was conducted by the office of the Director-General of Health, obviously part of the agency that proposed the NHI in the first place. This partiality led to confirmation and selection bias on the part of the drafters, who end up conducting not a proper impact assessment, but instead writing an elaborate advertisement for the NHI. This error is, however, not strictly the fault of the Department of Health, as it is in line with (ill-considered) DPME policy that the agency that sponsors an intervention should be the one to conduct both the initial and final SEIA on that intervention. 

The two other main flaws in the SEIA – imbalance and intellectual dishonesty – are the consequences of its partiality.

The imbalance of the assessment is clear from how it factored in, or failed to factor in, the submissions of those who rightly objected to the introduction of the NHI. Where national and provincial treasuries raised concerns about the cost of the programme and the implications for the constitutionally-guaranteed autonomy of provincial governments, the assessment records the dismissal of those concerns without much elaboration. Where the private sector and civil society objected – and recommended more affordable and rational alternatives – they were similarly told off, with the health department clearly unhappy with their refusal to buy into the ideology of centralisation underlying the NHI. The SEIA, properly, must have engaged with the objections, in detail, but did not.

Nowhere is the SEIA’s intellectual dishonesty more evident than in how it ‘assesses’ the affordability of the NHI. Government has been sketchy on exactly how much the NHI will cost the beleaguered taxpayer. Former health minister Aaron Motsoaledi, avoiding the question, once remarked that we “cannot balance books against service delivery on human life”. The SEIA, which properly should have lambasted the Department of Health for failing to properly cost the intervention, rises to its defence, and claims that focusing on the price-tag of the NHI “is the wrong approach”, and that the public must instead “frame the question around the implications of different scenarios for the design and implementation of reforms to move towards” universal health coverage. In other words, we must focus on government’s noble intentions rather than the disastrous, real-world implications and (usually unforeseen) consequences that will follow in the NHI’s wake.

Finally, a lethal flaw that dooms the SEIA’s integrity is that it failed to consider any alternative to the NHI. Every best-practice guide on regulatory impact assessments highlights the imperative of looking at alternatives, to enable the public to consider the pros and cons of each potential intervention (and the potential of not intervening at all) side-by-side.

Knowing about these flaws – which are only a taste of the problems in this assessment – it is not far-fetched to say that the SEIA amounts, at best, to a negligent misrepresentation of the true impact of the NHI and, at worst, to a fraudulent deception perpetrated upon the South African public.

Section 27(1)(a) of the Constitution is clear: It guarantees to everyone the right to have access to healthcare. According to Constitutional Court precedent set in the Grootboom case – dealing with housing, a comparable constitutional entitlement – this right is not merely a so-called ‘positive’ or welfare right whereby government must provide the service in question. It is also a ‘negative’ or liberty right, meaning government may not stand in way of, or hinder, access to housing or, in this case, healthcare. Yet, this is exactly what the NHI does.

The Department of Health all but acknowledges – with the SEIA’s endorsement – that the NHI will ‘amalgamate’ the private health sector into the collapsed public health system, under the ‘stewardship’ of the Minister of Health. Countless South Africans will lose their medical scheme benefits and will be forced onto government waiting lists. The NHI Bill even requires everyone to ‘register’ with the NHI Fund and carry their registration papers with them if they wish to access healthcare services – a true healthpas indeed. We embrace the NHI at our own peril.

Democracy has never meant that a government duly elected in a general election has a mandate to do whatever it pleases. Acquiring and keeping a mandate from the public is a continuous and arduous process. As it stands, government does not, and cannot possibly, have a mandate to continue with the NHI, given the shaky foundation upon which it has constructed its narrative. 

South Africans must insist that a proper, independent study be done, factoring in our dismal economic performance, shrinking tax base, and hopelessly corrupt and inefficient government, to provide a clear indication of whether a fantasy like the NHI is workable and affordable. 

The full report, commissioned by AfriForum, on the shortcomings of the National Health Insurance’s socio-economic impact assessment can be accessed here.

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