South Africa’s National Health Insurance at a Glance

Here are highlights of what are known so far of the lofty goals, objectives, structures and operating mechanisms of the South African NHI bill at a glance.

What is the NHI bill and who pays for it?

• The Bill seeks to provide universal access to health care services in South Africa and envisages the establishment of a National Health Insurance Fund (NHIF) while setting out its powers, functions and governance structures. The fund will purchase and finance health care services for all users who are registered with it.

• The NHIF will be paid for by tax payers and from general revenue.

• Individual out-of-pocket payments such as co-payments and user fees will not be used to generate additional funding for health care services to be covered under NHI.

• The NHI will be implemented in phases. Phase 1 which pertains to health systms strengthening initiatives (employing more healthcare professionals, improving hospital autonomy, improving halthcare infrastructure and provider reimbursement reforms) started in 2023 and will continue into 2026. Phase 2 will commennce in 2026.

What will the NHI do?

• The government through the NHI will buy health care services for all South Africans who live in the country from healthcare providers in the public sector and private sector.

• This means when you feel unwell, you can go to your nearest GP or clinic of your choice that has a contract with NHI and not worry about the cost of care. 

What are the benefits of the NHI?

• Access improvement: Assurances of access to universal health care for all South Africa without worry about cost at point of care.

• Improving service quality and reducing disparity: The bill is expected to improve service quality and outcome as well as reduce healthcare disparity between people through pooling of funds to serve the healthcare needs of all without discrimination of any kind.

• Reducing burden of disease: The bill will contribute to reduction in the burden of disease for South Africans through system level coordination of care.

• Financial risk protection: The NHI Fund will provide a safety net from poverty to individuals against financial hardship when they access healthcare services through elimination of out-of-pocket payments such as user fees, co-payments etc.

• Contribution to economic development and growth: Since a healthy population can work more productively, the bill will help to grow the economy of South Africa for the benefit of all.

• Integration of the healthcare system: The public and private healthcare systems will be integrated so as to ensure the principles of equal care and social solidarity across all socio-economic groups.

How will South Africa’s NHI work for its citizens?

• Government through the NHI Fund will serve as the sole purchaser and financier of healthcare services on behalf of all South Africans. This enables all people to have access to a clinic, a doctor or a hospital (public or private) of their choice, where they live or work without paying when they need the services.

• With the people having paid taxes already to the government, the government in turn will pay healthcare providers for the care received by them or their loved ones. There will be no coverage exclusion and no cash out of pocket payments for anyone.

Who will be covered under the NHI Fund?

• All South African citizens regardless of employment status, permanent residents, refugees, inmates and specific categories of foreign nationals will be covered by the fund.

• Asylum seekers and illegal foreigners will be covered for notifiable conditions and emergency medical services.

• All children will be covered for all benefits purchased by the fund regardless of nationality.

• Visiting foreign nationals will be covered by their mandatory travel insurance.

How will people register for coverage?

• Registration shall be free of any cost.

• The first and only registration needed with the fund will take place at any Clinic, General Practitioner, and Hospital that has a contract with the NHI Fund. Your registration information will always be available to all healthcare providers contracted with the NHI Fund no matter which clinic, GP or hospital you attend throughout your lifetime

• To register, you will need to provide a valid means of identification (i.e., your ID book, passport, or other identity document). Your fingerprints will be taken and put on the NHI Fund system. This will make it easy when you visit the clinic, GP or hospital again, or when your ID is lost. Fingerprints are a way to prevent fraud and identity theft but mostly to be absolutely sure that the medicines that you are given are for you and not someone else.

• Each time you attend a clinic, GP or hospital you will need to present your proof of identity. If you are unconscious, then the provider can still find your records using your fingerprints.

How will South Africans without ID register?

• Under collaboration between the departments of Health and Home Affairs to address birth and death records, South Africans without ID will be registered in facilities contracted under the NHI Fund using biometric identification (like finger printing, and other methods) This will ensure that all users have a health record that goes with them whenever they access healthcare anywhere in the country.

Will individuals be able to use facilities of their choice?

• Yes. All South Africans will be able to access NHI-contracted GPs, clinics or hospitals of their choice that is closest to them, whether public or private. 

What services will be provided under the NHI?

• Service benefits that will be available to South Africans will cut across primary, secondary, tertiary, specialized and quaternary levels.

• Once the NHI Fund covers a benefit, no other medical schemes may cover the same benefits.

• A Committee of the NHI Fund determines what are medically necessary benefits and these will include:

• Primary Health Care services: Visits to clinics, community health centres,  group practices, community health care outreach workers, integrated school health services.

• Hospital services: Outpatient and in-patient visits at all accredited hospital levels. Access to hospital services will require a letter from a Primary Health Care/ Provider unless in case of emergency). 

• Emergency medical services.

• Transportation for patients who are referred to and from another health facility.

• Others, including:

• Rehabilitation health services

• Palliative Care

• Mental health services

• Essential medicines and medical devices

• Diagnostic procedures (as specified under provided guidelines and protocols)

Who will run the Fund?

• The Fund will have a Board and various governance structures as required by applicable laws. The Board will have the responsibility of ensuring that there are institutionalised systems, policies and procedures that proactively prevent, detect, investigate and correct incidents/acts of fraud and corruption.

What role will private healthcare providers play in the NHI?

• Private healthcare providers will continue to operate privately under the NHI dispensation. The NHI is not going to abolish or do away with private health providers.

• However, NHI will not allow private health care providers to set their own fees for NHI funded benefits. The Fund will set the fees that it will pay to private doctors, hospitals and others on your behalf.

• Private General Practitioners will be a part of multi-disciplinary networks in their communities and will be paid by the NHI Fund using a capitation model.

• The private health sector providers will benefit from the opportunity to contract with NHI to provide health services to the broader public, rather than the small proportion for which they currently provide services. They will be able to provide services to patients throughout the year not worried about depletion of funds of patients at any stage.

• Private hospitals will see patients referred by primary health care providers in both public and private sectors and the NHI Fund will settle the bill at the prescribed rates.

Additional Information

Click here for more details of the policies, programs and operational guidelines of the NHI bill and Fund.

Source: South Africa Government News Agency