The NHI's newest generation of reforms are rolling out... but who exactly is in charge?

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Crisp was speaking at the 2022 Hospital Association of South Africa's (HASA's) conference held at Century City. A medical doctor and public health specialist, he has focused on public health management for many years, consulting across the African continent.

In his talk to private-sector medical personnel at HASA, he presented what he referred to as "the building blocks" of the NHI.

"Universal health coverage is very simple. It says every person gets the health that they need, when they need it, where they need it, without financial hardship. That's it. That's what we are striving for," Crisp said.

"We want to achieve universal health coverage so that the 60.6 million people in South Africa can use the health system. It can't just be for the 8.6 million medical scheme members.

Crisp went on to further clarify that "universal health coverage is not universal healthcare".

"As defined by the World Health Organization (WHO), universal health coverage is a global programme. We report to the WHO. All countries report to the WHO on the indicators of universal health coverage."

Each user and the other 65.6 million people in the country will get one ID which will incorporate fingerprint authentication to be used on the country's national health information exchange where users will be able access their own medical record.

"That record will be portable," he said, "so that when an individual moves from the private sector to the public sector, from the GP to the hospital, back to the GP, and from there to the physiotherapist, it will all reflect on one record as will their patient history."

Fundamental rights of health professionals

But South Africans are up in arms over a potential exodus of healthcare professionals who refuse to be subject to the scheme’s harsh conditions, as evidenced by the court ruling the department is appealing.

"We are all healthcare professionals, and healthcare managers and healthcare workers in our own right. We work with an unwritten policy that we've studied together and we work together," he said.

"The government is not interested in taking over GPS or hospitals; it is interested in buying the services from the entire private sector."

A central issue is the future role of private healthcare and medical schemes once the NHI is implemented. The NHI Bill states that when the NHI is ‘fully implemented', medical schemes will not be able to provide cover for services that are paid for by the NHI.

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It is not yet known which treatments and medicines will be paid for by the fund, and which will not be. "However, the National Health Council has taken a decision that all of us in the country are going to move to one grading system, and in order to be accredited their system needs to talk to our system. We're going to have interoperable systems," Crisp said.

In a statement, Discovery has said its strong view is that limiting the role of medical schemes would be counterproductive to the NHI. "There are simply insufficient resources to meet the needs of all South Africans. Limiting people from purchasing the medical scheme coverage they seek will seriously curtail the healthcare they expect and demand.

"We also believe that limiting the rights of citizens to purchase additional health insurance, after they have contributed to the NHI, would be globally unprecedented and inappropriate."

Crisp did not speak to the future role of medical schemes but did say "the private and public sector have been praised all over the world for the way they worked together to handle the pandemic and the administration of vaccines."

"That is seven and a half million vaccinations done, and we didn't even have a vaccine to begin with; we had to procure the vaccine. So we have learned enormous things about working together and working to look after our patients."

But, can South Africa afford the NHI?

When given the floor to respond to public submissions and to explain how the many glaring problems in the NHI Bill would be addressed. Health Minister Joe Phaahla said the target is to spend no more than the current 8.5% of GDP and to reduce administrative overheads.

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"The NHI is about redirecting current spending, and it will use tax tools to do so," Phaahla said.

"Can we afford not to implement an NHI especially given that South Africa is the most inequitable country in the world?" Crisp asked.

Currently South Africa's Gini coefficient, which measures inequity, is sitting on just on 0.7.

"This is very bad," said Crisp.

Yet, he questioned Phaahla's comment on SA's GDP target spend: "The global average target, including the United States, is 9.2% of GDP. We are somewhere between 30% and 40%, that's if you look at per capita GDP in the world rankings, and compare the global rankings with the world's biggest economy, and look at their health system."

More importantly, he said: "These are not events. These are reforms.

"I hear people talking about their economies, but Japan took 34 years to institute their universal health coverage, Malaysia took 14 years, the UK is still trying after 70 years.

"It's a journey. We will provide the leadership, but we are not going to do all the work. You've got to do the work too."