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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.114 no.5 Pretoria Mai. 2024




Will the NHI Bill be signed off before 29 May?



In February 2024, during the State of the Nation Address, President Cyril Ramaphosa announced that he would soon sign the controversial National Health Insurance (NHI) Bill into law. He was just 'looking for a pen'.[1] According to Natshaveni, a minister in the presidency, the Bill would be signed off before the elections so that full implementation could occur under the new administration.[2] With South Africans going to the polls on 29 May, Ramaphosa has less than a month to find his pen.

According to the World Health Organization (WHO), universal health coverage (UHC) is defined as all people having access to the full range of quality health services they need, when and where they are needed, without financial hardship.[3] Logically, prerequisites would be well-developed, resilient health systems and health systems security. The NHI Bill at the outset starts off with the promise of universal access to quality health services in line with section 27 of the Constitution.[4] However, except for a nebulous and impractical financing structure, there are no funding plans in the Bill. The financial risks are huge, both to the taxpayers and to the country. The package of benefits to be offered has not as yet been defined, and hence the true costs remain unknown. It is projected that an additional ZAR200 billion will need to be raised each year to supplement the current national health budget. This would be from increases in VAT, payroll and personal income taxes.[5]

Moreover, with the longstanding and worsening dysfunctionality of healthcare provision for the majority of people living in South Africa (SA), universal access to quality health services will remain a pipe dream for many moons to come. An article published in the Lancet recently highlights that despite the initial commitment by countries towards UHC through the United Nations Sustainable Development Goals (SDGs), and this commitment being reinforced twice thereafter, progress towards UHC has deteriorated. One hundred and eight of the 194 WHO member states have had worsening or no substantive improvement in health service coverage since the launch of the SDGs in 2015. Furthermore, there was inadequate policy implementation capacity, and health systems challenges including insufficient numbers of healthcare workers, poor supply chains and a shortage of pharmaceuticals and diagnostic technologies.[6] SA's healthcare delivery challenges are no different, with the doctor:patient ratio being 0.3 doctors per 1 000 people of the population.[1] This is well below the WHO recommended ratio of 1:1 000, and despite having close onto 800 unemployed qualified doctors in the country because of so-called 'budget constraints'. Besides these professionals being denied an income based on qualifications they have worked so hard to achieve, the patients at the end of the pipeline are the worse off, with overworked staff, longer waiting times and access to specialist care restricted.

The situation is further compounded by inefficiencies and mismanagement. For example, ZAR784 million was set aside by the Gauteng provincial treasury in March 2023 for the outsourcing of radiation treatment, but not a cent of this money has been spent yet. In March 2022, there were already 3 000 patients awaiting radiation oncology treatment. There are just two operational machines in the province for public sector patients.[7] What we see is a 12-month delay in providing life-saving treatment to patients with cancer, despite funds being available. This lack of respect for patients' lives is indeed unconscionable.

The list of dysfunctionalities in healthcare goes on. With the several concerns with the Bill itself and the current situation in healthcare delivery in the country, coupled with pervasive corruption, would any honest individual who puts people first actually sign off?



Prof. Ames Dhai

Acting editor



1. Fraser L. Ramaphosa 'looking for a pen' to sign the NHI into law. BusinessTech, 8 February 2024. (accessed 2 May 2024).         [ Links ]

2. Ramaphosa to sign off NHI Bill before elections. News 24, 1 February 2024. (accessed 2 May 2024).         [ Links ]

3. World Health Organization. Universal health coverage (UHC). Geneva: WHO, 2023. (accessed 2 May 2024).         [ Links ]

4. Republic of South Africa. National Health Insurance Bill. (accessed 2 May 2024).         [ Links ]

5. Medical Brief. Bold promises in SA as world experts urge momentum for UHC. Medical Brief, 1 May 2024. (accessed 2 May 2024).         [ Links ]

6. Bertram K, Aylward B, Bosio L, et al. Confronting the elephants in the room: Reigniting momentum for universal health coverage. Lancet 2024;403(10437):1611-1613.        [ Links ]

7. Medical Brief. Activists march for unused R784 million to be spent on cancer patients. Medical Brief, 1 May 2024. (accessed 2 May 2024).         [ Links ]

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