National Health Insurance (NHI) – towards Universal Health Coverage (UHC) for all in South Africa: a philosophical analysis

Abstract

This study is a philosophical analysis of the National Health Insurance (NHI) policy and legislation, including the related NHI Fund, with a view to assessing its prospects in realising Universal Health Coverage (UHC). The NHI system is about ensuring universal access to quality healthcare for all. The rationale is to provide free healthcare for all at the point of care/service. This legislation has the potential to transform, on the one hand, the relationship between the public and private healthcare sectors and, on the other, the nature of public funding for healthcare. Part of the challenge with the NHI system is that it seeks to provide healthcare for all, but by seeking to integrate the private sector it runs the risk of commercializing healthcare. The study is philosophical in that it holds that ideas have consequences (and conversely actions have presuppositions with certain meanings). In part, it aims to show that an implementing mechanism of the NHI system as presently envisaged has socio-political and economic implications with fundamental contradictions within it; for it seeks to incorporate the private healthcare sector in offering free public healthcare services. This introduces a tension for private healthcare services operate with a neoliberal outlook and methodology which is at odds with a public approach that is based on a socialist outlook. The analysis may make explicit conceptual and ideological tensions that will have practical consequences for healthcare. Much of the commentary on the NHI system have focused on the practical consequences for healthcare; my intervention is to explore and critically assess the various philosophical assumptions that lie behind these practical concerns. Some of these practical consequences are related to the possibility that healthcare is likely to become commercialized and the public healthcare sector will remain in a crisis. This study argues for the provision of access to high quality healthcare facilities for all members of the South African population. Healthcare must be provided free at the point of care through UHC legislation or by the setting up of the NHI Fund as financing mechanism. The study provides reason for the decommercialization of healthcare services completely – that is for eliminating private healthcare from contracting with the NHI Fund. Essentially, it argues for the claim that healthcare should not be traded in the market system as a commodity and that the NHI system in its current incarnation seeks to do precisely that. I further argue that in theory and in practice the neoliberal and socialist assumptions underlying the NHI system in its present formulation do not fit together. On the contrary, rather than a two-tiered system incorporating the private and public healthcare sectors, the dissertation argues for a different way of conceptualizing the NHI system that privileges the latter.