National Health Amendment Bill [B24-2011]: briefing by Minister of Health

Meeting report

Dr Aaron Matsoaledi, Minister: Department of Health, said that the Bill sought to revolutionise how South African healthcare was perceived. As 84% of the population received their healthcare in the public sector, the proposed National Health Insurance would not be successful without quality healthcare in the public sector and two preconditions had been identified for the introduction of NHI: A complete overhaul of the manner in which public hospitals were currently run; and prices in private healthcare had to be re-calculated. The time had arrived for the DoH to establish the Office, which had been written into the National Health Act in 2003.

The six basic Core Standards for quality healthcare which the Bill sought to enforce and with which members of the public would easily identify were: cleanliness; safety and security of patients; attitude of health personnel towards patients; infection control inside the institution; drug stock-outs; and long queues.

The Office of Health Standards Compliance would perform independent oversight on healthcare, with or without reference to the Minister and yet would report to the Minister. The Office consisted of the Inspectorate – people had been trained by the Quality Care Commission in the United Kingdom, Environment Healthcare Inspectors, who would work under a CEO; and the Ombud, a statutory office that would investigate and decide on accountability. In the past, the Minister took responsibility for any problems that existed in public healthcare. The Bill also sought to give institutes responsibility and to certify entities that complied with standards and requirements.

The Minister wished to acknowledge the Department for International Development in the British Government, which had brought together stakeholders in South Africa and funded workshops and training by the Quality Care Commission of the UK. The proposed Bill mirrored the work of the Quality Care Commission. Members of the Portfolio Committee on Health would be called upon to navigate on the powers of the Office – and those of Labour Law, Unions, the Administrative Justice Act and the Constitution.

Each public institution would be graded from A to F and management would be required to comply in terms of the Office of Health Standards Compliance of the National Health Act. For example, the expectation of the Act would be that hospitals had to be clean, by law. Although the Act included statutory bodies to deal with issues of the public, the amendments sought to expand legislation beyond individuals of the public, to competency within the institutions themselves.

Dr Carol Marshall, DoH Cluster Manager: Office of Standards Compliance, said that the bulk of the presentation would be about how DoH proposed that Chapter 10 of the National Health Act (2003) on “Health Officers and Compliance Procedures” should be altered. The background to the Bill was that the process of reviewing establishment of the Office started with a decision in 2009 that an independent quality accreditation and management body should be established. Subsequent work had been done towards the Amendment Bill. The National Core Standards were approved in 2010 by the National Health Council as policy guidelines for the National Health System. The Draft Amendment Bill was approved by Cabinet in November 2010 and gazetted for public comment from January to April 2011. A summary of the issues raised by the public can be found in the handout attached. The revised Bill was certified by the State Law Advisors in November 2011.

The Bill sought to amend the National Health Act (Act No 61 of 2003) and to empower the Minister to establish an independent entity, namely the Office of Health Standards Compliance (Office). Dr Marshall explained in detail the amendments to Clauses 1, 2, 3 and 4 (substitution of Chapter 10), 5, 6, 7 and 8 (see presentation attached).

Adv Monwabisi Nguqu, Senior State Law Advisor: Office of the State Law Advisor, added that the Bill had been extensively reviewed and that the Office of the State Law Advisor had worked hand in hand with DoH to refine the Bill and had certified it before it was submitted to Parliament.

Discussion
Ms M Dube (ANC) asked if the organogram of the Office would be a national body or if it would intervene as far as provinces and local structures. She also asked what role the Office would play in the clinics in the districts. The presentation referred to hospitals only.

Dr Gwen Ramokgopa, Deputy Minister: Department of Health, replied that the Minister had represented the whole National Health Sector, which was the National Health Authorities, Council, the MECs and SALGA. The National Health Act (2003) governed the whole health sector in the country, whether it was public or private, profit or non-profit. The extensive amendments were to establish the Office. The Bill referred to all health establishments and not only to hospitals.

Dr Marshall added that any body such as the Office would grow over time. In order to perform its work, it would probably require 300 to 500 people, but this would not happen immediately. Currently there was a Budget Vote which would enable DoH to cover around half of the requirements for the Office. In the first phase there should be around 100 to 150 people, but this did not cover the full scope. It would be nationally located in its upstart due to transport costs and staff. Once the body was established, it would make sense to branch outwards to ensure objectivity. It was not envisioned that there would be a provincial inspectorate, as this would contradict the purpose of the body - to be objective. Preliminary work on the organogram had been done internally, but the Office was ‘in transition phase’ until such time as the legislative process had run its course and the Act had been approved by Parliament.

Mr D Kganare (COPE) commented that the briefing proposed that the Bill was a precursor to the NHI and created room for the Office. His concern was that the Office was not implemented since 2003 and was now being implemented because of NHI, which was a separate issue.

Dr Ramokgopa replied that although not all sections of the 2003 Act had been promulgated, initiatives had been put in place to prepare for promulgation of the Office. A regulatory framework with accreditation of institutions was necessary to ultimately ensure mandatory compliance and to protect the public.

Ms M Segale-Diswai (ANC) asked what qualifications were required for appointment as CEO.

Dr Ramokgopa replied that Section 7A and D referred to what was fit and proper and the functions and responsibilities of the CEO. This would guide the expected competency of the CEO.

Ms Segale-Diswai suggested that the Committee be given time to revisit and understand the Bill, clause by clause. There were definitions which were unclear, such as what exactly was meant by Environmental Health Officer.

The Chairperson agreed that each Member should be given the opportunity to understand the Bill by heart. While the DoH presented the Bill, it was the Committee that had to convince the other caucuses of Parliament, communities and stakeholders that the Bill should be passed for the benefit of the people in the years to come.

Ms B Ngcobo (ANC) wished to add that there would be legal advice throughout debate on the Bill.

Mr G Lekgetho (ANC) asked what the difference was between a health officer and inspector.

Dr Ramokgopa replied that by law, the Environmental Health Officer’s duty was to reduce the risk of disease based on environmental problems such as pollution and compliance of restaurants for public safety. The Inspectors dealt more specifically with patient care. The document attached listed the seven areas that the Inspectors would assess for compliance. The Ombudsman Office would deal with complaints related to the work of the Environmental Health Inspectors and Officers.

Mr Lekgetho asked when it was expected that the President would annex the Bill into law

The Chairperson responded that the time depended on how soon Parliament passed the Bill.

Ms Ngcobo asked what duration of time the Ombudsman would hold office.

Dr Ramokgopa replied that Section 81 A outlined the appointment of the Ombud - appointed by the Minister for a non-renewable 5-year term.

Mr Lekgetho asked how prices of the private sector would be regulated.

Dr Ramokgopa replied that this was a global concern. They were well above inflation rates and affordability levels of the population. The consumer should be allowed to shop-around for the best price for a commodity to regulate price, and the industry would be responsive to offer value for money. However, health differed in that people went to the nearest health facility during emergencies and illness was not a choice. For the public’s benefit and to make healthcare more accessible to all citizens, it was necessary to regulate healthcare costs according to what was reasonably affordable.

Ms T Kenye (ANC) was concerned that there may not be enough public comment around compliance and accountability. For example, the South African Nursing Council and other professional bodies were always receiving complaints from patients.

Ms B Ngcobo (ANC) agreed that it was not clear what type of responses were received from the private sector.

Dr Ramokgopa replied that after the Bill was published for comment, there had been extensive discussions in the health sector and a number of fora had been presented with the Bill. This information could be made available to the Committee. Comments listed in the presentation were only those which were written comments. However, by no means had public consultation been exhausted and according to the constitutional and legislative framework, the Bill still had to go to the NCOP and provinces for public comment. It was necessary for the DoH to engage with sister departments on the impact of the regulation on sister sectors while advancing the health interest of the population. The relevant Ministry responsible for the Competitions Law had been approved and discussions had been held to highlight the health sector specifically in terms of the Competitions Law. The process was underway.

Dr Marshall added that all comments received were available for the Committee, as well as a summary of all issues that were raised, including those which disagreed with the policy direction.

Ms Segale-Diswai asked how the ordinary people and nurses at rural clinics would be trained to understand and comply with the norms and standards.

Dr Marshall replied that DoH was finalising a campaign directed toward users of services and frontline healthcare workers around standards so that concepts were clarified for those target groups.

Mr Lekgetho said he was concerned that verbal complaints to the Ombudsman would be abused, as they were often made emotionally. A written complaint would be more professional.

Ms Kenye asked what mechanism would be in place to ensure that the complaints were acknowledged.

Dr Marshall replied that although the Bill did not specify the operational process, some of the processes were unfolding within the mandate of the DoH. In terms of the complaints, anyone could make a complaint, and at the point of the complaint being investigated, it would need to be put in writing. Internationally, the Ombud did not investigate every complaint. There was a process of selection before the full weight of an investigation would be carried out. Thus, while the call centre may be inundated with complaints, they would not all filter through to the Ombud. If complaints related to another mandate or province, they would be referred.

Dr Ramokgopa added that the Ombuds Office would complement the various complaints systems which had originated after introduction of the Patients Rights Charter and other quality assurance measures. There should be recourse. However, to reduce the avalanche of complaints at the Office, the local manager in charge would be given an opportunity to intervene first - whether at ward, clinic, receptionist level. The Office would be available as the last resort, once issues had been escalated beyond the municipality and province to national office and would insist that inefficiencies were corrected, institutions improved their systems and that the patient’s complaints system was fully functional.

Dr Marshall added that there were provisions in the Bill that provided for the Office to contract people to assist with carrying out its function. Thus the Office could institute community members to monitor and collect information on how services were experienced, as a pro-active measure – so as to relieve the need to complain.

Ms Kenye asked how DoH would monitor standard compliance and accountability across the public and private sector and how the policy would be enforced.

Dr Marshall replied that a workshop would be helpful to explain how compliance of standards was monitored. There was concrete methodology and detailed measurement for verification of each standard. Although these standards were not yet prescribed standards, nor mandatory in law, Inspectors were being trained on the National Health Council standards. They would be monitored by obligatory daily reports from establishments on a number of risk indicators and also through the type of complaints received.

Ms Dube asked who would defend the healthcare worker against the patient dispute to the Ombudsman.

Mr Kganare asked if the revenue collect by the Office from the public and private sector would go to the Office or to Treasury. He also asked for clarity on ‘the Minister would prescribe fees to be paid to the Office for services rendered’ as well how, in establishment of the Office, revenue from private and public sector would ‘progressively offset costs’.

Dr Ramokgopa replied that DoH envisioned that facilities would receive an allocation from the system as well as charge for fees and that certified facilities would comply with audits in terms of the financial norms and standards. This would make the institute more sustainable. There was provision for state revenue but they should also be empowered to collect fees and use fees generated from services to continue their work. Should there be a need to modify the finance structure, the process would be guided by the Minister of Finance.

Adv Pholelani Khumalo, DoH Acting Chief Director: Legal Services, added that the entity - the Office - was classified as a public entity and would keep fees rendered for services. If it was a government component, it would not be eligible to keep fees.

Mr Kganare asked if the Office would replace the Council for Health Service Accreditation of Southern Africa (COHASA). This question did not relate to the Bill.

Dr Ramokgopa replied that contractual and transitional issues would be revisited. However, once enacted, the Act would take precedence.

Ms Dube asked who would be eligible to apply for a warrant to perform investigations and who would issue the warrant. She was concerned that there may be abuse of power.

Adv Khumalo replied that the head officer or inspector may apply for a warrant and a judge or magistrate would issue the warrant. It could take one day. The inspector would make an affidavit under oath to state reasonable grounds that he or she believed that there had been contravention of the Act at a premises. If the judge was satisfied that the grounds were reasonable, a warrant would be issued.

The Chairperson thanked the DoH for their passionate presentation and said that the legal advisors would assist the Committee with input that was required.