National Health Insurance (NHI) public participation: way forward

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13 October 2020
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Video: Portfolio Committee on Health 13 Oct 2020

More than 64 000 written submissions were received on the National Health Insurance Bill  after the call for comments in August 2019. There had been an agreement by the Committee in the previous meeting that an external service provider should sort and analyse the submissions received. Committee members had submitted proposals for the terms of reference which were presented at this meeting. The service provider should preferably be a reputable research institution using parliamentary procurement procedure with the main deliverable being an analytical report of the written submissions. The final draft report should be presented by 24 February 2021. This matter had general consensus.

The Committee agreed there were three elements to the NHI Bill public participation running concurrently:
- Provincial public hearings with ±900 oral submissions: this report by staff was ready for consideration
- Written submissions for analysis by an external service provider
- Virtual oral submissions by about 121 organisations heard from November 2020 to February/March 2021.

The Committee Chairperson committed to returning with a proposed schedule by the 16 October with timelines for the concurrent processes to ensure they had meaningfully engaged with all submissions and that the deadlines were upheld. The Committee would met later in evening for an urgent briefing by the Minister of Health on amended regulations on the National Health Act.

Meeting report

National Health Insurance (NHI): terms of reference for analysis of written submissions
Dr Nyiko Bandi, Unit Manager: Committee Support Services, summarised what had been discussed and requested at the 2 September 2020 meeting. In response to the August 2019 advert calling for comments on the National Health Insurance Bill, the Committee had received about 64 000 submissions with approximately half being emails and the other half being hard copy submissions. Due to capacity constraints, the Committee had been requested to consider an external service provider to process these submissions. Should a service provider be agreed to, it should preferably be a reputable research institution and the process should be based on parliamentary procurement procedures.

Dr Bandi said the main deliverable should be an analytical report of the public submissions. Approximately 100 submissions had already been dealt with by Committee staff and the service provider would continue from this point. Parliament ICT support staff had also conducted a voting poll via e-mail. A concern had been raised by Members about security. A new deadline was proposed for processing the submissions, extending the process by approximately one month. The final draft report should be presented by 24 February 2021. It was thus critical to give the service provider enough time to process all the submissions from October 2020.

Dr P Dyantyi (ANC) referred to the proposal at the 2 September meeting that Members and their political parties should submit in writing what they would like to see in the terms of reference for the external service provider. This presentation was the result of what Members had contributed. He suggested the Committee move forward with what was suggested if nothing had been omitted from what they had submitted.

Mr K Jacobs (ANC) appreciated the inclusion of the security concerns and the time frames. He was slightly concerned about the scheduled vacation in the schedule, but understood it was factored with mindfulness of the December holiday period. He suggested that the Committee agree to the terms of reference as he did not have any concerns with what was presented.

Ms S Gwarube (DA) said that there had been an agreement by Members at the previous meeting to have a service provider sort out the submissions received. This was not an issue. The manner in which the Committee would handle the work done by the service provider should be the emphasis of discussion in this meeting. She acknowledged the timelines put together by parliamentary staff. The presenter mentioned that oral submissions would not form part of the service provider’s work – how would these be sorted? She recalled 900 oral submissions were made during the provincial hearings and asked if these would be sorted per province and in a manner that Members could see. A compiled report was required.

Ms Gwarube’s second concern was the notion that both oral and written submissions could be sorted simply as ‘for’ or ‘against’ the Bill – this was a “very dangerous path to go down”. Many individuals who had made submissions did not respond with a “yes” or “no” – this was not the question. Written submissions in particular had arguments where support might have been shown for the Bill in principle, though with concerns. Could Parliament explain how these substantive comments would be factored in? If an ICT person was sifting through the submissions as “yes” or “no”, this was a non-comprehensive oversimplification. A number of organisations and individuals had taken the time to write submissions. Simply sorting them out into yes/no categories was insufficient. Each submission needed to be analysed and concerns noted. Finally, she was concerned about the briefing to the service provider. This was for political parties to oversee not the committee whip. Members should be in attendance to ensure all terms of reference were properly understood.

The Chairperson said the staff might have a limitation in replying to her questions. A spirit of transparency had always been relied on in the Committee. Legal challenges could be brought later about this and he confirmed that the briefing to the service provider would be done collectively. Ms Gwarube brought up the provincial oral consultations and the Committee had not seen a report on these hearings. He believed this needed to be dealt with, to view the report and check that it correlated with what Members had heard in the provinces. The staff had prepared a report on these which Members needed to interrogate. Ms Gwarube was correct that the written submissions were not simply a “yes” or “no” matter. Rather, those comments needed to be more deeply understood. This had prompted  the Chairperson to separate the public country-wide hearings and reports thereof from the written submissions. Consideration of the report on the provincial oral consultations would be a separate meeting, possibly over a number of days. The Chairperson wanted Members to focus on the current meeting for the time being.

Ms N Chirwa (EFF) was disappointed by the outsourcing of this task, when Parliament was the appointed  place where laws were made. Such a service would always be in demand in Parliament. The fact that there needed to be outsourcing indicated that there needed to be a internal unit within Parliament for handling public submissions.

Ms Chirwa firmly agreed with Ms Gwarube that submissions were far more nuanced than a simple “yes” or “no”. Even those who had agreed with the Bill had reservations which would not necessarily be covered with a quantitative capturing of a yes/no sentiment grouping. For example, those supporting the Bill might have raised concerns on how infrastructure or human resources would be addressed in already existing public facilities. This was not fully covered in the Bill. Some were supportive of the Bill, but had concerns with the referral system as per the Bill. This indicated how the Committee needed to decipher the terms of reference and way forward to ensure the best possibilities were captured. There was a key factor that between those who indicated support or non-support for the Bill had given the same clauses and/or concerns in their answers. It was important not to lose these important submissions. She asked if multiple signatures on a single submission were counted as many or one.

The Chairperson replied that the outsourcing had been agreed to.  If the Committee continued the work with only its internal staff at its current capacity, it would still be busy with the same work in two years’ time. This is what informed the outsourcing request. The other issues raised by Ms Chirwa would be clarified by staff.

Mr T Munyai (ANC) said that first and foremost, Members should not be allowed to misrepresent the outcome of the public hearings, or attempt to manipulate the hearings with misrepresentation. There were individuals that had said yes in support of the NHI Bill, and those who had said no. Members should not attempt to spin the voices of the people on the NHI.

The Chairperson interjected to request that this not be analysed.

Mr Munyai maintained that he was not analysing, but was referring to some Members who had spoken prior to him who had attempted to say people did not say yes. What was this? It was not true.

Ms Chirwa raised a point of order that Members should not be manipulated by Mr Munyai. He should state the name of the member to whom he was referring, and state at which point a Committee member said nobody said yes to the Bill. This made it obvious to Ms Chirwa that Mr Munyai was not present earlier on in this meeting, and was simply speaking for the sake of speaking. It is evidenced by the fact that his hand went up late to speak in this virtual meeting. A Committee member did not say that no one said yes in the hearings. She challenged him to state the name of the person he was referring to instead of “throwing shade”. The Committee was handling very serious business and did not have time to address the nuances of what people had the right to speak about. It was known that people had said yes, others had said no – and they had stated their reasons.

Mr Munyai said Ms Chirwa was on record saying people might not have said yes, or those who said no might not have said no.

Ms Chirwa said this was a lie. She requested Mr Munyai withdraw his statement, as he was lying in her name. He was being a “liar”.

Mr Munyai told Ms Chirwa not to be dramatic.

Dr Dyantyi requested the Chairperson handle the Members.

The Chairperson warned Ms Chirwa that she was not to speak if unrecognised. She had made a point, which the Chairperson listened to, though she came back into the discussion unrecognised. He requested Mr Munyai to continue speaking.

Mr Munyai continued by expressing his full support for the proposal put forward by the Parliament staff on the terms of reference. This was the way to go forward. He would not answer the rest as it was hogwash.

The Chairperson requested Members to refrain from using words such as hogwash. He asked that respect be shown to Members.

Mr Munyai responded that he had been called a liar, which was nonsense.

Ms Chirwa said that if he was lying, he would be called a liar. If he stopped lying, he would stop being called a liar. She requested the Chairperson address Mr Munyai lying in her name, as they wanted to move on and deal with serious issues.

The Chairperson urged Members not to speak when they were not recognised, otherwise the meeting would not be handled properly. He left the matter and called on Mr Shaik Emam to speak.

Mr Shaik Emam appealed to his colleagues that they maintain the dignity and decorum of Parliament in the meeting, especially as they were televised. He welcomed the report on processing the NHI submissions, and thanked the staff and Committee for the work done on the terms of reference. The NHI was part of the livelihood of the people of South Africa, many of whom had been deprived of universal healthcare for a long time. His only concern was the number and size of the submissions by individuals. He also had queries about public participation in the country. There were those that could afford to bus and taxi people to these public hearing events. However, very often, a large percentage of vulnerable people are left out of these hearings. Considering that many submissions had been made, and the Committee would conduct oversight to ensure whatever was done did in fact happen in the best interests of the Bill. He supported the proposal wholeheartedly.

The Chairperson was to have an urgent call with the Minister and requested Dr Dyantyi chair the meeting until he returned.

Due to poor network, Ms Gela commented in the chat of the virtual platform: “I am supporting the Terms of Reference 100%”.

Ms H Ismail (DA) referred to the public hearings consultation. While Members had agreed that there would be a service provider, it was essential not to disregard inputs by persons that had come to have their say at the public hearings. While all written submissions and petitions would be dealt with, she felt they were disregarding or side-lining the participants in the public hearings if these inputs were dealt with in a separate process. This was defeating the process of a public hearing. As such, she felt the terms of reference should refer to all aspects of the inputs given. This would ensure that participants may have said that they agree with the NHI but with certain conditions or concerns, this would be taken into consideration. If all the input was not taken into consideration, they would be doing a disservice to the initial reason for the public hearings. She agreed with Ms Gwarube that clarity was needed on how this would be addressed. She also asked about petitions, which might have been handed in by one person, although hundreds of thousands of signatures were on them. She wanted clarity that each and every signature would be regarded as a public participation input.

Dr Dyantyi clarified that all were on the same page about the role of the external service provider. She was under the impression that the full analysis would be provided by the service provider - which individuals had said yes or no with the reasons collated. This is also what was to be provided in the Committee report on the public hearings.

Dr Bandi confirmed Ms Dyantyi was correct. Data analysis included the reasons for supporting or not supporting the Bill. He requested that the Content Advisor, Ms Lindokuhle Ngomane, display the terms of reference (slide 3) for clarity. Point two clarified stated an analysis of the written submissions and writing of a report on the substance of the submissions. The analysis was also to provide Parliament with information on who is for or against the Bill, their reasons and recommendations where applicable – this spoke directly to matters raised by Members.

Ms Ismail pointed out that written and verbal inputs were not specified and requested that verbal inputs be added to resolve the clarity sought.

Ms Gwarube asked how written submissions on behalf of groups would be analysed. Some NGOs had submitted thousands of views, both varying and alike – how would this be counted? This was an important distinction. It could not be reported as one organisation’s submission, when in fact inputs were received from 10 000 people, for example.

Ms Gwarube agreed with Dr Dyantyi that there was slight confusion around the process and which submissions were being considered. According to Ms Gwarube, there were three elements to the submissions. The first was oral submissions, which had been received from ordinary South Africans across the country. They still needed to decide how these would be analysed, compiled and reported to have proper oversight of that process. The second was the written submissions, which Dr Bandi needed to explain how they would be grouped. If they were to be indexed – how so? The last element was the Committee would listen to oral submissions given by organisations in Parliament, which still needed to planned and held. Before this meeting was over, they needed to clarify exactly how the first two elements would be dealt with.

Ms Ismail added on the platform’s chat that she agreed 100%.

Dr Bandi said Ms Gwarube was correct. There were three elements to the submissions. The first was the oral submissions conducted nationally. As they had indicated, there were reports for those submissions which had been analysed. Public hearings in each province had its own report. There was also a consolidated report on the oral submissions which consolidated the input of public in all the provincial public hearings. The Committee might decide it wants to consider this consolidated report. The overall report, however, would cover all three elements: the provincial public hearings report done by staff; the written submissions report by the external service provider; and the report on oral submissions yet to be conducted in Parliament. Members needed to consider this.

Dr Bandi replied about submissions on behalf of a collective or multiple people, saying the qualitative research approach meant that the sentiments would be captured, but they had not yet decided whether the signatures on a report would each be captured as a submission on its own. At this stage, they were simply reflecting on all the submissions received for the purposes of transparency. How submissions would be defined would be looked at - at a later stage.

The Chairperson suggested Ms Gwarube’s point be raised in a platform outside the meeting. He wanted to discuss the Parliament oral submissions as the next item. He suggested Members agree that there would be a committee meeting in which they could dissect the provincial public hearings report. They had the sense that Members wanted this as a separate, standalone item before getting a comprehensive report on the NHI submissions. If they agreed, it would be fine.

The Chairperson suggested that the Management Committee propose the timeline. They had thought that they would be ready to hear the 121 organisations and institutions that wanted to make oral submissions in October by the decision to hear department performance reports had hampered this. Thus, they would begin in November while the terms of reference process was running in parallel. The Management Committee would seek tentative dates to listen to these institutions, starting in November and finish around February/March at the same time the draft report on the written submissions would be concluded. This meant that before Parliament rose in December, they would have started. He asked for feedback on his suggestion of the proposed timeline.

Mr Munyai referred to the written submissions report and said it needed to be compiled by a company that did not have a publicly expressed view on the matter to avoid any conflict of interest.

Dr Dyantyi spoke to the proposed timeline for oral submissions in Parliament. In the previous meeting, time frames had been given. It seemed that an October time frame would no longer work. She agreed that a programme be drawn up for that. Even within the report, information needed to be collated and analysed.

Ms Gwarube did not want the meeting to adjourn without everyone being on the same page. It was important to clarify the way the processes running parallel would be dealt with. When would the anticipated provincial public hearings report be presented to the Committee? In their discussion of terms of reference, there was still ambiguity about what constituted a submission. Dr Bandi had indicated they would decide what constitutes a submission, such that processes could run parallel. She was very uncomfortable with this, as South Africans had always been under the impression that they could make a submission in various ways. To retrospectively change what would be considered a submission could get the Committee into trouble. They needed to decide as lawmakers what constitutes a submission so that even if the process was happening parallel – which she agreed it should – all could be assured the matter had been dealt with.

Ms Gwarube agreed that the Parliament oral submissions need to start in November without waiting for the service provider to finish its work. However, she was concerned that concurrent processes were running without any of it being completed, which seemed haphazard. She asked the Chairperson for some guidance.

The Chairperson clarified the process he was suggesting. The first meeting would be the consideration of the provincial public hearings report, starting in Mpumalanga and finishing in Gauteng (with reports received two days before). Members would go through these reports, as presented by parliamentary staff, which might not be completed in a single sitting. The Committee's inputs for additions and subtractions to the provincial public hearings report would be attended to by staff and the report revisited two weeks later to perfect it. There would thus be an assurance within the Committee that the matter was not parked, but that those inputs would be processed. He did not understand what Dr Bandi was saying about deciding which submissions would be regarded as submissions. The written submissions report would be presented at the end of February as indicated. If they started the Parliament oral hearings in November, they could alternate those hearings with meetings to review the provincial public hearings report. He asked if there were any amendments to the proposal going forward.

Mr Munyai said that what was not submitted to Parliament directly to the email of the Committee Secretary could not be construed as a submission. What did not come directly to her could not be accepted.

Ms Gela indicated on the chat platform that she agreed with the Chairperson’s proposal.

Ms Dyantyi agreed to the proposal. She wanted to know if the public hearings report was ready. They could consider the report which would probably not be finished in one sitting, unless they were allowed to take an entire day (which was unlikely to be acceptable to Parliament).

The Chairperson requested two days to consult with management on the length of that meeting. In principal, if Members agreed to the proposal, a meeting would be scheduled soon. He asked the Committee Secretary about the readiness to present the report.

The Committee Secretary confirmed that the report was ready to view.

The Chairperson said it was necessary to schedule the meeting soon since the report was ready for inputs.

Ms Gwarube was glad that the report was done. This meant they would be able to conclude the first element of the process. It was the Chairperson’s prerogative to decide how this would work, but she did not think they would be able to get through all nine provinces in one day. She was assuming that the provincial hearings report was divided into Provinces. The Chairperson and his team could devise a programme which took into consideration the reports of the nine provinces and the timeline for the Parliament oral hearings. She wanted to clarify this to ensure the timeline was realistic.

The Chairperson requested that the management committee be given until Friday 16 October to submit a programme to Members on how the provincial public hearings report would be broken up for meaningful engagement. In the meantime they would prepare for the Parliament virtual oral hearings and notify organisations and institutions in advance to invite them make their submissions.

The Chairperson requested Members to indulge an extraordinary point, which had not been on the agenda. Members were requested to meet at 20h00 that night for an urgent meeting on the National Health Act regulations. The meeting would last for about 90 minutes with the Minister. It was not usual for the Committee to be consulted on regulations from the Minister. However this matter was so critical, that the Minister needed to have it before Committee as a matter of urgency. Members were formally invited to the briefing on an urgent matter by the Minister.

The meeting was adjourned.


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