National Health Insurance (NHI) Bill: public hearings day 2

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19 May 2021
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Video: Portfolio Committee on Health

NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee continued with day 2 of public hearings on the NHI Bill. Four organisations presented oral submissions.

All the entities indicated that they supported the principle of NHI, welcomed the introduction of a single payer system and looked forward to the realisation of universal healthcare coverage. There was agreement that the biggest achievement of NHI would be to try and achieve equity of distribution of financial resources that went into healthcare. There was a need to ensure that the skewed distribution, where the wealthy got the greatest benefits because they could afford them (through medical aid), was distributed more fairly across the population.

Notwithstanding this, they proposed a number of amendments to improve the Bill.

The Public Health Medicine Specialists and Registrars highlighted that the next phases of NHI implementation will require health system strengthening as well as the establishment of core processes and institutions. PHM specialists, by nature of their work, are able to play a role in multiple settings simultaneously to achieve these goals. They argued that efforts should be made to include PHM Specialists in the processes as well as to allow for PHM registrars to undertake work within the NHI in order to contribute to the process whilst gaining experiential knowledge that would be beneficial to the NHI once they have completed their specialisation.

The Public Health Association of South Africa said that the NHI Bill as currently formulated is essentially a standalone, independent piece of legislation, largely unrelated to much else in the National Health System. The Bill would be much improved if the financing mechanism underpinning the provision of the NHI were better located and explicitly linked to the National Health System, specifically in reference to the National Health Act, which is only mentioned briefly in the annexures together with other legislation that requires amendment. The National Health Act [61 of 2003] and the White Paper for Transforming Health in South Africa 1997, were foundational documents in formulating the rationale for the NHI Bill and they should work together to give effect to UHC, which the NHI Bill cannot do on its own. The entity suggested that sections of the current Bill that touch on arrangements not directly related to the establishment and maintenance of the Fund should either be removed, or that the level of detail around these other arrangements be reduced; to allow more time to consider the most effective proposals and to allow for learning from experience to decide on best potential future models.

The Oral Health and Dental Schools said that NHI should be the only funding mechanism for health in the Republic, replace all other funding mechanisms for health and take over from Medical Schemes. It also proposed that the Medical Schemes Act must be repealed in its entirety.

The SA Human Rights Commission expressed concern that the Bill further limits access to healthcare by asylum seekers in South Africa. It argued that the success of the NHI will, depend on, among others good governance. Therefore, the powers and function of the Chairperson, Deputy Chairperson and members of the board are crucial and thus need to be clearly set out in order to avoid conflict and ensure an efficient Board and assist in the decision-making process. The Commission was further concerned about the appointment process of the Board and its reporting lines. It highlighted that the proposed governance structure places concentrated power on the Minister and does not adequately ensure the independence of the Board, which is essential given its extensive powers, including strategic purchasing and the buying and selling of property.

The Committee asked why some organizations insisted on explicit inclusion in various sub-structures, as mentioned in the Bill - when they were an integral part of the health system. In addition, they asked about asylum seekers and their access to healthcare; facilities that did not meet standards; the independence, appointment and term of the proposed Board and if organisations believed in social solidarity or if they were comfortable with the current two tier system of healthcare – one for the rich and one for the poor.

Meeting report

Public Health Medicine Specialists and Registrars (PHMSR) presentation
Dr Shrikant Peters, Public Health Medicine Specialist, working as Medical manager at Groote Schuur Hospital and Dr Atiya Mosam, Public Health Medicine Specialist based at the University of Witwatersrand School of Public Health, presented to the Committee.

Advised structures and roles to build Public Health capacity and strengthen the implementation of NHI:
-Provincial PHM Intelligence Units, linked by Service Level Agreements to tertiary academic Schools of Public Health, must be established in each province, which are able to provide outreach and support to health districts requiring analysis of local burden of disease, health information management, monitoring and evaluation of healthcare service delivery, co-ordination of healthcare quality improvement and healthcare outcome measurement. At this level, PHM Specialists are also able to provide technical advice and support to National, Provincial and Health Programmes Managers and Directors.
-Central and Regional Hospital PHM Specialists should be appointed to monitor and evaluate service delivery and bridge the translational gap between the clinical and corporate functions of the hospital, strengthening decentralised governance structures. Currently, with the hospital-centric nature of healthcare services, in South Africa, many regional, tertiary and central hospitals have micro-complexities (along specialist services). There is therefore a need for PHM specialists and registrars to facilitate common objectives between corporate (i.e. business of health care) and health care service delivery through their day-to-day tasks within such institutions. They are equally capable of demonstrating dual reporting functions to clinical HOD’s of general and specialised departments, and to clinical executives. This competence aligns the coordinated efforts of service and support staff to achieve unit-specific and departmental objectives within an iterative implementation, monitoring and evaluation framework.
-District PHM Specialists should be appointed to the District Clinical Specialist Team (DCST), where they will play a critical support role; by bi-directional, continuous translation of pharmacy, finance, and supply chain procurement information to the clinical work of the DCST, and provision of mapped burden of disease, health services and healthcare outcome data to the District Health Management Office and it’s Contracting Units for Primary Health Care, by providing evidence based Public Health intelligence to inform healthcare purchasing and priority decision-making.

Clause 13(5)
-PHM Specialists have expertise in health care service financing, health economics, public health planning, monitoring and evaluation and would be suited as either candidates for appointment to the board or as ad hoc advisory members tasked with appointing suitable board members.
-SUGGESTION: Efforts should be made to include PHM Specialists in the NHI processes.

Clause 25(2)
-PHM Specialists have technical expertise in all the fields highlighted in Clause 25(2). Furthermore, they have trained within the healthcare service and are familiar with service delivery requirements at all levels of the health system. They are thus able to merge technical expertise with real world scenarios in the development of health care service benefits for the population.
-SUGGESTED EDIT: “[…] consist of persons with technical expertise or specialisation in public health medicine, medicine, health economics, epidemiology, and the rights of patients […]”

Clause 26(2)
-PHM Specialists have expertise in epidemiology, health management, health economics, health financing, and rights of patients and are thus able to contribute technical expertise to this committee. SUGGESTION: Efforts be made to include PHM Specialists in the processes highlighted above
-SUGGESTED EDIT: “[…] expertise in actuarial science, medicines, epidemiology, health management, health economics, health financing, labour and rights of patients, and public health medicine, and one member must represent the Minister.”

Clause 27
-PHM Specialists are well placed to provide a coordinating role between the various stakeholders highlighted in this section.
-SUGGESTED EDIT: “[…] associations of health professionals, providers, patient advocacy groups and public health medicine in such a manner […]”

Clause 36
-Given the cross-cutting competencies held by PHM Specialists (as highlighted above), PHM Specialists would be a valuable addition to the District Health Management Offices (DHMO).

SUGGESTION: DHMO should be headed up by, or include a PHM Specialist which can support the DHMO and the DCST.


Clause 37
-Epidemiological profile analysis of health districts is a core function of PHM Specialists. A District PHM Specialist should be mandated to perform this function in each health district, and thereafter assess referral system functionality, and inform the design of health service benefits for the district.
-Suggested inclusion 37(2) “The Contracting Unit is comprised of a district hospital, clinics and, or community health centres and ward-based outreach teams, private primary service providers organised in horizontal networks within a specified geographical sub - district area and with the support of the District Public Health Medicine Specialist, must assist the Fund to-…”

Clause 57(2)
-The next phases of NHI implementation will require health system strengthening as well as the establishment of core processes and institutions. PHM specialists, by nature of their work, are able to play a role in multiple settings simultaneously to achieve these goals. There are currently 81 registered specialists in South Africa with registrars completing training on an ongoing basis and these resources could be harnessed for the health system strengthening aspects of the next phases.
-SUGGESTION: Efforts should be made to include PHM Specialists in the processes highlighted above as well as to allow for PHM registrars to undertake work within the NHI in order to contribute to the process whilst gaining experiential knowledge that would be beneficial to the NHI once they have completed their specialisation.


(See Presentation)

Mr M Sokatsha (ANC) stated that doctors had indicated that they were part of the system of the Department of Health – why did they insist on explicit inclusion of public health medicines specialists in various sub-structures, whilst they were an integral part of the health system?

Mr T Munyai (ANC) asked whether the entity believed and supported the principle of social solidarity. Did they believe that the proportion of the funding should go public or should it be tax funded (i.e. NHI funded from tax revenue).

Dr K Jacobs (ANC) asked why they thought there was a need for themselves having to, with respect to every clause, emphasise the need for public health medical specialists to be part of the units. It seemed like they were mostly there to promote that – the Committee understood that there was a role for every single specialist, medical doctor and healthcare workers to be employed within the system and to participate in making meaningful differences to the country. Were there any other specific issues that they wanted to raise or comment on in relation to the Bill specifically? The comments made were helpful – he wanted to find out whether they had made submissions to the National Department of Health (NDOH) which would also assist to take things forward.

The Chairperson noted the presenter had started by making reference to the Gluckman report. He asked whether the presenter could help the Committee to understand its relevance to a universal health approach in society. In terms of the current arrangements of the health system – were they able to close the gaps they found within the current system? Or would a different health system allow them to close those gaps?

Ms A Gela (ANC) asked whether the entity supported national health insurance (NHI) or not. Why did they insist on the inclusion of public health medicine specialists in various sub-structures while they were an integral part of the health team?

Dr Peters responded to the question regarding the specific inclusion of public health medicine specialists. Most public health specialists in the country were employed – they struggled to find people to fill posts that were available. The problem was not that they did not have roles to fulfil, the problem was that the roles were not standardised in the country. One would find public health medicine specialists doing fantastic work in various fields. There was a problem in standardising the function of public health medicine specialists. Specifically in standardising functions to the value of the district health system and the value of the system envisioned under NHI, where the districts were capacitated to fulfil the role of planning, monitoring, evaluation and epidemiological analysis. They felt they would be pivotal in those roles. Currently, there was no mandate to have district public health specialists. That meant that the urban centres and those that were closely linked to the universities in Johannesburg, Pretoria and Cape Town had public health medicine specialists advising the chief directors of different districts in health. They did very good work; they understood the burdens of disease and understood how cost effective or ineffective the districts were. They gave input into supply-chain management for the districts and for facilitates, but they were not present in all health districts of the Country. The districts that required public health specialists the most – were the ones that did not have them – this was the case for rural and smaller health districts across the country. They were doing ‘fantastic’ work in a very small number of districts and he agreed that they were an integral part of the system but they were not standardised in their approach. He suggested that the work that they did should be standardised under the NHI system of district health services.

He clarified that the entity believed in social solidarity and public and private funding toward public healthcare. Everyone had their own range of opinions but those in social medicine and preventative medicine erred toward public funding of services and equitable distribution of healthcare. He did not think there was any public health medicine specialist who would not be supportive of tax funding for the public health sector. As a doctor and a public health specialist, there was the cost argument, that not enough money was spent in the public sector as opposed to the private sector. They also had the intuition to know that the money they were spending on the public sector could be used more effectively and efficiently. It was not just a resource argument. Simple re-arrangements in supply-chain management, finance and pharmacy as well as audit measures in facilities to understand morbidity and mortality could improve the system at current levels of financing. Obviously, they would support more financing through taxation.

In terms of why they had made mention of themselves throughout the document in various clauses, the difficulty was that they fulfilled a lot of functions. Functions such as systems management, service and design, epidemiological analysis, burden of disease studies, top-down management, strategic advice and economic evaluations of healthcare services. The fact that they were mentioned so many times in their submission was actually a function of what was being required of the health district as a unit of the health system. As units of the healthcare system, they need to be able to procure, analyse burdens of disease and ascertain at the local district level what the quality of care was that was being provided. If there were deficiencies in that quality of care, they needed to be able to improve them. There was a lot expected of them within the health district model – looking at the NHI documentation – that was definitely where they wanted to go. A fund that would be paying money to health districts needed to know that the district was functional in all of the items necessary to run a health service. Public health specialists had that functionality, which had been employed at a national and provincial level, the district required a public health specialist to capacitate itself to perform all those functions.

They had submitted to NDOH prior to the initial submissions in 2018 – he agreed that it was very important to engage with the Department. They were busy engaging with the NDOH in terms of training for registrars – it would be extremely important to engage them further.

He responded to the question regarding the Gluckman’s report of 1945 and whether they would be sitting in a different position/world had they applied it. At their annual conferences in public health, they had the ‘Gluckman speech,’ they looked back at past planning, where health administrators in the system (as there were no public health specialists at the time) were known as ‘medical officers of health.’ They longed for a system that would provide public healthcare but also looked at the wider systems of social determinants of health. They were, realistically speaking, moving into a very difficult period in the country’s history, in terms of the pandemic and the financial situation in the country. They needed to provide good quality care and provide good value of service. The money they spent on healthcare should be done appropriately. They could not allow the second point from the Gluckman report to occur – ‘hospitals should not be costly monuments to the failure of preventative services.’ It was in the 1940s and it was now.

Preventative services meant everything from making sure the education system was working, making sure they had safe communities and policing, security, hygiene etc. They could not only look at healthcare. Public health specialists played that role at the district level – it was important at the district level because they needed to integrate service providers and local government structures to truly influence and impact the health of people. They could not just cure people, they needed to prevent disease.

That report was ultimately never put into place as apartheid was instituted. The focus on nutrition, health, housing, education and caring for people in communities and understanding local area burden of disease went out the window. A dual system was applied of tertiary academic excellence for a small section of the population and under-funded primary care and traditional homeland structures for most of the population.

In terms of why public health specialists should be actively involved at a district level – it tied into the vision of wanting a system that had a central fund that procured and purchased services from capacitated district health systems. Capacitated health districts needed strategic advisors, they needed people who understood clinical health delivery and could marry that to supply-chain management and finance.

Mr Munyai asked to understand whether they supported the NHI. This question was raised before – did he support a single-payer, single fund that was based on the principle of equity and social solidarity.

Dr Peters replied that they supported NHI’s model of a single payer and single fund. His rationale for that was that he understood strategic purchasing. The whole aim of NHI being a single-purchaser of healthcare services in the country meant that they would dictate the price they were willing to pay for healthcare. He knew that was pushed back against by many people in the medical profession. They knew intuitively that good healthcare was not expensive. It was not necessary for healthcare to be expensive. There was an inflation in cost in the private sector – it was built on the assumption that there was poor quality healthcare in the public sector – which was not true. Coupled with strategic purchasing one would need to purchase services from a health district that was well capacitated. That was underlying the argument.

Ms Gela regained connection

Ms Gela asked whether they were fully supporting the NHI Bill. Apartheid left them with a legacy of apartheid – NHI needed to reduce the growing inequality in accessing quality healthcare. Did he agree or not with this assertion? Did they support the single payer single fund system?

The Chairperson stated that the issue around the single payer was responded to.

Dr Peters repeated that they supported the NHI Bill and supported the single payer and single fund as a strategic purchaser. The apartheid legacy was that two systems existed – first rate and second rate systems. The aim of the new government after 1994 was to increase access and quality of care to millions of members of the population – so that everyone had the right to health as contained in the Constitution. The apartheid legacy went hand-in-hand with the centralised control and management. Under the new system – they devolved a lot of power to the provinces. Under the NHI, even more power would be devolved to the district level. It went hand-in-hand with increasing access to quality coordinated care in each district of the country. For that reason, they needed decentralised strategic management of health districts. That was what public health medicine specialists would do.

Public Health Association of South Africa (PHASA) presentation
Dr Harsha Somaroo, Public Health Medicine Specialist and PHASA Committee Member,, and Dr Irwin Friedman, Public Health Physician and PHASA Committee Member, made the presentation.

-The aim of the Bill is to establish the NHI Fund in order to fund the provisions of Universal Healthcare (UHC), though the Bill also introduces organisational and structural changes to support functioning of a single purchaser and single payer funding system. Given the uncertainty regarding feasibility of certain proposed structural changes, which we think should thus be given more consideration before being legislated in the Bill; we believe that the Bill establishing the Fund should be written in a way that does not hinder future legislative processes, especially for issues that are not inherently related to financing.
-Thus, we suggest that sections of the current Bill that touch on arrangements not directly related to the establishment and maintenance of the Fund should either be removed, or that the level of detail around these other arrangements be reduced; to allow more time to consider the most effective proposals and to allow for learning from experience to decide on best potential future models.
-The NHI Bill as currently formulated is essentially a standalone, independent piece of legislation, largely unrelated to much else in the National Health System. The Bill would be much improved if the financing mechanism underpinning the provision of the NHI were better located and explicitly linked to the National Health System, specifically in reference to the National Health Act, which is only mentioned briefly in the annexures together with other legislation that requires amendment. The National Health Act [61 of 2003] and the White Paper for Transforming Health in South Africa 1997, were foundational documents in formulating the rationale for the NHI Bill and they should work together to give effect to UHC, which the NHI Bill cannot do on its own.
-There has been an inadequate recognition of the role of population/community/public health medicine in the Bill. This could be disastrous and costly to the health system. Public health professionals, including the discipline of Public Health Medicine (PHM), are a vital resource to assist in the delivery of UHC and need to be recognised as such. While these skills sets are acknowledged in the last Human Resources for Health policy in South Africa, which specified that the role of PHM Specialists and other Public Health graduates in management and strategy should be more explicit, and that the Department should work with universities and the College of Medicine of South Africa to develop related competency and jobs frameworks.
-However, this has not yet translated into career paths for Public Health professionals and PHM specialists. The latter is a field that was created specifically to meet the population health demands of the health system, with graduates having a prior medical training and being certified as competent with regard to preventative medicine, health management, strategic planning, monitoring and evaluation, health financing, policymaking, research, and leadership skills.
-This experience and expertise, in one cadre of human resource, has immense potential to impact the health system and population health if situated appropriately within the health system, which should be a significant consideration during planning for the NHI fund and UHC.
-Occupational health is another arena which provides an example of where non personal services are import. Occupational health deals with all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards.
-The health of the workers has several determinants, including risk factors at the workplace leading to cancers, accidents, musculoskeletal diseases, respiratory diseases, hearing loss, circulatory diseases, stress related disorders and communicable diseases and others.
-Employment and working conditions in the formal or informal economy embrace other important determinants, including, working hours, salary, workplace policies concerning maternity leave, health promotion and protection provisions, etc.
-The Bill should provide finance for the scaling up efforts to provide healthier and safer workplaces and access to occupational health services, and to ensure health coverage for all workers, noting that large numbers of people who develop illnesses and die every year from preventable occupational diseases and injuries.

Chapter 1
-It is recognised that the NHI Bill is aligned with provisions set out in the Constitution, the National Health Act, the Refugees Act, and the Immigration Act, as relates to refugees’ rights to access health care services in South Africa. However, there remains much concern and debate around the lack of full population coverage and the restricted access to healthcare services for asylum seekers and illegal foreigners.
-There are human rights considerations as well as the potential impact of communicable diseases that are not notifiable, including HIV, on overall population health.
-The increase in number of foreigners who are living illegally in South Africa emerged over many years and was due to the interaction of many complex factors. The number of illegal foreigners in the country has been estimated to be as high as approximately 10% to 15% of the current population.
-Notwithstanding the Department of Home Affair’s efforts to fix and strengthen the immigration system; we believe that, given the current context, it would be important at a population health level, for asylum seekers and illegal foreigners currently in the country, to be afforded the same rights as refugees, to access health care services.
-Section 5 on registration of users will restrict access to health care for those who might not have been able to register e.g. due to a lack of documentation identified in section 5(5), which could result in hindering access to health care for the most marginalised sectors of the population, and further entrench health inequity in the country. Access to health care services might similarly be prevented in emergency situations.

Thus, we recommend that explicit provisions be made in the NHI Bill, for how users without documentation will be registered in the system and retain their right to access health care services despite not having documentation.
-Section 6 (o) outlines the right of users to purchase health care services not covered by the Fund, through alternate funding mechanisms. This has implications for the package of health care services that will, or should be, offered by accredited health care providers, and for health care service providers whose scope might fall outside the NHI funded benefits package.
-Additionally, there might be the case where unaccredited providers may decide to offer services not provided for in the Formulary, which could in turn impact performance of the accreditation system, the organisation of health services in a region, and the quality of care provided.
-Ultimately, the lack of clarity surrounding organisation of the service delivery platform and the benefits package needs to be addressed, albeit be via alternate prescripts and legislation, before many decisions related to the rights of users can be appropriately determined.

Chapter 2
-The Bill establishes the Fund as a Schedule 3A autonomous public entity, yet the powers of the Minister are heavily concentrated throughout the structure of the Fund, likely undermining its autonomy.
-The Bill provides for significant centralisation of decision-making power with the Minister, including for very technical issues raising the question of accountability and transparency.
-The Fund should be ultimately accountable to parliament, and the powers of the Minister should be reduced to minimise the risk of political co-option. International evidence has shown the importance of having long-term vision that is not undermined by the five-year political life cycle of a Minister2, and requires leadership that is vulnerable to political motivation.

Chapter 3
-Sections 13 (1), (3), (8), and (9), grant extreme power and authority for appointment and removal of Board members, to the Minister of Health. There are no mechanisms in place to ensure that a Minister is not vulnerable to potential political influences that might lead to politically motivated appointments, rather than purely technical experts, who would be in a better position to provide unbiased and independent oversight.
-International evidence has clearly demonstrated the importance of the clear separation of political and administrative powers across every level of the public health system.
-The Minister’s oversight powers should be reduced or counter-balanced by another authority, such as Parliament. Mechanisms should be specified beyond the public interview process, defined in Section 13 (3), in order to ensure that appointments are not politically motivated, and there should be an open process of appointment, such as that used for appointing the SARS commissioner.

(See Presentation)


Mr Sokatsha noted that the presenter had talked about sections that needed to be removed from the Bill – which sections specifically? How did PHASA expect a CEO to exercise oversight over himself or herself if they were expected to provide governance over the Fund? He asked whether they supported the Bill.

Mr Munyai asked whether they disagreed with the evidence from elsewhere in the world – ranging from China to the United States (US) - that a fee for a service medicine drove up the cost of healthcare and induced unnecessary service use. Did they believe that the amount and quality of healthcare that someone received should depend on their medical need or their ability to pay? How did they ensure more equitable distribution of health workers and service availability, when the prices and the wage paid in the private sector were so much higher than in the public sector? He wanted to establish whether the presenter believed that the introduction of a national healthcare system was neoliberal?

Ms Gela asked whether they proposed that the implementation of the cap on an incremental basis as with all new programmes should be applied. The Bill stated that NHI would be implemented in a phased approach – what was the presenters’ view on this and the understanding of the NHI journey, having started as far back as 1944 with Gluckman. Did they agree that all South Africans should get the health service that they needed, as per section 27 of the Constitution, keeping in mind that section 27 mandated government to take substantive measures to achieve that. How could they ensure more equitable distribution of health workers and services availability when the prices and wages paid in the private sector were so much higher than in the public sector?

Dr Jacobs stated that the Committee was aware there was a section of schedules to amend the National Health Act and there were other amendments envisaged in the near future. Did the presenters have any comments relating to those schedules in relation to the envisaged role of the health districts? The presenters mentioned the medical legal claims – the Committee understood the challenges but it was being addressed by the Department of Health and the South African Medical Association.

The Chairperson stated that there were some people that held extreme views about the asylum seekers – ‘that reference to them should be removed from the Bill.’ The presenters had suggested that what was said about asylum seekers in the Bill was not adequate. What was the presenters’ view – what did they want to see stated in the Bill? They seemed to want to ring-fence the NHI funding so that the medical legal litigations did not impact on it – how did they see that happening. How did they want that structured? There would always be medical legal litigation – at best one could reduce it. He asked that they shed some light on the ‘no-fault’ compensation fund.

Dr Somaroo responded to the question regarding what should be removed from the Bill. She stated that in certain places they had felt there was room for minor amendments to enable the incremental process. Where new structures were proposed, that had not been tested; they felt it would restrict options by putting it in the Bill and legislating it. Leaving this out at this point in time might allow for a more robust approach to deciding what was the most appropriate health system structure going forward. It might well be that what was proposed in the Bill – when tested – would be the best structure or answer for the population. Without understanding it and putting it in the Bill, if it was found to be ineffective they stood the risk that they would be mandated by the legislative process to continue with it - even if it was not the most reasonable approach.

They supported the principle of NHI, and they looked forward to the realisation of universal healthcare coverage. When they said ‘progressive’ they had not meant that it should take ‘the longest time possible’ but it needed to take the required time. Hopefully it would be a quick process. Given the current context, they needed to plan pragmatically. If they considered the green paper on the NHI that was introduced a few years before – there were timelines articulated that by 2017 they had hoped to address all the healthcare inequalities in the healthcare system. They had not achieved that yet. They needed to be pragmatic about the timelines associated with the Bill. Leaving those things out of the legislative documents might give them more flexibility in this regard.

They supported the introduction of the single payer system. Their only concern was how it was being introduced and the service delivery platform it was being aligned with in terms of funding the process. Would it actually work straight away?

Dr Friedman responded to the question regarding CEOs conducting oversight over themselves. Clearly, they did not believe in that. They believed in very strong governance mechanisms and that was why they were advocating that the strongest possible accountability be to Parliament. They believed this was because with the pooling of funds, if anything was to go wrong with the functioning of the NHI – it would have very severe consequences for everybody in society – particularly the vulnerable. They could not afford to have a State controlled entity, such as the NHI failing under any circumstances. They strongly supported the Bill and its progressive realisation as provided for in the Constitution. The ability to pay should not be a factor in providing healthcare. They supported the suggestion that the wealthy make a greater contribution to the healthcare system. They supported the notion of progressive taxation, and if necessary, surcharges in the form of some kind of medical surcharge which would be paid by people of a higher earning capacity. They recognised that there was differentiation between the public and private sector health sector wages – that services needed to be available equitably for everyone. NHI was not neoliberal – it was a progressive idea. That was why it was puzzling why they would start to use commercial language – if it was not a neoliberal idea – why did they not emphasise universal health coverage?

They had suggested the implementation of an incremental approach – they needed to do this in a developmental way and build capacity for it. Although there was a phased approach already – it was not sufficiently phased and they needed to be even more cautious than the phased approach. There was a lot more detail provided in their written submission. It was a longtime since they made that submission and a lot had changed since then.

In terms of the medical legal litigation – there had been some progress to avoiding this. Progressive countries had shown that it was important to put legislation in place that would help to limit litigation by providing no-fault compensation for everybody. There would not be a necessity for lawyers to prove that there had been an injury or negligence. Everyone would be compensated; the compensation would be reasonable and would not be related to a person’s wealth.

Dr Somaroo stated that the issue around asylum seekers was a controversial issue, particularly given the situation of illegal immigrants, asylum seekers and refugees in the country. At this point in time it would be more relevant to actually afford asylum seekers the same rights that were afforded to refugees.

The Chairperson asked whether they felt that in the Bill there was an indication that it would be a prolonged process. He requested clarity regarding the Office of Health Standards Compliance (OHSC) - would it assist in accrediting a facility’s readiness to implement? It was anticipated that other Ats would be affected by the introduction of NHI. Did they have a challenge with that approach?

Mr Munyai stated that there was a big contradiction made by the presenters in terms of the early point that the Bill needed to be focused on the establishment of the Fund and later comments that the Bill must explain what must happen to the facilities that did not meet the standards set by OHSC. There was a need for the presenter to explain what must happen to facilities that did not meet the standards set by OHSC.

Dr Somaroo explained that with respect to the incremental approach – it was not explicit in the Bill. The proposed structural changes were very different to the current context and current organisation of the health system. It suggested that it was not really an incremental approach from where they were currently to where they wanted to be. In that sense it did not clearly articulate how it would be incremental. OHSC was an enabler of the Bill and facilities that needed to be accredited. The concern was what the OHSC had actually found in its evaluations and the current assessment of the quality of public healthcare facilities in the country. With that background – moving to the next step might not be feasible within the short-term. The timelines were not visible in the Bill. It would be important to know how they would deal with instances where facilities did not meet the accreditation requirements. The legislation should not restrict them in terms of being responsive to what they found within the health system and responding to their context when they were implementing a new system or organisation. They needed to monitor this and ensure that it was working. If not, they needed to adjust accordingly – thus it was important that they were not restricted by the pre-existing legislative context.

Dr Friedman stated that they understood that there would be changes to other acts – in fact that was what they were suggesting – that the Bill become a roadmap. That it provide a philosophical view that the country was moving toward universal healthcare and it would happen as soon as possible. They wanted to ensure that they succeeded, there was going to be incremental legislation and regulations on a continued basis for likely the next 20 or 30 years. This was an important piece of ‘social engineering’ as this would create equity in one of the most important sectors of the economy – being health services. Giving everyone access to affordable health. They wanted to see this continuing to come back to Parliament to be ‘tightened up.’

Oral Health and Dental Schools (OHDS) presentation
Professor Simon Nemutandani, Head and CEO of the School of Oral Health Sciences at the University of Witwatersrand, presented to the Committee.

Supports the National Health Insurance and believe that:
-Oral health services will have better funding under NHI
-Our people will have access to oral health services
-The legacy of African child growing and experiencing toothache, pains and removal of teeth will end.
-Our senior citizens suffer indigestions of food, cannot chew food because they cannot afford false teeth /artificial prosthesis
-Former white universitie should be forced through funding system to train dental therapists
-Posts must be created for middle level oral health workers

We further advocate that
-The National Health Insurance (NHI) should be the only funding mechanism for health in the Republic.
-Replaces all other funding mechanisms for health.
-Takes over from Medical Schemes
-This committee must repeal the Medical Schemes Act in its entirety.
-NHI should focus on funding and contracting matters

Section 25 requires Benefit Advisory Committee
-a) Instead of having all heads of Medical School have one representative of Medical Schools, One representative of Dental Schools, One Representative of Nursing Schools, One representative of Pharmacy Schools, and other Health programs.
-b) Instead of having nine provincial health representatives, have one representative from National Health Council or a member Technical Advisory Council for National Health Council (TAC).
-c) Instead of having two hospital Association representatives, have one representative from Hospital Associations and a Representative for Primary Health Care Services and Community Health Services.
-Section 27 requires Stakeholders Advisory Committee
-This committee is mainly composed of Statutory Councils. It will be significant that oral health Voice is represented at the HPCSA and SADTC

Duties of the fund
-5 (1) (d) “Enter into contracts ........base on health care needs of users”
-INPUT: the contract with service provider must be based on type of services that must be provided e.g. Primary, secondary etc. This categorisation is much defined than “ health care needs of users” which are many and variant.

Functions of the Fund
-6.1 (a) “must employ suitably qualified accordance with organisational structure .........after consultation with Minister and the Minister of Finance.”
-INPUT: Employment of Fund staff: Only the Board and executive must have a final say in the employment of staff of the Fund.
-Organisational structure: The Minister of Health and Minister of Finance must only be consulted in the Organisational Structure establishment or changes.
-6.1 (h) “may purchase health care service..........that are of a reasonable quality.”
-INPUT: The reasonable quality is extremely  subjective, therefore it must be “evidence based
-10 (1) “The fund must reimburse health care providers........rendered to the eligible users.
-INPUT: There must be a way for users to confirm that they did receive the service claimed to have be done so that service providers do not claim for services they did not perform.

Graphic photographs were shown in particular a child with rotten teeth suffering from a severe eye infection, it was stated that the child lost his/her eye.


(See Presentation)

Dr Jacobs stated that Prof Nemutandani had shown the impact of lack of dental care in terms of infections impacting the sinuses, eyes and brain (meningitis etc). This really showed the need for universal health coverage.

The Chairperson appreciated that Prof Nemutandani had highlighted the potential for NHI to remove or reduce the suffering of those children. He requested that Prof Nemutandani expand on that. The Professor had tasked the Committee to repeal medical aid schemes – he suggested that the Professor needed to motivate this and prepare a motivation in that regard. He asked whether the Professor thought that what was written about in terms of medical aid schemes in the Bill was sufficient. Was there more that needed to be done in that regard? The Committee was tasked with calling former white dental schools to train more dental therapists. What was the significance of not having a dental therapist in a province? What were they missing in those provinces as a result?

Prof Neil Myburgh, Dean UWC Faculty of Dentistry, stated there needed to be a clear set of strategies to deliver the dental public health interventions – i.e. brushing programmes, sugar consumption reduction. Those were the only things that would eventually reduce the disease burden. Without this they would have an endless and un-meetable demand for curative clinical services and dentistry – that cost a huge amount of money. Many opted out of getting treatment because the costs were so high. They need to get oral health promotions in place, NHI needed to be able to fund that level of intervention otherwise they would not make much progress.

In terms of the medical aid scheme, the funding of national health insurance was a complex scenario. In dentistry they also suffered from serious over-treatment and over-charging, this came up earlier in the public health presentation. A design change was necessary. Capitation systems had been used elsewhere and that was one of the options to consider. The biggest achievement of NHI would be to try and achieve equity of distribution of financial resources that went into healthcare. There was a need to ensure that the skewed distribution, where the wealthy got the greatest benefits because they could afford them (through medical aid), was distributed more fairly across the population. Abolition of the current medical aid schemes was clearly necessary. In recent research looking at public private partnerships, they had learnt that the administration of the benefits and payments etc, required a very complex bureaucracy. At the moment, the public sector did not have it. Whereas the medical aid systems did have it. The administration systems of paying and handling claims needed to be adopted in the new approach. They could not have all the money ‘locked up’ in the medical aids. That would be the motivation for why in their current form they would have to be removed and reconstructed.

Dr Mzimkhulu Mcuba stated that dental therapists were part of primary healthcare services. If one did not have them in their health service, one tended to employ dentists. One of the cost drivers in the service pricing was the compensation of employees. If one employed dentists to do primary healthcare, one was increasing the pricing of that service. The compensation of dentists was twice that of dental therapists. In provinces where there were less dental therapists at primary healthcare level – there were dentists providing primary healthcare packages, which cost more. As a result of limitations in funding, one tended to employ less human resources to do a huge part. Primary healthcare package of services constituted close to 70 to 80 percent of services – such as prevention, early diagnosis and early treatment. Under the current DPSA remuneration, the entry level for a dentist was about R950 000 per annum, excluding other benefits. Dental therapists were paid R520 000 to R540 000 per annum. It was almost double to employ a dentist in the public sector.

The Chairperson asked why there was no appetite for former white dental schools to train dental therapists.

Prof Nemutandani responded that in terms of dental therapists in the public sector – there were no posts for them; the Western Cape only had two posts for them post democracy. Even if they were produced in a university, the Department of Health had not created the posts for them – that was where the challenge was. If they were going to implement a primary healthcare approach, it would be a disaster to put dentists in a clinic and not have oral hygienists and dental therapists – because at a primary level they were appropriately trained for that. Dentists were highly skilled officers who should not be giving instructions of how to brush teeth nor oral health education – that would be a waste of resources. The universities by their nature had resisted training dental therapists. If there was a funding mechanism and a bursary that was allocated for dental therapists and the creation of posts – in terms of NHI and oral health it would be a success.

Mr Munyai asked to understand the position of the institution without ambiguity, as to whether they were in support of the NHI Bill. The inclusion of the oral health practitioners in all committees of the NHI Fund might pose a challenge, as all professional categories wanted representation. This might not be feasible as the number of professional categories were extensive. Would it be appropriate if they were included as part of the multi-disciplinary team in the regulations, instead of the Bill?

Prof Nemutandani stated that they would be happy with that, they just wanted to make sure that they were not left behind, so that things were done properly for oral health.

Ms Gela reiterated that the inclusion of oral health practitioners in all the committees in the NHI Fund may pose a challenge as all professional categories wanted representation. 

Prof Nemutandani reiterated that they welcomed inclusion in the regulations.

The South African Human Rights Commission (SAHRC) presentation
Ms Fadlah Adams, Senior Researcher and Ms Yuri Ramkissoon, Senior Researcher, presented to the Committee.
While the SAHRC supports the principles of the NHI, it has some concerns about the existing NHI Bill as circulated for comment. The presentation will deal with some of those concerns.

Basic health care services:
-The Bill has not defined what “basic health care services” is. This definition is important especially in light of the fact that reference is made to provision of “basic health care services”.
-The definition of “basic health care services” must be in line with the Constitution as well as accepted international standards.

Population Coverage
-The NHI Bill further limits access to healthcare by asylum seekers in South Africa. It is common cause that it takes a long time to finalise immigration matters of persons who are seeking asylum. Persons seeking asylum are therefore left in an indeterminate state especially as far as registration for services is concerned.
-The Commission has on numerous occasions raised concerns about the slow processing and finalising asylum seekers’ applications, in some cases waiting periods taking several years.
-The Commission notes that Section 4 of the NHI unfairly discriminates against asylum seekers and undocumented migrants and thereby unlawfully restricts their right to access health care in South Africa. Under Section 4 of the Bill, asylum seekers and undocumented migrants are only entitled to ―
-“emergency medical services, treatment and screening for notifiable conditions of public health concern.”
-Migrants' socio-economic rights have been developed and given meaning by the courts.

Powers and functions of Chairperson, Deputy Chairperson and Members of the Board:
-The success of the NHI will, depend on, among others good governance.
-Therefore, the powers and function of the Chairperson, Deputy Chairperson and members of the board are crucial and thus need to be clearly set out in order to avoid conflict and ensure an efficient Board and assist in the decision-making process.
-The Commission is also concerned about the Bill does not specify a minimum term of appointment for the appointment of the Board.

Conditions of service of board members:
-The Commission is also of the view that the remuneration and conditions of service of Board members should be clearly stipulated.
-If clearly stated this may help to protect the Board from undue external interference and thereby help to guarantee the Board’s independence.
-The remuneration of the Board should be determined by the Independent Commission for the Remuneration of Public Office-Bearers in line with the Remuneration of Public Office Bearers Act, 20 of 1998 so as to guarantee its independence.

Concentration of power in the Minister of Health:
-The Commission is concerned with both the appointment process of the Board and its reporting lines.
-The proposed governance structure places concentrated power on the Minister and does not adequately ensure the independence of the Board, which is essential given its extensive powers, including strategic purchasing and the buying and selling of property.

Relationship between the Minister and Chief Executive Officer:
-The Commission notes, with concern, that Section 21 of the NHI establishes a relationship between the Chief executive officer (CEO) and the Minister even though the CEO is accountable to the Board.
-The Commission is concerned about the separation between political and operational spheres as the lack of separation may weaken the role of the Board.
-This relationship requires additional clarification.

Operation of the Fund:
-The Commission notes that the NHI provides for a single purchaser of health care services based on population needs.
-The Commission welcomes this approach as it allows the Fund to ensure that it purchases services at lower prices and because it allows the Fund to control health care spending and diverts health care resources to the needs of the population.
-This, in turn, allows for greater efficiency in health care expenditure and limits fruitless and wasteful expenditure.

General Comments
-An accessible, effective, efficient, appropriate and adaptable healthcare system that provides quality healthcare services to its users has the potential to significantly reduce poverty and inequality in the country and reduce the wastage of invaluable resources and capacity, which is desperately needed in the public sector.
-The NHI aims to address the socio-economic injustices, imbalances and inequities of the past.
-It is important to note that those socio-economic injustices and severe inequalities remain.
-The current public healthcare is beset with systemic issues, which were further highlighted during the COVID pandemic.
-The NHI will not automatically solve these issues.
-Much up-scaling of resources and capacity is required prior.
-In addition, strong leadership and governance, multiple checks and balances and transparency is needed.
-A clearer more streamlined NHI and Fund is required to the one proposed.
-There should be no retrogressive measures applied to other socioeconomic rights to fund the NHI.

Ms S Gwarube (DA) was interested in the elements the SAHRC had identified around the independence of the Board – she asked that this be fleshed out. She realised that good governance models were something that the Human Rights Commission was concerned about – ultimately that was what gave rise to whether human rights were upheld. She requested clarity on their actual concerns around the independence of the Board – and the governance relationship. She asked what they envisioned the governance role looking like. It was important for them to hear from the entities what some of their suggestions were around those things so that when they did look at all the comments they could incorporate them where necessary.

Mr Sokatsha asked whether detailed implementation issues should be prescribed in the Bill or in the implementation plan. Should they not avoid too much detail in the Bill so that it did not pose unnecessary challenges – what was the view of the Human Rights Commission in that regard?

The Chairperson stated that the Commission came in with the thinking that asylum seekers should get a basic package of services – how would they deal with some of the South Africans who said ‘remove anything that spoke to asylum seekers in the Bill.’ A birth certificate and/or an Identification Document (ID) were the only things that allowed one to even access social services in the country. No one would get the grant unless they had those documents. There had not been any issue raised by the SAHRC to say that they had discriminated against that group of people – who came and requested support of the grant without an ID. What other forms of identification should they have? In Limpopo currently, there were people in Africa who came in and accessed health services at clinic number one, because they had a poor system of identification, on the same afternoon that person would go access services at clinic number two. The next morning before the person closes the border, they would go to clinic number three and access a package of services that otherwise was meant for one individual for one illness. That indicated the value of identifying one clinic to be relied upon. He requested clarity regarding the other forms of identification.

He asked whether they did not think that a number of the issues raised would be addressed in regulations and not in the actual Act. He thought he had come across a statement in the Bill that said that Board members would be appointed for a term of five years – that could be renewed once. Did they pick that up – or did they not agree with that?

Mr Munyai requested clarity regarding their statement that the Fund was complex and created confusion – what did they mean by this? He asked them to advise which section said implementation of NHI would be disadvantaging other programmes – especially in the Bill. He requested that they raise issues specifically in relation to the Bill. What was the difference with the NHI Fund to other schedule 3 entities? Why had the presenter said that there was no term of the Board – the Chairperson had responded to this. Section 13(5) stated that the Board would be appointed for a term of five years. The SAHRC needed to indicate whether it comfortable with the current two tier system of healthcare – one for the rich and one for the poor. He raised these issues because almost 16 percent of the money that was available went to the administrators of the medical aid schemes.

Ms Ramkissoon stated that their concerns were specifically in relation to the independence of the Board and that it be ensured. They could not raise concerns around the functioning of the Board, their concerns stemmed from engagements with other departments and entities that also had boards that functioned in a specific way. Their presentation had highlighted that they needed clarity on aspects of how the Board would function, particularly with respect to the relationship with the Minister. Would it just be the Minister who would be appointing? Would it be a panel? Did the Portfolio Committee have any role in monitoring the appointment of the Board or the Board’s functions? They would like clarity in that regard.

Details on the implementation of the Bill could be provided in a plan of action, but it needed to be made clear that this would be specified at a later stage. This would allow them to inform stakeholders of this. It was common practice with other bills.

In terms of asylum seekers and South Africans stating that they did not deserve basic services – that was a Constitutional matter. The Commission’s stance on asylum seekers was that they required their help – they were human beings entitled to rights. It was thought that the NHI should provide for them.

With respect to people without ID’s, it was important to note that they also got complaints from people who battled with identification and accessing grants as well. They were working with the Department of Home Affairs to solve those issues. She was not suggesting that any alternate form of identification be used – it occasionally happened that people did not have identification. There needed to be some allowance, even if it was for a set period to allow for alternative forms, not all forms, but perhaps an affidavit or a proof of residence. This was something that hopefully the Committee could consider. If they required further guidance on that – they could provide a written submission from the head of their equality unit. In terms of accessing various packages of services at different points – that could happen – but their studies showed that it did not happen very often. People rarely accessed various points of service.

The Bill did state that the Board members would be appointed for a maximum of five years – they were curious as to how it was decided. When they said that the structure was complex, it was complex in understanding who the CEO would report to, what were the functions of the Board, Chairperson, Deputy Chairperson were – it got complicated when it came to the buying units. Specifically, in terms of people who would be buying services that related to offers of health products, procurement and contracting units. The structure was not unworkable – they just needed clarity so that people understood how the structure worked. People would, as a result, know how to engage with the system.

They were certainly not happy with the two-tier system. It did not make sense for South Africa to have a two-tier system. The majority of the resources of the country were spent on a system that only served ten percent of the population. The public sector was overburdened. It was not a sustainable system. The Commission, in principle, agreed with the NHI. It was important to note that when the Commission made its submission to the International Committee on Economic, Social and Cultural Rights, they pushed for the timeous and quick adoption of the NHI – and the Committee took on their recommendation.

The Chairperson requested clarity regarding what exactly they wanted to know regarding the appointment of the Board as it seemed clear to him.

Ms Gela asked a question relating to undocumented immigrants and asylum seekers. What proposal were they making on how healthcare be funded in an environment where they had limited resources and an overburdened system. What was their suggestion based on international best practice?

Dr Jacobs noted what the presenter spoke about regarding whether the details should be contained in the Bill. He asked for more clarity on that, she spoke about there being an absence of detail in certain aspects.

Mr Munyai asked whether they were comfortable with the current state of governance – in terms of how ministers were appointed via Cabinet. Why should the NHI be an exception in this regard? The SAHRC was likely not happy with the exclusion of people presently from medical schemes – which NHI was providing an alternative. It would include everyone regardless of employment status. Could they be explicit as to whether they supported NHI?

Ms Gwarube stated that Members needed to be careful to receive the comments that they got from the entities for what they were – but not seek to have them as points of debate. The question of whether the SAHRC had confidence in the Minister – as being neither here nor there – but it was also inappropriate. They had put together comments that they as a Committee would, outside of this process, consider. Surely, they should not sit there and debate the entities and the things they had to say.

The Chairperson stated that he would not allow a debate on that. He would leave it to the Human Rights Commission to answer, but they would not go back to it.

Ms Ncumisa Willie, Research Advisor, addressed the issue raised regarding the term of the Board. She made reference to their written submissions. In section 3(3), they acknowledged the fact that the Bill said that the Board members were appointed for a term not exceeding five years. Their issue was that there needed to be the creation of security of tenure. ‘Would not exceed five years,’ did that mean that the person was appointed for a year or for two years? In order to create security of tenure, there needed to be clarity on the minimum term a person could serve – that was why they had recommended that each member serve for a minimum term of three years to achieve the highlighted objectives that they spoke of.

She wanted to highlight that the Human Right Commission was enjoined by the Constitution to work with organs of State and to advise them in terms of policy and any other matters relating to human rights. To this end, they had done that. They had worked closely with the Department of Health and MECs. Throughout their monitoring they had written reports to them to give recommendations on how they thought the health services could be improved and how human rights objectives, in the health services could be provided. They had a section 11 Committee on Health which consisted of experts in human rights and various fields. They had one on mental health – those experts also gave recommendations and advice which they provided to the Minister of Health and the MEC. They were always open to assisting the Department of Health and government as that was their mandate.

She wanted to touch on the issue of undocumented persons – it was a very political issue as it did not only touch on South Africa’s international obligation but also South Africa’s Constitutional obligation. As the Human Rights Commission, they had written a number of submissions on how undocumented persons could be assisted and accommodated in order to make sure that South Africa achieved its international obligations. They could re-submit this to the Committee if the Committee wanted them to.

Ms Ramkissoon stated that they were happy to hear that the implementation strategies would be outlined in the plans of action. The Commission unequivocally supported the NHI.

Prof Bongani Majola, Chairperson, SAHRC, thanked the Committee for the opportunity to present on NHI. The government had done a lot to grant healthcare to many people. Part of their job was to go around and see what was happening on the ground. They had seen what was happening in rural areas across the country in terms of access to healthcare. NHI should come with a promise – and keep that promise, that there should be universal access to healthcare. There were communities currently that were struggling with access to healthcare. He worried about the many facilities that had a problem with the very poor infrastructure – this made it difficult for people to have access to healthcare. They had been to places where the infrastructure was so poor that when it rained it rained on patients. They had spoken a lot about NHI – but they needed to rise to meet those expectations. The Commission supported NHI and would do everything they could to ensure that it worked. They needed to work with government to achieve this. They would make themselves available if the Committee required any additional information.

The meeting was adjourned.

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