National Health Insurance (NHI) Bill: public hearings day 3

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20 May 2021
Chairperson: Dr K Jacobs (ANC) and Dr S Dhlomo (ANC)
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Meeting Summary

Video: National Health Insurance (NHI) Bill: public hearings day 3 

NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee continued with day 3 of public hearings on the NHI Bill. Two organisations presented oral submissions.

Both entities said they are fully supportive of the introduction of the NHI Bill. They endorsed the principles of universal health coverage, cost effectiveness and equity.

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

The National Health Laboratory Services said it had the platform available to ramp up the increased needs for healthcare that would come with increased access to health services, including specialised health services and the consequent laboratory tests that would be required to support that. It recommended that the NHI Fund contracts with the NHLS as a designated service provider for all pathology services. Further, the NHLS did not think the Bill should have every detail – it needed to contain the principle. It supported the notion that the legislation should be enabling pointing out that if any amendments needed to be made – it would be more difficult to make changes to the Bill than the regulations.

The Committee asked what experience the NHLS had gained through the COVID-19 period. It queried why services were not provided to the entire population and whether the NHLS could increase capacity to meet that need. Clarity was requested regarding their support of duplicative cover. Members asked whether the Bill needed to provide extensive detail on the financing or whether that could be left to the budget. The Committee requested clarity regarding the proposed reimbursement model under national health insurance - did they propose a service fee or capitation.

The South African Medical Research Council felt that the issue of provisional accreditation had not been fully addressed. There was a substantial concern – this was not just amongst colleagues at the SAMRC but more widely - that there may be issues around the accreditation of many existing facilities. Accreditation was incredibly important in ensuring the quality of care that patients deserved. The SAMRC did not want to see the accreditation process undermined by a situation where – if standards for accreditation were high and vigorous - that many health services and facilities were unable to meet those standards.

The Committee asked whether the addition relating to provisional accreditation would be addressed by the national quality health improvement plan. It asked whether the proposed advisory committee should be separate or integral to the Fund. The Committee asked whether the Council thought that the health technology agency could afford to establish capacity or capability in the short or longer term. It was asked how programmes like the National Institute for Health and Care Excellence in the United Kingdom were established.

Meeting report

National Health Laboratory Services (NHLS) Presentation
Prof Eric Buch, Chairperson, introduced the presentation and Dr Karmani Chetty, CEO, presented, on behalf of the NHLS.

With universal health coverage (UHC), more citizens will be able to access health care services that will result in an increased demand for diagnostic testing, both for clinical diagnosis in disease states and for screening of healthy people. This would require regular data on test utilisation and costs to efficiently manage pathology expenses for the NHI fund. The NHLS is uniquely placed to fulfil both the mandates of access and coverage as well using existing data systems to provide pathology utilisation data. In addition, the NHLS has unique pathology expertise to define evidence based best practices for ordering tests to improve the appropriateness of test utilisation.

Chapter 1
-The NHLS is fully supportive of the introduction of the NHI Bill. The NHLS endorses the principles of universal health coverage, efficiency, cost effectiveness, quality, and equity.
-The NHLS believes that the NHI offers a strategic advantage in the form of creating a market with only one buyer.
-The NHI fund will be in a position to pre-dictate prices and set the standard for health care services.
-The single purchaser and single payer principle are a good funding mechanisms to achieve the UHC objectives.

Clause 57
-The NHLS recommends that the NHI Fund contracts with the NHLS as a designated service provider for all pathology services. The NHLS has been designated as the service provider for the transition phase. This should be the case beyond the transition period.
-One of the advantages would be that the NHI can streamline both service provision as well as, pathology payment. The benefits of the NHLS as a designated provided include: o The burden of monitoring provision and payments of pathology services can be taken away from the Fund as the NHLS can perform this and report to the NHI Fund.
-It would serve as the repository of all laboratory data using systems that have already been established such as the corporate data warehouse and laboratory information system (LIS).  These systems could be used to provide national patterns of test utilisation. This would take the burden of monitoring the pathology service from the fund. Laboratory data could also be interfaced with NHI patient record system for bidirectional communication. The NHLS could implement electronic order entry to facilitate paperless tests ordering.

Chapter 4
Composition of the Board:
-In principle, we agree to the concept of technical representation.
-The experience from the NHLS Board shows that having organisational representatives has the advantage that these organisational representatives provide important feedback on the services and the end user experience.
-The NHI Board will need to implement mechanisms to obtain feedback from organisations and stakeholders, if the Board only has technical representatives.
-Consideration should be given to the costs of setting up and running Boards and Committees, which could be substantial.
-The Fund could be run as a government component/agency and therefore reduce the expenditure on setting up a Board.

Clause 48
Financing mechanisms:
-The NHI Bill does not contain much detail on the financing mechanism for different providers.
-Contracting with the NHLS as the designated service provider has the advantage that the NHI only has to determine the financing mechanism with the NHLS and the same mechanism can then be used by the NHLS to sub-contract with the private laboratories.
-This mechanism can also be used to cap utilisation and prevent over-servicing.

Clauses 25 & 27
Benefits design:
-The Bill should state whether the benefit package will be implicit (i.e. name what will be in the package) or explicit (what will be excluded).
-The Bill should also state how benefits will be paid for if it is not in the benefit package.
-The NHI Fund should also allow for duplicative health insurance i.e. everyone should be compelled to contribute to mandatory pre-payment.
-However, for those who want to buy a similar package through voluntary insurance should be able to do so.
-This will reduce the burden from the NHI Fund.
-The disadvantage of this however, is that it could lead to a two tier system.
-This risk can be mitigated by the Fund prescribing administered prices for the voluntary packages.


(See Presentation)


Mr M Sokatsha (ANC) asked Dr Chetty what experience the NHLS had gained during the COVID-19 period. He noted the NHLS had said it is the designated service provider and the sub-contractor of private labs.

Dr Jacobs noted services were provided to 46.5 million people – compared to the population of 58 million people. He noted that the price per test that they performed, was on average a fifth of the price that people paid in the private sector. If they had the skills, competency and infrastructure – he wanted to know more about expanding their capacity to test the entire South African population. Clearly there was only a difference of 12 million people as per the presentation. It seemed that scalability would not be a challenge – he requested an answer to that. How did they reconcile their support for duplicative cover to reduce the fragmentation and multiple risk pools – in other words how did they think they would achieve solidarity in a duplicative environment. What were their views on taking them to that position apart from them saying that they wished to be a designated service provider for the NHI?

Mr T Munyai (ANC) asked questions relating to financing. Should the Bill spell out funding for every provider based on forecasts of the principle? Should the details of the allocation not be left to the budget process and the allocations? Did the NHLS concretely support the NHI as it was? He asked what experience the NHLS had gained during the COVID-19 period. Was it comfortable with the current two tier system of healthcare in the country, which left the majority of poor people without access to quality healthcare. With the two tiers, most of the money went to private aid medical schemes – rather than serving the people. He asked that they clarify their position concretely.

Dr Dhlomo asked whether there were any discussions during COVID-19. Going forward there would have to be one service provider for health laboratory services. He knew where they stood in terms of per capita expenditure. Would it be possible to have a discussion – he was leaning on what Mr Sokatsha had said – had there been collaborative discussions during COVID-19. COVID-19 made people come together – both public and private.

Professor Buch responded to the governance level questions. In terms of the support for the NHI and the principles embedded in it and broad direction of it – the Board of the NHLS was very clear in expressing its support. The Board did not get into details about the models for NHI – because that was outside of their mandate as a schedule 3A public entity. They did not debate alternatives around the operational mechanics of the NHI. They certainly did support broader measures – such as achieving universal access and equitable care for all South Africans as well as issues around contracting against performance standards and many of the other features that the NHI would offer to achieve both greater equity for all South Africans and improved efficiency in the health system. It would ultimately be better value for the total expenditure on healthcare in the country. Consequently, there were benefits, not just to healthcare, but to health of all South Africans. They foresaw an improvement in health outcomes. They looked forward to the idea of performance based contracting and to meeting expectations and demands because they were confident of the quality, efficiency and value for money of the services they provided. They had the platform available to ramp up the increased needs for healthcare that would come with increased access to health services, including specialised health services and the consequent laboratory tests that would be required to support that.

Dr Karmani Chetty stated that COVID-19 really did bring together the public and private sectors. They worked in a very cooperative manner – not just with the private sector - but also with the academic sector. They pulled together knowing that by working together they would be able to deliver on the mandate to do the testing for COVID-19. The private sector was very overloaded with tests – that were referred to them. When they had an overload of tests, they referred them to the private sector. That was the cooperative model they saw working in the NHI. The private sector would also have a role to play in diagnostic testing. They called on the academics and NGO sector, that sub-contracted in order to perform the tests. The payment was done by the NHLS and it used to be done quite efficiently. Their lab information system was able to know exactly what tests were contracted to which laboratory and they had a billing system linked to that. They also had a system that monitored the quality of the tests.

In terms of their capacity to test all South Africans, they could easily increase their capacity. It was not only with the bulk routine tests – they also handled rare tests. The model they were looking at was not necessarily that they would do all the tests – they worked out a system where 20 percent of the tests could be sub-contracted to the private sector – administered at set prices – so that they did not have over-charging and over-servicing.

In terms of the issue of duplicate cover and how to achieve solidarity with that, there was ultimately a risk that the two-tiered system would continue. They were stressing that the solidarity would be reached by ensuring that there was mandatory pre-payment or payment to the NHI Fund – so that everyone was compelled to pay. They believed that there was a very small portion thereafter that would be able to afford having duplicate cover. The NHI Bill indicated top-up cover – they anticipated that this would be a very small proportion of the population, that would be able to afford that. Solidarity would be achieved via pre-payment into the Fund for all citizens. They proposed that the NHLS should be the designated service provider that the NHI contract with. If there was sub-contracting it was done through the NHLS.

They did not think the Bill should have every detail – it needed to contain the principle. As in other countries, one then had a schedule with the regulations which provided more detail. They supported the notion that the legislation should be enabling. They realised that if any amendments needed to be made – it would be more difficult to make changes to the Bill than the regulations. The NHLS whole heartedly supported the NHI. They believed it needed to be implemented as soon as possible.

With respect to the COVID-19 testing, from the statistics, one would see that the private sector had done more tests than the public sector. They often got asked, why this was. It was not the NHLS that drove the testing – they did not drive demand. It was the clinicians and hospitals who decided whether tests got done. They would conduct the tests and then send them to the NHLS. In the private sector demand was driven up by the provision of access through drive-through centres. They serviced the public hospitals and clinics. Initially they had problems with backlogs due mainly to the fact that the suppliers were problematic – as a result of the lockdown - suppliers not having enough staff. A lot of those problems were sorted out. During the second wave, one would have seen that NHLS coped quite well with that. They did not believe that there should be a two-tier system. Nobody should be suffering financial hardships – there should be equity in the financing mechanism – this would be achieved through universal health coverage.

In terms of COVID-19, the NHLS had discussions with the private sector on the price of the polymerase chain reaction (PCR) tests. They had meetings. The private sector indicated that they had other costs that needed to be included in the price. The price from the NHLS for a PCR test was R507 whereas in the private sector it was R850. That was an example of the differentiation in price. When they negotiated with the academic sector – they proposed a price that the academic sector was comfortable with.  The Solidarity Fund kindly funded the academic sector research programmes – they also funded the first 450 000 tests done by the NHLS. They gave the benefits to the provinces – as they did not charge them for those tests. They had a very good collaborative environment within the laboratory sector.

Prof Buch stated that when he was last before the Committee, he was an outgoing Chairperson of the board of the NHLS. He informed them that he was re-appointed by the Minister as the Chairperson of the board of the NHLS for a period of a further three years. This appointment was made in the last couple of days.

Dr Jacobs congratulated Prof Buch. He referred to the question he had previously asked regarding the duplication. The question was whether the duplicate cover would deprive the NHLS funded system of critical human resources – meaning that pathologists for example would still move to the private sector when they were subcontracted by NHLS. How did they see themselves capacitating the public health system – if they lost those human resources to the private sector. He was in no way saying that the private sector was not needed. He was asking this in relation to the subcontracting system.

Prof Buch stated that Dr Jacobs had put his ‘finger on the pulse’ of a very critical issue. The private sector was able to pay pathologists at a higher level than the public sector. The difference between the earnings of NHLS employed pathologists and those employed in the private sector – and many of whom were partners in private practices – was very wide. That was definitely a pull-factor, that drew pathologists out of the NHLS and into the private sector. In anatomical pathology it made it much more challenging for them to retain enough anatomical pathologists – including those with extensive experience in the NHLS. They worked hard to offer other values to their pathologists that they felt helped retain them. They imagined that under the NHI, the amount that was being paid for a test would be standardised – therefore whoever the pathologist was would get the same amount of payment for the test. That meant that the margins in the private sector would maybe not allow the huge differential in earnings. That would bolster the pathologist capability of the NHLS under the NHI.

Dr Jacobs asked a question on behalf of Dr Dhlomo. He asked how the NHLS planned to budget for training of registrars under the NHI – how would they organise those budgets for training and did their costs structures include a training budget?

Professor Buch stated that the current situation was that the NHLS received a conditional grant to support training responsibilities for registrars. In other words, registrars were medical doctors who were specialising in one of the pathology disciplines as micro-biologists or chemical pathologists etc. Some of their time was spent in service work and some of their time in academic. They employed professors and lecturers as well as trained specialists who were on their staff for four year contracts. They paid them and a proportion of their salaries were covered from the income they received from the laboratory tests they did, in accordance with their service role. They also received a conditional grant from the Department of Health to help them cover the academic teaching side of their responsibilities. Their assumption had been that even under the NHI, there would be a conditional grant that would cover teaching and academic responsibilities where they incurred costs. The costs of the tests did not include that cost. There would be two ways to receive it – the one would be as a conditional grant from treasury as part of the general tax allocation - that would be most supportive. The other would be to put a levy onto the fees of the laboratory services for the teaching and training component. They felt it was better to keep the service costs with the service and the teaching and learning costs covered independently. It did not make sense that when one paid for fuel – there were levies added on. They had not envisaged such a levy with laboratory fees – rather a separate grant to carry out those responsibilities.

Dr Chetty stated that there needed to be more financing – because there would be a whole lot of services that would need to be funded through a top-slicing of the budget. They had indicated that the work around the National Institute for Communicable Diseases (NICD) and the work of the National Institute for Occupational Health (NIOH) were funded by the conditional grant. The teaching and training in other countries was not funded through NHI – it would need to be that the NHI Fund top-sliced it – or it could be done directly through Treasury. There was an issue that they had raised regarding the basket of services. If the Fund had an explicit or implicit basket of services – what happened when there were services outside of that basket. There might not be top-up funding to fund services outside of the basket of services. Those sorts of details needed to come out through the regulations or in the implementation plan.

Mr Sokatshe asked what the reimbursement model the NHLS proposed to use under NHI. Was it a fee for the service or a capitation?

Dr Chetty stated that they had been working on an alternative reimbursement model through capitation. They had been looking at the pros and cons of a number of different models. A capitation model would be the simplest. If one had a fee for service model – it could work if there were administered prices – so that the prices were set. They called it an ‘alternative reinvestment model’ because it was a modified capitated reimbursement model. They had discussions with the Department of Health to that effect. They had also looked at global budgets and various other models. A fee for service model and set prices would be the easiest to manage.

Prof Buch stated that Dr Chetty had referred to a modified capitation model, a simple capitation model was when one got a certain amount per patient or population. The risk with a simple capitation model like that was that there was no incentive to limit the number of tests one provided – because there was money being paid upfront and one could order more and more tests without any additional fee being paid. This could compromise the NHLS. A simple capacitation model, based on historical trends, suggested that when there was no fee for service people took twice as much. They would get twice as many laboratory tests ordered – but they would have the same income. That was why they proposed a modified capitation model. If they went that route, they needed to agree that NHLS would provide a certain basket of services with a certain level of volumes. If the requests escalated way above those volumes it would become a problem – and then there would need to be additional payments for those models. There needed to be a basic agreement as to what the basic operating procedures were – in terms of when tests were done and what happened if the numbers got out of hand. It would pose a big risk to the NHLS if there was a sudden massive increase in tests simply because one was not paying per test – and they would have no means of garnering additional income to respond to that.

At the moment, on the fee for service model, if more and more tests were ordered – then they billed provinces more and more money and they had to pay NHLS. Provinces had an incentive to ensure that patient care needs were met and patients were not deprived of tests they needed. They also needed to ensure that doctors were careful of not over-ordering tests than were absolutely necessary. Provinces did do some active management – they did not want their bills to escalate unnecessarily without clear benefit to their services and patients. They managed the demand for tests. If under the capitation model the provinces had no responsibility for direct payment – then there was no incentive for them to cap the number of tests ordered. They would still have to provide the tests if there was over-ordering. They were not suggesting that patients should not get the tests they needed. The health market enquiry had shown that there was the potential to over-service, over-provide and over-order. The principle of their answer was that they were flexible on the payment model according to the policy decisions and perspectives of the fee for service model. They supported there being a set fee for a service. This was one model that was suitable to operate under the NHI. They were not averse to other models but if they were looking at capitation, there needed to be other modifications made to that capitation model. He suggested a modified capitation reimbursement system to address the risks and concerns that were previously raised. 

Mr Munyai asked whether they agreed to clinical guidelines and protocols in this context. This would include referral pathways, implemented by NHLS services. Was that their position?

Prof Buch responded that there were two levels of clinical guidelines. There were general clinical guidelines for practice in hospitals and there were clinical guidelines in relation to laboratory services. They supported both.

Dr Chetty stated that they also took some of those guidelines and they had electronic gate-keeping where they could easily apply some of those guidelines. Their electronic gatekeeping had been instituted and implemented in all of the provinces.

South African Medical Research Council (SAMRC) Presentation
Professor Rachel Jewkes, Executive Scientist for Research Strategy in the Office of the SAMRC President, and Dr Tamara Kredo, |Senior Specialist Scientist, presented on behalf of the SAMRC.

Challenges and opportunities
-The NHI Bill is one of the largest sets of reforms proposed for the country since 1994.
-SAMRC remains committed to provision of best healthcare to South Africa and supportive of principles underpinning the National Health Insurance plan
-Reforms are being introduced at a time when:
-Major national and global societal, social and economic challenges
-COVID-19, public health emergency, is having a profound impact on economies and funding available for health care and the demand for health care services
-COVID-19 has revealed fault lines in health care services delivery, access to critical health information and also created opportunities for efficient collaborative work and improvement  in some places (e.g. HTA processes).

Evidence-informed planning and implementation
-The Bill currently sets out a specific two phased timeline for implementation (sections 57(1) and 57(2))
-We support the step-wise, resource-informed approach outlined in the Bill.
-NHI decisions should be evidence-based and partners such as the SAMRC are well placed to provide support for the conduct of relevant research.
-Government Pilot projects, as already conducted, are valuable. We suggest that implementation steps be piloted, evaluated and readjusted using research methods.
-Regular stakeholder engagement for example participatory decision-making with relevant stakeholders affected by decisions is important. This includes consultation with the public and providers at all levels of the health system

Research Advisory Committee
We recommend establishment of a Committee that advises the Minister. This committee should:
-Advise on the commissioning research and establish a framework to do this
-Receive oral and written presentations of research findings
-Report on the key learnings from research conducted with fenced funding for NHI related research
-To make recommendations on arrangements for research and data access in Phase 2

-Chapter 7 Advisory Committees Established by Minister
-We recommend the following additions:
-The Minister must, after consultation with the Board and by notice in the Gazette, establish a committee to be known as the Research Advisory Committee as one of the advisory committees of the Fund.
-The membership of the Research Advisory Committee, appointed by the Minister, must consist of members from such institutions such as the research councils, public health entities, higher education institutions, civil society representation.
-The Minister must appoint the chairperson from amongst the members of the Committee.

Accreditation and risk of privatising health care delivery
-One of the WHO prerequisites for successful UHC is that a well-run healthcare system should be in place prior to implementation of UHC.
-The accreditation process as envisaged by the Bill could render many currently operational public sector facilities ineligible to be contracted by the NHI fund, resulting in a heavily private sector dependent delivery model. (section 39(2)(a) and (b))
-This accreditation process carries the risk of socialising the funding of health care but privatising the provision of health care in the country

Section 39 (9) add new (e):
-(9) If the Fund withdraws the accreditation of a health care service provider or health establishment, or refuses to renew the accreditation of a health care service provider or health establishment, or fails to provide accreditation to an existing health care provider or health establishment, the Fund must—
-provide a health care service provider or health establishment with notice of the decision;
-provide a health care service provider or health establishment with a reasonable opportunity to make representations in respect of such a decision;
-consider the representations made in respect of paragraph (b); and
-provide adequate reason for the decision to withdraw or refuse the renewal of accreditation to a health care service provider or health establishment, as the case may be.
-consider whether it is appropriate to provide provisional accreditation pending progress on a road map for improving care and facilities to meet the standards of full accreditation

Add provisions to the NHI Bill to:
-Provide a clear mandate for the further development (where existing) or establishment of these support agencies
-Describe the scope, functions and level of autonomy of these technical support institutions
-Outline how they will interact with the other NHI committees and units
-Provisions need to be added to prescribe the role these institutions have in the functioning of the NHI, for e.g. HTA  in determining the basket of services. 
-SECTION 39 (5) – add an additional data point:
-(5) In order to be accredited and reimbursed by the Fund, a health care service provider or health establishment must submit information to the Fund for recording on the Health Patient Registration System, including—
-national identity number or permit and visa details issued by the Department of Home Affairs, as the case may be;
-diagnosis and procedure codes using the prescribed coding systems;
-details of treatment administered including medicines dispensed and equipment used;
-diagnostic tests ordered;
-length of stay of an inpatient in a hospital facility;
-Outcome: death or discharge
-(f g) etc (renumbered)

Payment models
-The NHI Bill is detailed and prescriptive regarding how service providers will be paid – Global budgets, Diagnosis Related Groups, capitation etc. (sections 35 and 41).
-The specific prescriptions may require Bill amendment as the NHI implementation proceeds and processes mature.
-Provisions may be reworded to set out the underlying principles in deciding how to remunerate providers for services, rather than prescribing specific payment mechanisms.

Mr Sokatsha asked a question in relation to section 9. The SAMRC stated that it was making an addition on the provisional accreditation – would it not be addressed by the current national quality health improvement plan? Regarding their submission on section 35, they suggested it should include an aspect relating to ear-marked funding for primary healthcare. If all services were ear-marked would this not allow flexibilities in cases of emergencies?

Dr Jacobs referred to their point on the research advisory committee – were they suggesting that this should be a separate advisory committee or could it be integral to the Fund as contained in section 20 subsection (3) of the Bill. With respect to the health technology agency – did they think that the Country could afford to establish this capacity or capability in the short-term or would it be possible to do this in the longer term? How were programmes like the National Institute for Health and Care Excellence (NICE) in the United Kingdom established? Was it right at the beginning or something that was brought in over a longer period.

He then communicated questions on behalf of Dr Dhlomo. Was there a need to put legislation in place on the role of the SAMRC and other bodies? Why when there were many research organisations, including universities, did they have to do that? Was there a suggestion from the SAMRC that the whole Bill should be re-written or what was their suggestion in this regard.

He then asked questions on behalf of Mr Munyai. He asked a similar question as to whether the legislation regarding the SAMRC be amended to align with the NHI. He referred to section 33 of the Bill that related to medical aid providing the same services as part of the NHI services. Would that not create inequality that NHI was aiming to reduce.

Prof Jewkes addressed the question relating to provisional accreditation. The SAMRC felt that the issue of provisional accreditation had not been fully addressed at present. There was a substantial concern – this was not just amongst colleagues at the SAMRC but more widely - that there may be issues around the accreditation of many existing facilities. They thought the accreditation overall was incredibly important in ensuring the quality of care that patients deserved. They did not want to see the accreditation process undermined by a situation where – if standards for accreditation were high and vigorous that were many health services and facilities that were unable to meet those standards.

In relation to the question about section 35 and ear-marked funding, they raised this because it was a problem with health systems across the world – that hospital care consumed an increasing proportion of the budget within the health system. Unless it was very firmly checked, the primary healthcare budget was squeezed. It was their belief that unless there was sufficient investment in primary healthcare, they would not be able to stem the tide of patients presenting with more severe health concerns in the tertiary and secondary systems. They would not be able to contain coughs within the health sector. Adequate investment in primary healthcare started at the level they were at the moment. Investment in primary healthcare, with a small supplement, was the starting point and should be incrementally increased in order to ensure they curbed the otherwise relenting tide of increasing illness across the Country that would require treatment through more extensive services provided at hospitals.

The research subcommittee, they believed should not be part of the Fund, it should be a separate advisory committee. The reason for this was because an advisory committee was independent. It should be able to give independent advice, if it was within the Fund it may not have the ability to do so. It needed to be able to independently advise the Minister and the Fund. This was critical so as to have an impartial voice from the research sector to be able to provide guidance and input into the process. They had seen partly - with the Ministerial Advisory Committee during COVID-19 – the valuable role research could play in providing input into those types of committees.

With respect to health technology assessment, NICE was established in the mid-1990s, that was not the time when the NHS was established. However, the world of health systems research and management moved very rapidly from the 1980s onwards. The idea of having something like a technology system organisation, like NICE, had not really been on the table for any country much before the mid-1990s. They had the advantage of setting up NHI almost 20 years later. It would be valuable to build in best practice approaches from other systems from the start. It did not need to be a completely separate entity, with a separate Board and management and financial structure. It could be embedded within an existing institution. A programme like NICE, needed to be completely integrated into the system.

In the presentation they gave a series of suggestions where extremely small changes could be made to the Bill in order to strengthen it. They were in no way suggesting major changes to the Bill. They believed that the SAMRC had a very valuable role to play in terms of supporting NHI. They had many capabilities, including their ability to put out requests for proposals and manage funding to enable a generation of research knowledge to guide government policy across a wide range of different research providers in the Country.

In terms of their recommendation relating to section 33 and inequality. It really depended whether one had a glass half full or half empty approach. It would be problematic if services were not accessible across the Country in both rural and urban areas. Inequality could be looked at in different ways. Such as having to go to the private sector in small rural towns because of a lack of service delivery in the public sector – whereas in urban areas it would have been services would have been accessible in the public sector. She referred to an example of accessing services to terminate a pregnancy in urban versus rural areas. It was unequal when people were denied access to important and effective affordable treatment and needed to use their own funding for that.

Closing Remarks
Dr Jacobs thanked all the presenters.

The meeting was adjourned.

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