National Health Insurance (NHI) Bill: public hearings day 6

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02 June 2021
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Video: Portfolio Committee on Health, 02 June 2021

NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee held public hearings on the National Health Insurance Bill. Three university faculties presented oral submissions.

All three faculties supported the initiative of universal healthcare coverage for all South Africans; however they proposed a number of amendments and recommendations in relation to the Bill.

The Faculty of Health Sciences at Stellenbosch University stated that the NHI represents major and complex health system reforms, in both the public and private sectors. It argued that a phased approach will allow the time and space for the Health Systems Strengthening interventions (HSS) within a fragile public health system to take root as well as for the incremental launch of carefully crafted innovative models in line with the NHI proposals. It highlighted that the Bill did not make a distinction amongst health professionals, and as a result excluded a number of key role players, such as community health workers, mid-level workers and traditional healers. In terms of population coverage, it suggested that the Bill include asylum seekers, undocumented migrants, students and all children. Suggestions were made in relation to the powers of the Fund - and the necessity of strong financial, legal and administration staff as well as systems. Concern was raised regarding the powers of the Minister.

The Faculty of Health Sciences at the University of Cape Town stated that the Bill needed to be explicit about health benefits, referral pathways, essential medicines and laboratory lists, areas of disinvestment and the rationalisation of clinical guidelines. Concerns were highlighted regarding the power of the Minister and various suggestions were made in this regard. A number of proposals were made in relation to the advisory committees. It was highlighted that the health facilities were not accredited and this was largely due to a lack of resources. Training platforms for health sciences and pathology services were discussed in relation to the Bill. It was suggested that specific guidelines or directives needed to be included in the Bill in this regard.

The Faculty of Social Science and Humanities at Fort Hare University focused on the need to recognise mental health. It was highlighted that mental health expertise needed to be included in the advisory structures of the Bill. It suggested that preventative work needed appropriate funding and support. Reference was made to the priorities of the universal Sustainable Development Goals and the opportunity to meet these through the Bill. Mental health issues in the Country were highlighted as well as the role preventative work could have in reducing the burden. The impact of the national COVID-19 lockdown was highlighted in relation to mental health in society, especially on people with a history of mental illness.

The Committee asked whether the health system needed to be strengthened prior to the implementation of national health insurance.

The Committee asked how funds can be raised to cover undocumented foreigners that seek to gain access to healthcare services.

Concern was raised that only one percent of the facilities in the country met the norms and standards that would allow them to register as NHI facilities. The budget cuts to primary healthcare, staffing and infrastructure were also highlighted.

Presenters were asked if they supported the two-tier healthcare system, the NHI pilot project and if it was successful, why they were concerned about the Minister’s powers, if there was a need for every sector to be represented on the Board and if so, should this be reflected in the bill or elsewhere.

Members asked if implementation of the Bill was dependent upon the establishment of the health management information system and for comparisons with other countries that rolled out a NHI.


The Committee noted that concerns were raised but explicit proposals were not given by presenters. It requested additional information be submitted in writing.

Meeting report

Presentation by the Faculty of Medicine and Health Sciences (FHMS), Stellenbosch University
Assoc Prof Rene English, Head of Division: Health Systems and Public Health, University of Stellenbosch, presented to the Committee.

Inputs on the Bill (2019): Overarching Comments
-Committed to principles of social solidarity and universal health coverage (UHC)
-UHC not equivalent to a funding model

-Proposed model for funding model for medical care as opposed to consideration for broader principles of philosophy of PHC which includes social determinants of health.
-Introduction of fragmentation as opposed to a unified health system.
-Strengthening of current health system to be prioritised and funded in preparation for NHI
-Our position aligns with international, national conceptions of PHC, UHC, health systems thinking and related research evidence. It acknowledges that health systems are complex and adaptive and recognises the importance of governance and leadership, and the ‘software’ of the health system.

-Line: ‘In order to’, after ‘achieve the progressive realisation of the right to access to quality personal health care services’ add ‘within a strengthened public and private health system’
-Add a clause ‘address the social and economic determinants of health to promote health and disease prevention through inter- sectoral collaboration and strengthening non-personal health care’

Whilst ‘health care service provider’ is defined fairly generically, the way the Bill refers to such providers appears to indicate health professionals, and important cadres such as community health workers, mid- level workers, and traditional healers do not appear to be included.

Population Coverage
-4(1) add ‘Asylum seekers, undocumented migrant, students and all children’
-Remove 4(2)
-Refrain from using the term ‘illegal foreigners’. Replace with ‘undocumented immigrants’

Registration as users
-Add to section 5 ‘passport, drivers licence’ as another option for registration and ‘asylum seekers’. If it is not clear whether the details regarding this category will be covered in 4(1)(e) or (6)
-Regarding ‘proof of habitual place of residence’. Not all residences have proof of habitual residence. How this will impact the registration of the user is to be made explicit.
-The implications of not having any documents as stipulated in this section on registration of the user should be discussed in the Bill.
-Details of the management and maintenance of the register, as well as registration of users at unaccredited facilities are required.
-What will happen if the user does not have proof of registration?

Healthcare services coverage
-With regards to user access to accredited facilities as presented in this section, there is a risk for limited coverage of services and/or increased costs for users who have to travel to other facilities should the facility they are meant to access not be/no longer be accredited.
-7(2)(d) lists the referral pathway and (iii) states that failure to adhere will mean that the user does not require services. What happens should there be a medical emergency? Thus, add additional clause that addresses management of the user should they present with a medical emergency.

Structures and powers of the Fund
-The functions and powers of the Fund are broad and cover a wide range of activities and actions.
-The Fund will require a range of health, financial, legal, business and other technical staff, including administrative staff and strong operational and strategic managers.
-Strong and well- functioning administration systems are also required. Furthermore, there are about 4000 public health facilities in South Africa (excluding the private sector facilities).
-11(1)(h): We propose that an independent entity investigate complaints against the Fund.

Establishment of the Board
The Board is accountable to the Minister in the Bill. This chapter establishes the NHI Fund as a Schedule 3A autonomous public entity. The Minister has extensive powers in the current Bill (such as section 13.(8) and 13.(9) of this section). This may undermine the purpose and effective implementation and independent functioning of the Fund.

-We propose that the Fund reports to Parliament and that the Minister’s powers are reduced

Advisory Committees to be established by the Minister
-FMHS welcomes this change from the 2018 Bill, that health service benefit determinations and pricing are separated from the Fund, and incorporated into the roles and functions of Advisory Committees, as well as the establishment of a Stakeholder Advisory Committee.
-However, clarity and details regarding the powers, roles and capacities of the various members of the Advisory Committees is required.

Purchasing of healthcare services
-In terms of section 35 (2), the Fund can only purchase services from accredited and contracted hospitals.
-Whilst the strategic purchasing of health care services by the Fund is intended to reduce costs and improve value of health services and impact on health outcomes, any single buyer system like the NHI Fund, on its own that is without complementary supply-side regulation cannot succeed. In a mature and long-standing single purchasing system like NHS in the United Kingdom, all public and private providers that provide care paid for by the NHS are regulated by Monitor, the independent supply side regulator (now part of NHS Development) as well as by the Competition and Markets Authority, the competition enforcement agency.

-Progressive implementation and piloting
-Use of research and evidence to inform and guide best practices
-The role of local innovation and expertise – particularly of established public servants are not to be undermined.
-HEIs can play an important role throughout the planning for and implementation of the financing mechanism towards UHC attainment.


(See Presentation)

The Chairperson stated that the Bill spoke about asylum seekers but the presentation gave the impression that there was no mention of asylum seekers in the Bill. He asked that the presenter clarify that.

Mr M Sokatsha (ANC) stated that the institutional arrangements were covered from sections 31 to 39. He requested clarity as to whether the presenter suggested that more detail must be articulated in the Bill or in the regulations. In terms of illegal migrants versus undocumented migrants – did the presenter have reference in the Constitution or Refugees Act as to how that category of persons was described.

Ms A Gela (ANC) asked what the presenter’s proposal was on improving capacity at sub-district level. Must the detail of accreditation be contained in the Bill or could it be in the implementation plans? Was the presenter suggesting that because the health management information systems were still under development, the Bill should not be processed and passed? What was the presenter’s understanding of the difference between the national health information system in section 34 of the Health Information Act and section 40 on the information platform for the NHI Fund?

Dr S Thembekwayo (EFF) was worried about the composition of the management of the Faculty; it was not gender nor racially balanced. The presenter proposed amendments under section 2(a) and (b), why did she not provide an explicit amendment to the definition under ‘healthcare?’ The same applied to chapter five under ‘responsibilities.’ The presenter needed to motivate, suggest or outline explicitly how the responsibilities in the Bill should be reflected. What would be the best possible acceptable responsibilities in chapter five?

Ms E Wilson (DA) noted that the presentation highlighted similar things to the presentation the day before. She heard from the presenter that a lot of clarity was needed. Was the presenter suggesting that if the Bill was passed in its current state, it would not work? Given that only one percent of medical facilities in South Africa had sufficient infrastructure, to be in a position to be accredited as an NHI provider, she noted that the presenter had emphasised more focus on getting facilities properly equipped to meet the accreditation criteria. However, they were in a situation, where over the short-term, the budgets had been cut. This was the case for budgets on infrastructure, on staffing and primary healthcare. In light of that, what would the presenter propose be done. What was the way forward, especially given that there was no budget?

She agreed with the presenter regarding the role of provinces and the centralised purchasing model. As a result of these issues and the potential concerns around the Board were they looking at a two-tier system and what was their position in that regard? She thought that their report needed a lot of engagement. She agreed with Dr Thembekwayo regarding the provision of specific re-wording suggestions – such suggestions would be gratefully received.

Ms H Ismail (DA) stated that the presenter had mentioned paper-based documenting. Would it be possible to modernise the system to take the paper-based system online? How long did she think that process would take them? Considering all the issues raised in the presentation – with regards to infrastructure readiness and the lack of human resources – did they think that the NHI was ready to be implemented presently?

Mr T Munyai (ANC) asked whether the University of Stellenbosch had a fear or doubt that the country had the ability to train the right people to do the right job at District Health Management Office (DHMO) level. If yes, the role of provinces would change with health management in the country – was this a problem in their view? Was the presenter aware that the National Health Service (NHS) in the United Kingdom (UK), was implemented in 1948 following the Second World War? There was no hesitation that the British Health System had collapsed at that stage. The Minister at the time did not hesitate in pushing ahead the reforms. The NHS was one of the best health systems in the world. The presenter seemed to be concerned about the capacity in the health system to implement NHI reforms including health information systems. Was she aware of pillar nine of the Presidential Health Compact? It would be interesting to get feedback from the presenter in this regard. In terms of identification, could foreign passports or driver’s license stand in the rigour of confirmation of who the individual was? Was this form of identification prescribed by the Department of Home Affairs?

The Chairperson asked whether their capacity – in terms of contact with other countries and universal coverage programmes – could help the Committee in providing any information regarding the NHS programme in the UK. Did they have to wait for all the population to be in the electronic data system before they could embark on their programme. This would help them understand how long they would have to wait. Was there any country that underwent such a ‘massive overhaul’ of their health system and was ready to get going the day after implementation? There was a section in the Bill that spoke about the role of provinces and there was an explanation about the district health and primary healthcare approach – he suggested she refer to that.

In terms of accreditation – which was highlighted in the presentation as a challenge – did the presenter propose that this be included in the Bill or be included in regulations? What specifics would she suggest in terms of improving capacity at sub-district level?

Assoc Prof English stated that the Faculty would be happy to provide detailed suggestions relating to the Bill. In terms of access to primary healthcare services, termination of pregnancy and care for children under six years, everyone, according to the Constitution was entitled to healthcare services. This was per the National Health Act. No one could be refused medical treatment – asylum seekers and undocumented migrants were entitled. The Bill had departed from that – the Bill specifically stated that in section 4(2) an asylum seeker or illegal foreigner was only entitled to emergency medical services and services for notifiable conditions of public health concern, whereas, section one outlined who was eligible for healthcare services – which would be determined by the Benefits Advisory Committee. This would include South African citizens, permanent residents, refugees, inmates as well as certain categories of foreigners. Thus, this departed from legislation and did not speak to health for all. The impact of not being able to provide asylum seekers and undocumented immigrants with HIV services as well as pregnancy and sexual reproductive health services was problematic. They had seen the impact of COVID-19.

In terms of building capacity at sub-district level, that spoke to the questions that were raised around the information systems and other aspects of strengthening the health system. The Faculty fully supported the move towards attaining universal health coverage. They supported a funding mechanism that addressed the inequities of the past. Their concerns related to the how. The aspect of the Bill that spoke to the progressive implementation – details needed to be considered in this regard. The NHI Bill introduced a mechanism to finance the ultimate attainment of healthcare services delivery for all. It was centred around the pooling of funds that would purchase services, that would be delivered to the community by frontline health services. All those processes would take time. All those processes should be evidence-based. The comment about capacitation would be around – how could the Fund generate sufficient finances to support the strengthening of the health system which would mean being able to ensure that they had enough well-capacitated people at the different levels. That would speak to the role of the Department of Higher Education, it would speak to in-service training and the Department of Public Service and Administration (DPSA). All of that would require time and specific approaches and engagement with specific ministries and bodies that oversaw that kind of training.

How did they ensure that they strengthened the health information system? She was aware of the pillar relating to the Presidential Health Compact – but at the same time would propose that priority be given to ensuring that they were able, to not only implement the hardware and software, but that they designed the systems so that there was inter-operability. They needed to ensure that they trained their frontline nurses and managers to use a computer. Their evidence showed that even if one put a computer in a health facility, it did not mean it got used.

In terms of being able to implement the NHI Bill the next day – it was not an easy question – and not a question she would want to give an authoritative answer to. A phased approach could certainly be looked at. How could they pilot? How could well-functioning existing structures be leveraged to be able to start thinking through planning, testing and identifying those practices? How could that be used to inform policies and ultimately legislation? She proposed that as the funds came in – they should not be used immediately, to implement some of the legislation that was not well-thought through, but should first be used to identify what needed strengthening in the health system. The right committees, the right people, needed to be part of the discussions to leverage strengths and capacities that existed. Institutions and higher training institutions needed to be engaged with to be able to build capacity, ensure that there was infrastructure and that they met the requirements to be able to deliver adequate services. At the same expertise and knowledge that existed amongst academics and practitioners needed to be leveraged to be able to use evidence, research and monitoring and evaluation to test implementation as they went along. The things that were certain as a result of that could be legislated as a result of such research. There was opportunity to learn from the NHI pilot sites, where there were issues around the availability of finances and management. Care should be taken not to repeat the same mistakes.

In terms of fear and doubt in relation to capacity; there was concern and there was hope. That was an area where all universities could play a much larger role in ensuring that they were able to provide the kinds of support to build capacity. There were many initiatives that had taken place in terms of building leadership and management capacity. There were various ways training could take place. Both the University of Cape Town (UCT) and Stellenbosch University offered various courses relating to leadership and management within the health sector. Due thought needed to be given to aspects of curriculum development. Were they developing a curriculum that aligned to the context and training programmes that were fit-for-purpose. These were things they were grappling with presently.

In term of the driver’s license, her understanding was that it was legitimate documentation, she was happy to double check that.


Much had been written about the readiness of different countries to implement. There was not an example of a country that had it ‘all together’ prior to implementation. There was a group of them who worked together to look at such matters, she would share some of this with the Committee. She was happy to provide further information and responses in writing. The Faculty was fully supportive of the reforms within the health sector to attain universal health coverage. The Faculty’s concerns were around governance, stewardship, transparency and readiness in terms of unifying the health system.

The Chairperson stated that any additional questions could be communicated to the presenter in writing and the Faculty would respond in writing to the Committee.

Presentation by the faculty of Health Sciences, University of Cape Town
Prof Lionel Green-Thompson, Dean of Health Sciences, UCT, presented to the Committee.

Proposed approach to the reform
-Protect existing service delivery, while seeking to test new initiatives or interventions within iterative cycles of action and learning.
-Rationalise the legislation        
-Determine essential elements to legislate
-Incrementally incorporate elements as they get tested and refined with experience during implementation

-Extremely challenging to create a list of explicit benefits that is affordable to all in need as is in Chapter 2
-If we get the benefits wrong, there are likely to be new medico-legal threats.
-Many health systems (including the United Kingdom National Health Service) have ‘implicit’ benefits, at least for some aspects of care.
-We therefore propose that part of the benefits need to be implicit.

The Bill needs to be explicit about:
-health benefits,
-referral pathways 
-Essential Medicines and Essential Laboratory Lists.
-areas of disinvestment
-rationalisation of clinical guidelines

Chapter 4, 5 & 6: NHIF Board & CEO
-We are concerned that power is centrally concentrated in the Minister
-National Health Insurance Fund (NHIF) Board be accountable to Parliament not the Minister
-Board and Committees include civil society and user groups
-The NHIF Board appoint its own chairperson and the CEO of the NHIF
-Ad hoc advisory panel to appoint (e.g. CEO of the Fund)
-include user groups, civil society, provider reps & academia
-have clarity around how transparency is to be achieved

Chapter 7: Advisory Committees
-Benefits Advisory Committee, Stakeholder Advisory Committee, Health Care Benefits Pricing Committee and supported as national bodies.
-Outputs of these bodies are highly technical and also politically contentious
-Suggest an incremental approach to implementation, with clear cycles of feedback and learning.
-Concerned that the Benefits Advisory Committee is too far removed from issues of cost and affordability and that it may be more appropriate for the committee to be the “Benefits and Pricing Advisory Committee” so that issues of affordability can be properly considered.
-Recommend Committees to appoint their own Chairpersons
-We support progressive incorporation of economic evidence into decision-making
-We support a movement towards making benefits transparent and explicit as data and evidence become available
-This inclusion of economic evidence will allow for the consideration of horizontal equity (i.e. equal access to benefits for equal need) as well as for vertical equity (i.e. supporting additional claims for key vulnerable and marginalised groups including disabled, trans and gender diverse people, and those living in rural areas
-We note that the Benefits Advisory Committee will need substantive technical and institutional support to make procedurally fair, evidence based and coherent decisions about which services should be made available under NHI
-This will require a different approach to that used currently for decision making.
-For example, the existing Essential Drugs Programme relies on substantial volunteer resources and donor technical support to produce the Standard Treatment Guidelines and Essential Medicines List.
-The production of the NHI services package will require a fully resourced and competent workforce and mechanisms for producing evidence and analysis.

Chapter 11
-While health technology assessment (HTA) is proposed as a mechanism for assisting in decision making, taking into account affordability, equity and efficiency, more consideration is required as to the nature, remits and form of processes that utilise HTA methods.
-We recommend that the Bill consider explicitly establishing the institutional arrangements for such technical support to the Benefits Advisory Committee as the decision-making processes relating to the NHI services are critical to both early planning and buy-in from stakeholders as well as the longer-term sustainability of the NHI Fund
-High-profile examples of institutional arrangements include the UK’s National Institute for Clinical and Care Excellence (NICE) or Thailand’s Health Intervention and Technology Assessment Program (HITAP).

Chapter 8: DHMO CUPS & PHC
-We support the establishment of the Office of Health Products Procurement
-Medical Schemes
-Clause 33 says “Once National Health Insurance has been fully implemented as determined by the Minister through regulations in the Gazette, medical schemes may only offer complementary cover to services not reimbursable by the Fund”
-There is lack of clarity on what ‘fully implemented’ means, and there is lack of clarity around how the Minister will make this determination (e.g. whether it will be a progressive determination or once-off
-Assimilation of the > 8million persons on MAS and those paying out of pocket should be in phased manner.
We suggest:
-to follow the detailed recommendations made by the panel of the Competition Commission’s Health Market Inquiry.
-gradual phasing out of the Medical Scheme tax rebate (not a sudden removal)
-We support a ‘panel’ approach to community-oriented primary care with an enrolled population of 2000-10000 per panel and
-Multidisciplinary team including Ward-Base Outreach Teams with strong team- based links to facility-based health professionals.
-We suggest that a Primary Health Care Service Package be defined by:
-The PHC elements of 285 guidelines in SA
-Medicines List (Starting with Extended PHC Formulary)
-Lab List (Starting with Extended NHLS PHC List)
-Office Procedure List (136 from NHRPL to limit hospital referrals)
-Home- and workplace-based screening and health promotion
-Rehabilitation Services
-Performance Outcomes (starting with Ideal Clinic requirements)
-Services that need attention:
-Palliative Care
-Service for those living with disabilities including intellectual disabilities
-The PHC service package would be revisited on an annual basis and could form the basis of a Comprehensive PHC benefit package
-For Community Health Workers, we emphasise the importance of training, supportive supervision and acceptable conditions of service, including from a payment perspective.

Accreditation of health facilities
-We support the work of the Office of Health Standards Compliance in accrediting health facilities so that they can provide quality services within the NHI framework
-However, over the past few years, scores from National Core Standards assessments have not improved and few public facilities are able to achieve compliant scores.
-This is because the resources are not available.
-If no resources are available to improve scores, then the process is entirely punitive.
-In addition, we are concerned that private providers and tertiary and regional hospital will find it easier to gain accreditation, leading to monopoly power and cost escalation through supplier induced demand, particularly in urban centres.
-We recommend: public and rural facilities must be assisted to gain accreditation earlier in the process in order to counter the potential for monopoly power in private providers and in hospital care undermining PHC

Training platform for health sciences
-We are concerned about the potential impact on the training platform for health sciences from the implementation of NHI.
-It is not clear where training will take place, how trainers will be contracted, etc. For example, several scenarios might suggest that:
-There will be very few trainers remaining, particularly if the public health sector cannot compete with private.
-There will be limited scope for training in public health facilities at specialist level – with the possibility that much of specialist care gets moved to private.
We welcome the establishment of:
-The National Tertiary Health Services Committee responsible for developing the framework governing the tertiary services platform
-The National Governing Body on Training and Development responsible for advising the Minister on the vision for health workforce matters, for recommending policy related to health sciences, student education and training, including a human resource for health development plan
-We propose that the role of private medical schools or private training platforms and payment for training as part of service delivery needs to be clarified

Pathology Services
-Unlike the general clinical training platform where there are multiple provincial bodies responsible for the interface of service and training, the NHLS is the sole custodian of pathology in South Africa (in partnership with universities).
-Thus, there is no redundancy in the system, and special care should be given to this critical national platform
-We are supportive of the pathology sector’s move towards greater quality of service, and laboratory accreditation.
-Neither the NHI Bill nor the White Paper gives any guidance as to what form, level and timing of laboratory accreditation will be required.
-Both the NHLS and private laboratories will need to give assurance of accreditation and quality standards at time of contracting.
-No guidance is given as to whether provinces (or districts) would contract private pathology service providers, or whether the entire mandate would be allocated to the NHLS, which in turn would then contract the private sector for segments of the population. This needs clarification
-We propose that the NHLS be the primary custodian of pathology services everywhere, and that private laboratories bid through open tenders for specific parts of the country. It may be possible to pre-specify the proportion of the national pathology work that is available to private providers (at pre-specified costs per test) using this mechanism.
-The NHLS also has a research mandate
-The current grant given to the NHLS (separate to fees-for-service charged by the NHLS) to support pathology teaching, training and research is woefully inadequate, and is subsidised by the general budget of the NHLS.
-The new system needs to acknowledge that reality, and ensure that there is adequate funding for the teaching, training and research mandates of the NHLS.
-The importance of the NHLS to the universities should not be understated. However, the Bill gives no clarity on the ongoing relationship, and how teaching of pathology will be structured and funded.
-Every university with a health science faculty is reliant on a functioning NHLS and a healthy teaching/research relationship that supports the discipline adequately.
-Other matters relating to costing of pathology, logistics, infrastructure, etc are critically important, but the University of Cape Town supports the NHLS submission in this regard


(See Presentation)

Mr Sokatsha asked a question in relation to the transitional arrangements. Section 57 articulated the phasing approach based on financial resource availability – was this not sufficient in terms of transitional arrangements? Was the presenter suggesting that the advisory committees needed to advise Parliament, instead of the executive responsible for health, being the Minister.

Mr Munyai stated that the health benefits should not be listed in the Bill because they could change per the advice of the Benefits Advisory Committee. There was a view that the NHI needed to be implemented straight away and yet in the Bill clarity was provided saying that it needed to be instituted in an incremental manner. What was the presenter’s view on that – did it need to be implemented immediately or in a phased approach? He asked whether they supported NHI.

Ms Gela referred to section 33, she asked that the presenter clarify the recommendation made by the Health Market Inquiry – was he supporting the duplicative or complementary funding system?

Dr Thembekwayo referred to chapter seven on matters relating to the advisory committee and the incremental implementation approach. She requested that the presenters make detailed suggestions relating to the sections. She had hoped that the presenters would have indicated suggested amendments in that manner. She noted that the presenters had requested clarity regarding where training would take place and how the trainers would be contracted. Was this not expected from them as a university – to make suggestions relating to the training in terms of specific sections in the Bill? The same applied to the section on pathology services, where it was stated that they needed to be given guidance on what needed to be done. It would be better if they provided guidance in terms of specific sections.

Ms Wilson expressed that one of her concerns was that they were getting presentations that highlighted concerns but not specific suggestions. Extensive written submissions were submitted, it was important that the Committee received the full written submissions from those who had presented over the last couple of days – a lot may have been misinterpreted as a result of it being a short presentation versus a long explicit report submission.

She referred to the phased approach and the pilot project. In principle that project failed because there were no measurable; there were no specifics relating to what those pilot sites were supposed to do. There were no specifics given as to what area of health they would target (i.e primary health). In terms of the phased approach – one could not do NHI if it was not a phased approach. The Bill could not be implemented without specifics relating to the phases and priorities. In terms of the lack of evidence – as a result of the unsuccessful pilot projects – would the presenters suggest that perhaps they needed to run some more pilot projects based on explicit measurables and results using the priorities of health (i.e mother and child and primary healthcare). Once it was established how well those went – and how the NHI Fund would cope in those situations – the Bill could be passed.

Ms Ismail requested the presenters view on the NHI pilot projects that took place and what was their view was on the potential success of NHI – based on the pilot projects.

The Chairperson asked whether the presenters were aware of the Presidential Health Compact document. If not, it may assist them. He viewed that document as an enabler of NHI. It actually said, ‘until and unless there was a significant improvement by government on those issues it would not be possible to realise NHI.’ Section 57 of the Bill outlined the role of provinces – could they express their opinion on that. He asked what the presenters view was on the centralised system and the associated role of provinces in that regard. The Presidential Health Compact document spoke of a phased-in approach in relation to implementation. They were trying ‘to build an aircraft as they flew it.’

Prof Green-Thompson stated that the Presidential Health Compact was an important document and they had not cross-referenced as a result of the speed with which the presentation was engaged.

Ass Prof Susan Cleary, Health Economist and Health Systems Researcher, UCT, stated they were all hugely supportive of the concept of universal health coverage and the promise that it held for increasing equity and access to health services as well as for social justice. Their submission came from that stance. The faculty forum in which they were involved, was very much around how they saw, or what changes did they feel needed to be made to the Bill. If one looked at the written submission, one would see that they had been quite constructive in many areas and they had made a number of suggestions about what they thought would be useful ways forward toward the achievement of NHI.

Many of the things that were covered in pilot sites, were not necessarily key issues within the Bill. The Faculty was supportive of an approach that tried things out and paused and assessed to what extent it was working. There were things like strategic purchasing, health technology assessments, being explicit about the benefits package and all of those things were currently untested – but could be tested. These things could be taken forward relatively quickly. The Faculty would support that approach. In terms of the advisory committees and who they should report to, within their submission, it was outlined that there needed to be transparency and accountability in terms of who appointed the chairpersons of boards and who appointed the Chief Executive Officers (CEOs). There were a number of different committees that were proposed – this was contained in the Faculty’s written submission. The Faculty was concerned about the number of times the Minister was mentioned within the Bill, in terms of appointing key chairs. Suggestions were made in their submission that there should be greater involvement of civil society, transparent processes and academia should be included in some of those appointment processes.

Assoc Prof John Ataguba, Health Economist and Director of the Health Economics Unit (HEU), UCT, stated that the submission was done almost two years before. A lot of things had changed and evolved since then. The Faculty supported the NHI 101 percent. They supported what NHI sought to achieve, especially given the history of the Country and where it was currently – they could not let this window of opportunity pass them by. They were keen to help shape the NHI in such a way that it became the baby for the country, that would deliver on its promises. In terms of the learnings from the pilot – the pilot was a misnomer. It was essentially not piloting the NHI – it had aspects that were within the NHI. If one understood that – one would understand that because the pilot was unsuccessful it did not necessarily mean that NHI was unsuccessful. The pilot only contained a few elements of what NHI sought to achieve. The most important thing that NHI sought to achieve was the Fund. There were some lessons to be learned from the pilot – that was where they came in, as academics, to see what the pilot was able to achieve. Health sector reform was a gradual process. They were aligned with the phased-in approach of the NHI. There were many aspects to look at. In their submission they looked at the possibility of having the NHI contracting with providers – not directly – while it was being strengthened – contracting could be done at a certain level, i.e provincial level and then filter down as it was phased in. Section 33 of the Bill spoke to the role of the private medical schemes when the NHI was rolled out. The Faculty did not support the concept of duplicate cover – they wanted one health system. If there were private medical schemes moving forward – they could only provide services that were not covered by the NHI. This should be phased in. It was not a matter of turning a switch and it would be implemented. There needed to be some intermediary steps.

Prof Green-Thompson stated that they would look at the Bill again, in terms of training and try and comment on what they thought should happen. The Faculty’s commitment was to continue to train in an environment which cut across the platform entirely from primary care all the way to tertiary services. They would respond in writing to any unanswered questions.

Ms Ismail stated that she was more concerned, given the responses, in relation to the pilot projects. She requested clarity regarding some of the responses. She got the impression that the pilot projects did not do enough to give them an idea of how the NHI would be implemented and how it would function. What was the purpose of the pilots if there was no minimum length? Did this mean that the NHI had not been properly piloted? How would they ensure successful implementation without pilot projects or research to support implementation?

Ms Wilson stated that she was basically covered by Ms Ismail – she had largely expressed the same concerns that she had. It was critical that the Committee got copies of the full submissions that related to the oral submissions they had received. This would include the detail they were looking for that was not specifically included in the presentation.

The Chairperson stated that the UCT Health Sciences Faculty could not answer the question – as they were not the creator of the pilot projects. Why were they not asking the relevant people about that instead? The Faculty was free to comment on that – but he did not feel that it was a fair question to pose them.

Mr Munyai stated that he was covered by the Chairperson’s remarks.

Prof Green-Thompson stated that his sense was that the questions revolved around the pilot projects. He would accept the mandate to look at the evidence that existed outside of that and offer an opinion in that regard. He did not have the terms of reference of those reflections or the questions that were expected to be answered through the pilots. That could form part of their reflections.

Presentation by the Faculty of Social Science and Humanities, University of Fort Hare (UFH)
Ms Lucille Hendricks, Counselling Psychologist and Lecturer, UFH, presented to the Committee.

Response to the Bill
-In a society where trauma, suicide, violence, depression, sexual abuse, substance abuse, and unemployed and poverty has become a norm, it is imperative that one recognises the value and contribution of preventative work, in particular the role and effectiveness of Psychologists and Counselling Psychologists in particular.
-Community-based mental health services are highly desirable.
-Ideally, mental-health professionals should be available to citizens, as specialist services to which a Primary healthcare team can refer.
-This is not addressed in the NHI Benefits.
-General Mental Health needs to be integrated more effectively into the National Health Insurance Bill
-Assurance equitable access to health services for all people needs to prioritised
-Mental health expertise need to be included in the advisory structures of the National Health Insurance Bill
-The area of preventative work needs to receive appropriate funding, and support (the ramifications of these psychological stressors and events negatively impact on the families, communities and greater society).

Specific comments on the Bill
-As mental health professionals, we commit in particular to providing input relevant to supporting a health care system, which will improve access to mental health care in South Africa.
-Goal 3 of the 17 universal Sustainable Development Goals (SDGs), in force since January 2016, explicitly notes the centrality of mental health and wellbeing to overall health status of nations. Sub Goal 3.4 states: “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being”. Sub Goal 3.5 states: “Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol”.
-Goal 3 is also acknowledged to underpin all other goals. The priority groups identified for special focus by the SDGs are women, children, the aged, poor people, and people with disabilities (which includes people with intellectual and psychosocial disabilities).

-In order to achieve Goal 3 above
-Counselling psychologists already assess, diagnose and intervene with people in dealing with life challenges and developmental problems to optimise psychological well- being.
-However, there is a gap between the vision and the practical implementation of above objectives.
-In order to achieve these objectives, we propose that the NHI budget funding should reflect this goal. We propose that a third (30%) of the NHI funding should be set aside for professional preventative interventions in order to achieve the goal of general mental health for individuals, families, groups, and communities.
-The NHI Fund should offer our country the opportunity to develop and implement interventions focused on three mental health related issues.
-These are, (1) the promotion of healthy lifestyles and mental wellbeing, individually and within communities, and not only within health facilities; (2) We suppose a more robust embedding of a mental health orientation to physical health promotion and treatment services; and (3) providing adequate mental health services for people with enduring mental illness (psychosocial disability) within our health system.

-In a society where trauma, suicide, violence, depression, sexual abuse, substance abuse, and unemployed and poverty has become a norm, it is imperative that one recognises the value and contribution of preventative work, in particular the role and effectiveness of Counselling Psychologists.
-Counselling Psychologists should be appointed on the Benefits Advisory Committee and health Diagnostic related groups.
-Recently, South Africa’s national lockdown presented serious risks to public mental health in a society where one in three individuals develop a psychiatric disorder during their life. Authors Kim, Nyengarai and Mendenhall (2020), evaluated the Mental Health Impacts of the COVID-19 Pandemic in Urban South Africa, and reported that citizens experienced extremely high “anxiety, financial insecurity, fear of infection, and rumination. Higher perceived risk of COVID-19 infection is associated with greater depressive symptoms among adults with histories of childhood trauma during the first six weeks of quarantine. High rates of severe mental illness and low availability of mental healthcare amidst COVID-19 emphasise the need for immediate and accessible psychological resources in South Africa”.
-Community-based mental health services are highly desirable and needed.
-Ideally, mental-health professionals should be available to citizens, as specialist services to which a Primary healthcare team can refer. This is not addressed in the NHI Benefits however.
-Furthermore, the lack of attention given to Counselling Psychology in the NHI Bill forces us to question if the Bill is working against making psychological services more relevant to the vast majority of South Africans, and against promoting decolonialisation where its emphasis is on dismantling vestiges of supremacism?
-In July 2019 a call to provide mental health and forensic services was published by the national directorate for mental health, and called for submissions by registered counsellors and clinical psychologists only, thus excluding Counselling Psychologist who work daily in these areas within our communities.
-As one of the major role players for achieving the mental well-being of individuals, families and communities, Counselling Psychology, deserves to be recognised and prioritised in the NHI Bill.


(See Presentation)

The Chairperson referred to the Constitution, section 27 which stated that ‘everyone had a right to have access to healthcare services, including reproductive healthcare.’ Point two stated that ‘the State must take reasonably legislative and other measures within its available resources to achieve the progressive realisation of each of those rights.’ It did not say ‘ophthalmic health services’ nor ‘adolescent and youth services’ nor ‘men’s health’ etc.’ Why did the presenter feel that it was not covered under the overall provision of ‘healthcare services’. Healthcare services surely covered all of that. He asked the presenter to provide clarity in that regard.

Mr Sokatsha asked a question in relation to mental health funding, if it was stated in the Bill and needed to be changed, would it not require the Bill to be brought back to Parliament for amendments? Was it not better to include it in the Money Bill which was tabled annually by the Minister of Finance. The presentation focused mainly on mental health, as if it was a standalone discipline. How did they reconcile this?

Ms Gela asked whether the presenter was implying that funding for training healthcare professionals should be included in the NHI Fund.

Ms Ismail noted that the presenter focused on mental health – she understood the reasoning why. She asked for the presenter’s view on Life Esidimeni and how it was handled. Did the presenter feel that NHI was implementable in its current form – given the existing failures in the current health system? Did the Faculty feel that the NHI was implementable immediately or pretty soon given the lack of sufficient services? After COVID-19, which impacted residents due to loss of family members, illness, loss of incomes, retrenchments etc, was the NHI workable? Had the presenter considered the NHI pilot projects? Would the presenter support the NHI as it was?

Mr Munyai asked that they explain and provide evidence for the figure of 30 percent that the presenter highlighted. What percent out of the 30 percent would the presenter assign to mental health? Did she agree with the two-tier system? The originator of the pilot site of the NHI, was not any of the presenters, it was the Department. That point needed to stand, as previously clarified by the Chairperson.

The Chairperson noted that worldwide when there were budget cuts on the Department of Health, for whatever reason, mental health was the one that suffered most in the whole basket of services that was provided. Did the presenter not think they should create a group of activists? Even if there were budget cuts – they should not let mental health be the first one to suffer – why should it be like that?

They had previously listened to presenters who stated that no money should be allocated to asylum seekers, the Bill put forward particular package of services that could be accessed by asylum seekers. The presenter had suggested that the provisions that were there might not be adequate – what would be her suggestion in terms of funding asylum seekers and illegal migrants. How big was the purse of South Africans in taking care of its own citizens – and how many citizens from other parts of Africa would they be able to accommodate going forward? He requested her insight and suggestions in that regard. He asked whether there was a general concern relating to lack of quality in the sector.

Ms Wilson asked where the mental health sector saw themselves fitting into health. Should they be considered under primary healthcare? How was the cooperation with South African Social Security Agency (SASSA) social workers – what was the link with them and mental health?

Ms Hendricks stated that in terms of funding, if it was not in the NHI Bill, the precedent was set that mental health was not important and should not be prioritised. If there was no budget allocated for mental health within the NHI Bill, it would suggest that it was an area that could be side-lined.

In terms of focusing on mental health – the Faculty was aware that there would be other individuals who would be speaking more broadly or specifically during the hearings on the different areas. The Faculty gave quite a lot of input when they did their combined submissions with the Psychological Society of South Africa (PsySSA), in terms of specific rewordings. Part of their departmental decision, in giving this presentation, was to focus on speaking from their mental health position, because that was where their expertise lay.

She had not implied that funding should be indicated in the Bill toward training.  She thought it might be unfair to take from the NHI for training of the individuals. Although in theory it did need to be supported – in terms of up-skilling of people and proper remuneration of people on the ground.

She stated that the Esidimeni case was a tragedy. If they looked at the things that were still ongoing in terms of monitoring and capacity development, residential care and care for people with disabilities and the elderly – there was still a lot of psycho-social distress. In general, the lack of attention to services, that would have mitigated those risk factors in the service delivery of mental health and health service delivery, it was quite a tragedy and they should have done more. That was a hard lesson for them to learn as South Africans and health care providers in general.

In terms of the implementation of NHI as it currently stood. She disclaimed that this was her personal view. When she had looked at the report on the pilot project and the stark lack of representation of mental health services reported on in the report - she did not have much confidence in the NHI Bill as it stood. However, as a whole she did support the Bill in theory. She was concerned about the implementation of the Bill as it stood – there was still a lot of uncertainty around the practicalities and operationalisation of the Bill. Conceptually the Bill was something they could work with. It was better that they had something they could work with, that they could implement and then consider the shortcomings of. They would need to look at how to mitigate potential difficulties coming through - especially when they looked at their other supporting agencies within government, such as the Department of Labour or Home Affairs. Issuing of identification (ID) documents might be an issue that would impact the registration process. They would likely need to create temporary access measures. If they could find ways to work around those issues – they could look at implementing the Bill on a much broader scale and they could look at mitigating some of the risk factors as they moved along.

In an ideal world, regardless of one’s economic status, regardless of how much tax they paid – if every single person had access to the same quality of healthcare, citizens would be a lot more accommodating of each other and a lot more vested in the Country. The separation of the rich and poor caused a lot of issues amongst citizens. Some people had to wait months to years to get access to treatment, that others could just pay for and receive. That was an unfair system. She fully supported the NHI Bill, where every single citizen had access to the best healthcare. In terms of the appropriating of 30 percent – she could not answer this off the top of her head – she would need to revert back to her Department and look at exactly what they budgeted r in terms of preventative programmes and why they looked at 30 percent of the NHI funding budget.

The ideal would be to see mental healthcare as a part of primary healthcare. There was quite a monopoly in terms of private healthcare that had forced psychology out of primary health within government institutions. For example, if one considered the job advertisements that went out from the Department of Health, it was rare to find a post for psychology within the public health sector. Sometimes there were posts for clinical psychologists but not counselling – that was why they wanted to have the conversation with the Committee about including counselling into the NHI Bill. Work was done at a grass roots level with the community; preventative work needed to happen in that space. It also needed to be incorporated into primary healthcare. She would get back to them in writing regarding the issue around SASSA.

Closing Remarks
The Chairperson stated that the House Chair had agreed that they do oversight in Gauteng. They wanted to try and visit two districts. Details would be provided on that.

The meeting was adjourned


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