National Health Insurance (NHI) Bill: public hearings day 7

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15 June 2021
Chairperson: Dr S Dhlomo (ANC) & Dr K Jacobs (ANC)
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Meeting Summary

Video: Portfolio Committee on Health, 15 June 2021
Audio: National Health Insurance (NHI) Bill: public hearings day 7
Document: Speech-Language Therapists and Audiologists in South Africa

NHI: Tracking the bill through Parliament

Organisations representing a wide range of medical disciplines presented their opinions on the National Health Insurance (NHI) Bill and welcomed the initiative to improve access to quality health care services to all South Africans, and proposed a number of recommendations in relation to the Bill.

A joint presentation was given by practitioners in the field of rehabilitation, comprising the South African Association of Audiologists, the South African Speech-Language Hearing Association, the Occupational Therapy Association of South Africa, the South African Society of Physiotherapy and Rural Rehab of South Africa. They emphasised that rehabilitation practitioners were not allied health professionals, but registered practitioners under the Health Professions Council of South Africa, and that this should be noted in the Bill. The organisations supported national health insurance and the principle of universal health coverage.

Issues relating to human resources were outlined in the context of the transition to NHI. It was highlighted that sufficient piloting needed to be conducted before comprehensive implementation of the Bill. A number of transitional arrangements were outlined. Considerations relating to contracting were emphasised, as well as financial matters contained in chapter 10 of the Bill. Issues around accreditation were noted, specifically section 39(7) of the Bill, which stipulated a five-year renewal process for health service providers. Recommendations were made in relation to governance structures, as outlined in the Bill.

Each of the five organisations presented sub-presentations.

The South African Association of Audiologists highlighted the education and medico-legal exclusions in the Bill. Limited healthcare coverage, first line practitioner exclusions and frozen posts relating to governance for rehabilitation specialists were outlined. Their recommendations were aimed at addressing these exclusions.

The South African Speech-Language Hearing Association presented a sub-presentation to the Committee. A brief automated presentation was given. This highlighted the role of practitioners in a person’s life, specifically in terms of the role of speech therapists and audiologists. Various statistics were shown relating to the inequity in accessing care and the provision of care across the country. It was highlighted that the Bill placed the NHI as a funding strategy. Concern was raised regarding the potential to exacerbate existing inequalities. 

The Occupational Therapy Association of South Africa's central concerns were around the financing of national health insurance and its impact on the provision of healthcare to those in need. Concerns relating to the role of healthcare providers in that context were outlined.

The South African Society of Physiotherapy outlined the scope of physiotherapy, as well as recommendations relating to the Bill. It was suggested that patients should not be limited in terms of choosing their healthcare provider/service, that pockets of excellence should be considered in the accreditation and contracting of services. It was suggested that more pilot projects were required to test contracting, service provision and different reimbursement models.

The Rural Rehab of South Africa highlighted the worst inequities in relation to the provision of healthcare. Challenges in the provision of healthcare to persons with disabilities, poor inter-sectoral collaboration and access for stateless and migrant persons were emphasised. Concerns relating to the rural context of providing healthcare were outlined, and attention was drawn to issues relating to transportation. Contracting issues were highlighted, and it was suggested that piloting was required in that regard.

The Committee noted the state of the healthcare system, particularly in rural areas, as outlined in the presentations. The need for piloting was acknowledged. It was further noted that pilot projects had been conducted but had provided little substantial information or data, as no measurable standards were incorporated into the study design. It was suggested that more piloting needed to take place. Members commented that most of the presenters were based in the private sector, and suggested that this resulted from a lack of posts within the public sector.

They queried whether the presenters’ suggestion to maintain a form of private funding would promote a two-tier system, which would exacerbate existing inequalities. They asked whether the children highlighted in the presentation as having to go to school in wheelchairs because of the unavailability of transport attended ‘special’ or mainstream schools, and wanted to know whether transportation did not cater for wheelchair users. Members asked whether issues around the package of services and comprehensive coverage could be resolved and decided by the Benefits Advisory Committee. Issues around financial risk were noted, and it was asked whether the Bill did not sufficiently cover this, in reference to section 10(2).

Clarity was requested regarding the presenters’ statement that the NHI was a funding strategy and not a strategy for access to healthcare. The Committee stated that an overview would be provided in the amendment of the National Health Act, relating to health technology, and asked whether this would cover the presenters’ concerns.

The Dullah Omar Institute highlighted that the NHI Board played a critical role in terms of finance, redistribution of healthcare services and the equitable provision of services across urban and rural areas. It suggested that the legislature, Parliament, should play a bigger role in the NHI than currently envisaged, and that the President should make the final appointments relating to the Board. The composition and issues around the dissolution of the Board were outlined. The Institute also indicated that there was confusion in the Bill around the role of the district health management offices. It also suggested that sufficient mechanisms needed to be put in place to limit the opportunity for corruption.

The Committee commented that the role of the provinces went beyond what was outlined in the Bill. It asked whether section 36 of the Bill covered the presenter’s concerns relating to the role of districts in the provision of health services. It noted that the Institute supported the single payer system, and pointed out that the suggestion relating to the President’s final say on appointments of the Board might require a Constitutional amendment, and asked whether this was what the Institute proposed. Questions were raised relating to the freedom of choice in relation to healthcare providers.

The South African Orthotic and Prosthetic Association referred to the challenges its members faced in the provision of orthotics and prosthetics. Proposed solutions were outlined, including increasing accessibility, the upgrading of facilities and machinery, and the implementation of the ideal hospital/facility framework. The implications of the NHI as medical insurance management were discussed, and the impact on referral pathways was outlined.

The Committee asked what the Association’s understanding was of equity, and questioned whether the presenters could offer any solutions or proposals in relation to the issues they had highlighted. Did the presenters understand that acts were enabling, and that regulations followed after one had a framework in law? The Committee requested clarity regarding a proposal involving the Money Bill. It asked whether the Association regarded the Road Accident Fund, Workers Compensation Assistance and healthcare benefits as part of the social security platform intertwined with the objectives of the NHI.

The South African Society of Anaesthesiology outlined the context of the implementation of the NHI, drawing attention to the national lived experience relating to corruption, the cost of healthcare and the lack of sufficient human resources. It stated that the Bill contained preconditions that might threaten quality patient care centres, access to care and enable fiscally unsound principles. It highlighted that it had the potential to override independent regulatory oversight.

The Committee asked the Society to comment on the matter of the Presidential Health Compact, specifically in terms of ‘building the aircraft as it flew.’ It asked whether medical aids currently sanctioned professionals. Clarity was requested in relation to the migration of doctors from the public to the private sector. It asked whether information relating to the information technology (IT) system should be detailed in the Bill. Did the Society think that funds were well-spent in the private sector, given the Health Market Inquiry? What would be deemed to be sufficient human resources? Did the Society support the NHI model as presented in the Bill?

The Occupational Therapy Association of South African outlined the need for clarity relating to funding, and presented suggestions in that regard. The certificate of need was described in terms of the accreditation of providers by the NHI Fund. The Association welcomed universal health coverage as a human right.

The Committee asked whether the Association considered the Road Accident Fund and the Compensation for Occupation Injuries and Diseases Act as part of the social security platform. Should all 88 disciplines regulated by the Health Professions Council of South Africa be represented on the Benefits Advisory Council? Why did the Association consider asylum seekers to be neglected in terms of emergency care coverage? It asked whether the Association was familiar with the Presidential Health Compact, and whether the certificate of need was the same as accreditation. It also wanted to know whether the presenters were familiar with the health market inquiry.

The South African Society of Cardiovascular Intervention outlined the implications of the health market inquiry, and relevant aspects to consider in relation to national health insurance. The role of funding in the running of the national health insurance system, and the potential for corruption and governance outcomes, was highlighted. The Association’s major concerns were centred on the lack of governance, the provision of funds for academic medicine and centres of excellence, strict adherence to rigid pathways, and the role of private healthcare. It commented that information on the outcomes of the pilot sites, the National Treasury financing paper and the availability of basic infrastructure, was still outstanding.

The Committee requested clarity regarding the presenter’s concern that improved primary healthcare would uncover an increased demand for tertiary care. It asked what specific governance structure the Society wanted to see implemented, specifically in terms of preventing corruption. Did the Society not see NHI as a solution to the dysfunctional two-tier system? What was its opinion was on similar systems, such as the National Health Service in the United Kingdom?

The Cancer Association of South Africa highlighted the message from "The Elders," and the related recommendations that the Association supported. This included the need to tackle corruption in the health system and the need to develop protocols. Concern was raised regarding the lack of detail regarding the funding of the NHI. It was suggested that the NHI would experience a number of constraints if not well planned for, given the weak macroeconomic conditions, the fiscal pressures on government and the exponential burden of disease. It pointed out that with the centralised control, the vaccination roll-out had been difficult to effect. Recommendations were made in relation to the multiple funding streams, the advisory committees and referral pathways. Concerns relating to cancer specific health benefit coverage were outlined. The governance structure of the NHI was also questioned.

The Committee acknowledged that the South African Medical Research Council had reported that over the previous three years there had been a 30% increase in the number of cases of cancer in the country, and expressed its concern at the lack of sufficient facilities to address this, as well as the delays which impacted cancer patients' health status and outlook. It asked for clarity regarding the navigation systems, and wanted to know whether the presenter was suggesting that taxes directed towards NHI should be earmarked. The Committee stressed that the Special Investigating Unit had identified and was dealing with corruption decisively. The Association was asked whether section 48 of the Bill was not sufficient in outlining the sources of income of the NHI Fund. The Committee had seen at first hand the situation in the Charlotte Maxeke Hospital relating to the challenges of cancer patient care. If the presenters thought the registration process would pose challenges, what suggestions could be made in that regard?

Meeting report

Joint Rehabilitation Presentation

A joint presentation was given by various members of a number of organisations. The South African Association of Audiologists (SAAA), the South African Speech-Language Hearing Association (SASLHA), the Occupational Therapy Association of South Africa, the South African Society of Physiotherapy (SASP) and the Rural Rehab of South Africa (RuReSA) presented to the Committee the topic of rehabilitation. Thereafter, each organisation presented sub-presentations relating to rehabilitation in relation to their respective professions

Key points to remember about rehabilitation

  • Rehabilitation practitioners are not allied health professionals. Were health practitioners registered at the Health Professions Council of South Africa (HPCSA)?
  • Lack of opportunities for training, and regulatory body MLW.
  • Inter-sectoral collaboration, e.g. transport, labour/social grant, housing.
  • Social determinants – economic activity, physical environment, education, food security – access to healthy life, social integration and community engagement, health care system – quality of care.
  • Services provided from the acute to chronic phases, including community-based rehabilitation CBR.
  • Services provided throughout the lifespan of a patient -- challenges.
  • Ability of access to services should not be determined by income.
  • Multi-disciplinary nature of rehabilitation – experts in their own area.


  • Support in the principle of Universal Health Coverage (UHC).
  • Willingness to support and work together, improve the health services and quality care.
  • However, rehabilitation by definition involves exclusion from the National Health Insurance (NHI), and there were concerns about the scheme.

Regarding UHC, people should be able to access appropriate health services based on need and not their ability to pay.

The key principles involved were equity and financial risk protection, as well as:

  • Progressive realisation of restorative justice;
  • Accessible, affordable, appropriate, acceptable services;
  • Targeted strategies needed for vulnerable groups;
  • Experiencing inequities in access and outcomes

Using NHI to address inequities, using good Disability and Rehabilitation (D&R) practice examples, would include defining essential disability services, with minimum standards, contextualised guidelines and skills mix; reassessing data systems such as Statistics SA (StatsSA and the District Health Information System (DHIS); enforcing universal design; addressing FRP through decentralised service delivery; and attempting to strengthen inter-sectoral service delivery.

In the area of human resources, all possible referral pathways had to be explored. Current legislation and processes to establish partnerships were cumbersome and time consuming. A transitional solution would be for the national Department of Health (NDOH) to make session posts available; to provide access to private beds; to explore innovative finance models for MLW and disability workers through service level agreements with non-profit organisations (NPOs) and days payable organisations (DPOs), and tapping into the Expanded Public Works Programme (EPWP). The government needed to demonstrate a commitment to establish a fully integrated health system. Contracting of private sector therapists would be possible where there was a need. It was critical to examine the actual staff structures in the public sector.

General Input

  • In theory, contracting had the potential to address issues in coverage and quality of care;
  • Theory to implementation: Type of contract, payment approaches, whether incentives meet health objectives and health indicators selected, whether services are appropriately audited and contracts monitored, length of contract, and whether repercussions to non-compliance or poor performance are implemented determines success… did they have the capacity and the resources???
  • Transitional arrangements were welcome: health systems strengthening and addressing gaps in coverage and quality through interim measures, including addressing public sector posts in low resource settings, and selective contracting in key areas;
  • Piloting: no piloting had occurred with rehabilitation and disability services that they were aware of, so different models of care, aspects of care and types of contract and payment approaches should be trialed in different settings;
  • There were concerns around the lack of knowledge of D&R at all levels of the healthcare system, including the District Health Medical Offices (DHMOs) and Central Processing Units (CPUs) envisaged. There was potential for inappropriate budgeting and contracting. Would there be inclusion/participation of D&R representatives in these organisations?
  • There were fragmented and inaccessible D&R information systems, and they could not begin without baselines and the ability to monitor progress towards UHC.

Transitional Arrangements

For data, this would involve the disaggregation of general household survey (GHS) data to sub-district level, by disability status; the disability status should be linked to International Classification of Diseases (ICD)-10 coding and Health Patient Registration System (HPRS) inter-operability; determination of the HR distribution data (public and private), with possible assistance from the Health Professionals Council of SA (HPCSA); and a whole system analysis of the inequities in health utilisation and access, involving people with disabilities (PwDs).

Key gap areas would need to be identified and prioritised according to their impact, such as contracts at the primary healthcare (PHC) level involving neurological rehabilitation services, wheelchair seating services, psychosocial (disability) services, operation and maintenance (O&M) services, acute care neurological services (spinal cord injuries - including traumatic, infective and atraumatic, head injury, young strokes), and sessional posts in public hospitals for both inpatient and outpatient care.

Piloting the contracting of the above would require: 

  • Different settings, outcomes, referral pathways and retention in care, a skills mix including MLRWs/service level agreements (SLAs) with disabled people’s organisations (DPOs), information systems, and unbundling of key services
  • Inclusion in gap analysis and planning -- this should involve therapists from various settings and contexts, particularly those at coalface and end users, such as PwDs.
  • Urgent attention must be given to the MLRW deficit: issues in accreditation of training for select cadres, in training opportunities and post creation for all cadres, and in the establishment of a regulatory authority, which could perhaps piggy back on community health worker (CHW) developments?
  • Supporting health information systems were critical -- the inclusion of ‘experts’ from the coalface, as well as academia, information technology (IT) and data experts was critical. Without this, there was a risk of not knowing what worked and what did not.
  • Urgent attention to guideline contextualisation and development to support contracting and quality of care.
  • Strengthening the public sector D&R services now, as many opportunities had low costs or required organisational reform, including integration of D&R in planning at all levels across health programs and reviewing routine data systems.
  • Addressing key issues affecting inter-sectoral collaboration, budgeting and planning at all levels: integration of D&R as a cross cutting service, and socio-economic support (SES) and health outcomes dependant on inter-sectoral collaboration.
  • Addressing infrastructure backlogs, planned patient transport (PPT) and transversal tenders: universal design.

Contracting: Particular considerations

  • Accessibility: Longstanding access issues were largely around out of practice experience (OOPE), service structure/content, availability and acceptability of care, and community awareness/stigma.
  • Affordability: High risk of impoverishment through OOPE in accessing care by PwDs, and a need for decentralisation and care coordination.
  • Acceptability: High risk of loss to follow up for above reasons, with significant (costly) secondary complications, and a need for inclusion of PwDs in the planning and implementation of services.
  • Appropriateness: prioritise services with huge gaps in coverage and significant morbidity (moderate and severe disabilities, as well as early identification/intervention).
  • Cost shifting -- costs should not be shifted on to the patient and their families- vulnerability
  • Objectives, outcome measures and indicators needed to be determined for different services. Health systems' strengthening and community engagement take time!
  • Key aspects affecting quality of care and health outcomes were not currently reimbursable -- for example, inter-sectoral collaboration, multi-disciplinary and family meetings, administrative functions associated with coordination of care, community engagement, HCW training.

Financial Matters

  • No. 51 (1a): The Bill did not stipulate any corrective action and/or accountability if audit and financial records were not submitted timeously. 
  • No. 51 (3): On items included in the annual report, it was noted that there was no health outcome measure reporting to encompass health and disability and the impact on the economy.
  • It is not stated/ unclear how civil society and professional bodies would have easy access to annual reports.  

As recently as March 2021, the Auditor-General (AG) had called on government leaders to ensure:

1)   sustainable solutions, to prevent accountability failures;

2)   ensure consequences for accountability failures;

3)   prioritise improving financial management of auditees; and

4)   take opportunities for progressive and sustainable change.

  •       No. 54 (e):  Fine for theft and fraud: R 100 000 and less than five years in prison.

Their comments were that this hardly indicated a serious, robust intent to discourage fraud and corruption, and needed to be reviewed.

Timeframe of Accreditation

  • In section 39 (7) of the Bill, mention is made of a five-year renewal process for health service providers, which seems to exclude health establishments.
  • Health establishments should be included in the timeframe.
  • There should be ten years for stability and commitment to grow the health system.

Certification by Office of Health Standards Compliance (OHSC)

  • Agree that there must be standards to adhere to.
  • Work closely with the OHSC and provide inputs of what is required for rehabilitation facilities and providers.
  • There was great concern about facilities in the public sector which are not compliant, but were the only facilities in the area.  Government must be responsible and step in.
  • If the health provider was certified but the facility failed, could services continue?
  • Emphasis must be on facilities to ensure full accessibility for PwDs.
  • Listing and publications of accredited health service providers and health establishments must be published annually.
  • The Bill should allow the Board and Fund to outsource functions, such as accreditation by the OHSC

Governance of structures of the NHI Fund

  • All NHI governance structures must adhere to standards of best practice, as recommended in the King IV Report on Corporate Governance in SA 2016 (King IV).
  • A “no fault provision’’ must be added to the Bill.
  • An overt percentage cost for the governance structure should be specified so that it does not overrun essential funds for service delivery.
  • The Fund must be externally audited by a reputable independent company.
  • The range of powers of the politically appointed Minister of Health are a concern.
  • An effective and efficient board should be in control of key functions of the NHI Fund and service delivery.
  • Membership of the board and the Chief Executive Officer (CEO) of the NHI Fund must be appropriately qualified, and open to robust public scrutiny with a transparent process.
  • At least one of the members should be a rehabilitation professional (in consultation with the rehabilitation professional associations and societies).
  • All proposed Ministerial Advisory Committees must include an appropriate number and mix of health care professionals, and include rehabilitation professionals to ensure informed decision-making in respect of rehabilitation services. Also a mix of the contracted and employed health care professionals (HCPs).

Civil society should have:

  • A robust appeal committee and access to a reporting process.
  • Consumer satisfaction for health service must be in place to inform planning and strategies.

Centrally managed procurement and suppliers:

  • Need to be efficient to prevent long provision details.
  • Yearly reviews were not feasible.
  • Must include a separate spares and repairs policy for assistive devices.
  • Rehabilitation providers should be consulted about the procurement of professional equipment and assistive devices.

Implementation of the NHI

  • Support for full implementation by 2026, but implementation should not be time based (S 57), but milestone-based, to further explain (S 33).
  • Implementation should not affect the continuity of care of patients, especially where interruptions of care may cause harm. Accountability must be provided for in S 57 (transitional arrangements).
  • Health service delivery is inter-sectoral, but robust responsive relationships between the different departments -- Basic Education , Higher Education, Social Development, Transport (Road Accident Fund), Employment and Labour (Compensation Fund) -- are lacking in this Bill

South African Association of Audiologists (SAAA): Sub-presentation

Ms Liepollo Ntlhakana, President of the South African Association of Audiologists (SAAA), presented the sub-presentation to the Committee.

She said the SAAA recognised the need for health care reform in South Africa, and was supportive of the concept of a NHI model. However, there were aspects that needed further clarification, such as the role of the private practice in accreditation; the role of the Office of Health Standards Compliance; aspects of remuneration; the multi-disciplinary practice concept; and HPCSA rules

SAAA's view of NHI

There were three parts to these comments:

  • General: it focuses on doctors and nurses, education and medico-legal exclusions.
  • Healthcare services: Limited healthcare coverage, first line practitioner exclusions.
  • Governance: Frozen posts for rehabilitation specialists.
  • PHC and supply of devices

Recommended solutions

  • Inclusion of rehab specialists across all levels of service delivery.
  • Universal health coverage in line with the South African population and the audiologists’ ratios should be considered.
  • Availing of posts, bottom-up, from community service practitioners upwards.
  • Technology: buying and maintaining durable equipment and devices for audiologists and patients, e.g. audiometers, hearing aids.

South African Speech-Language Hearing Association (SASLHA): Sub-presentation

Mr Mershen Pillay, Past President, SASLHA, presented a brief automated presentation that highlighted the role of practitioners in a person's life. A number of statistics and graphs were shown in relation to equity in accessing care.


  • Impaired communication affects every aspect of a person’s life, including family, and work interactions.
  • A speech therapist and audiologist assists in the prevention, diagnosis, treatments and management of communication disorders.
  • Speech therapists were the only healthcare professionals who were mandated and trained about assessments and interventions for people with disorders.
  • The role of breast-feeding for long term health.

According to StatsSA, 5.2% of the population over the age of five years had disabilities in hearing or communication. There were vast differences between provinces and the provision of healthcare in terms of therapists to population ratios and the incidence of negation disability. Some therapists were responsible for 317 patients, such as in the Western Cape, rising to 4 061in the North West province.

The Bill

  • The Bill provided no clarity on how it intended to provide clinical provisions in terms of what was required for practitioners to carry out their jobs properly.
  • Services required a package of resources.
  • Space, equipment, consumables, therapy resources, assistive devices, and transport for staff and patients were needed to provide a comprehensive service.
  • New technologies were invaluable in the sector in relation to hearing and speech – and there was concern about how these would be sourced, monitored and allocated under the NHI Fund. The current budget for assistive devices in the public sector was limited, or did not exist.

Central concerns

  • The Bill placed the NHI as a funding strategy, and not as a strategy for the provision of equitable healthcare. It assumed that all the required services existed and merely needed to be funded for the general population to gain access.
  • There were vast gaps in the provision and equity of services in both the public and private sector.
  • The current inequity in accessing services would merely be exacerbated.

Occupational Therapy Association of South Africa (OTASA): Sub-presentation

Ms Anisha Ramlaul and Prof Patricia De Witt, of the Occupational Therapy Association of South Africa (OTASA), presented to the Committee.

They said that while OTASA supports the principle of Universal Health Coverage, the notion of a single equitable health care system, and the           provision of quality health care that includes rehabilitation to promote the health and wellbeing, the Associations concerns as health care providers were related to the financing of the NHI, and therefore the UHC.

Regarding the financing of the NHI, the Bill indicates:

  • No cost to the user at the point of service, but a lack of detail on how this quality health system would be funded and sustained, considering the state of the economy and the low growth rate.
  • Two sources of funding would add to the considerable tax burden of its members, as there would be a payroll tax for employers and a surcharge on personal income (Chapter 10 section 49).
  • There were no projected costs for setting up and sustaining the NHI structures and functions, nor the percentage cost of the total budget.
  • There was concern that the resources needed to support the NHI system would impact on the funds for service delivery.
  • An effective, efficient -- and therefore costly -- national information system would be required. The Bill does not speak to the cost of the development, maintenance and operationalisation of such as system. This was of concern, should this system be central to efficient service provision and control of the payment of service providers (Chapter 8: 40).

OTASA said the role of healthcare providers was to provide service delivery and continuity of care. Timeous and accessible ongoing intervention prevented disability, with a prescribed referral pathway, versus “a reasonable amount of time.” For many users, particularly those with mental health conditions, continuity of care was essential for health and well being, and the practicalities of these referral pathways required efficient communication and easy access, without long waiting times.

OTASA had concerns about future job security, remuneration and providing quality services with adequate resources and in an acceptable service delivery context. The Bill did not provide clear reassurance on these concerns. What service packages the NHI would fund was unclear, and therefore what occupational therapy services may be offered privately was inadequate for critical professional decision making.

Emphasis on evidence-based practice was welcomed as a function of the NHI. However, South African evidence to inform quality practice was weak owing to challenges with human and financial resources.      Emphasis on outcomes-based practice was also welcomed, but needed urgent attention and consultation.

South African Society of Physiotherapy (SASP): Sub-presentation

Ms Lonese Jacobs, Deputy President of SASP, said the Society was founded in 1924 and represented 4 092 of registered physiotherapists, physiotherapy students and physiotherapy assistants or technicians in South Africa. Its working environment was the public and private health sectors, covering hospitals, clinics, community health centres, sports institutes, private practices, academic institutions, schools, sports events, as well as employers. Its members provide services at all levels of the health care system -- primary, secondary, tertiary, specialised and rehabilitation levels of care -- and their national footprint could contribute to providing high-quality physiotherapy services. The SASP supports the universal health coverage philosophy envisaged by Section 27 of the Constitution of South Africa, and participation in the NHI legislation

A video clip was shown.

Ms Jacobs described the extensive scope of the profession, with the expertise to be recognised when contracting physiotherapists for the delivery of services under the NHI at all levels of care, including in the contracting units for primary health care services. Physios provided critical care to maintain and improve patients’ respiratory, mental and physical functions. Physiotherapy departments and practices at this level had the infrastructure, knowledge and the clinical skills to rehabilitate patients due to the complex nature of their conditions. They provided emergency services, such as when a patient aspirates or experiences breathing difficulties, or provided critical care in intensive care units (ICUs) and high-care wards. In hospital situations, physiotherapy was available one a 24/7 basis.


  • Persons must not be restricted in terms of where they choose to buy their healthcare services, and private health insurance should be permitted to offer voluntary comprehensive medical cover.
  • The pockets of excellence and expertise within the scope of physiotherapy should be considered in accreditation and contracting of services.
  • Engage with funders and the Council for Medical Schemes (CMS) for  evidence-based packages – neck and back; hips and knees, oncology.
  • Consider the findings and recommendations of the Lancet Commission -- those included in the Healthcare Market Inquiry (HMI) Report
  • More pilot projects are required to test contracting, service provision and different reimbursement models.

Rural Rehab of South Africa (RuReSA): Sub-presentation

Ms Maryke Bezuidenhout, Rural Physiotherapist of the Rural Rehab of South Africa (RuReSA), presented to the Committee, and said people with disabilities should be prioritised for services, particularly in quintiles 1 and 2. Rural and low resource settings had the worst inequities in service coverage, access to assistive devices and health outcomes at present, and should be prioritised. Service design affected access, utilisation, retention in care and health outcomes, and was affected by contracting and payment approaches, as well as meaningful integration of D&R across programme planning and implementation, and the inclusion of PwDs as end users in planning and implementation.

Inter-sectoral collaboration was poor, and they would never achieve good health outcomes without a holistic approach. Community-based rehabilitation (CBR) was an appropriate strategy for this at grass roots, but was currently ‘on the margins’ of NHI considerations.

RuReSA was supportive of the transitional approach suggested in earlier slides, and there was an urgent need for gate-keeping to increase the quality, availability and accessibility of care at the PHC level. Undocumented migrants and stateless persons should have access to comprehensive services based on a needs analysis. Savings gained through efficiencies and governance should be able to cover this vulnerable group.

Key issues

  • Recognising PwD as a priority group.
  • How does one provide rehab when hospital discharge rates are so high, and poverty prevents access to rehab?
  • Service design must address underlying causes of inequities and barriers to uptake and retention in care.
  • Rehab standards need to be established for multi-disciplinary teams (MDTs), equipment and consumables, and service packages.
  • There must be coordinated care across platforms and professionals.

Referring to specific concerns, Ms Bezuidenhout said PHC services required longer term commitments, and significant health strengthening and community engagement was required.

She asked what the specific plan was for institutions/practices not meeting accreditation standards in LRS -- did it include incentives and timeframes? What was the specific plan around CPUs not meeting the full health benefits package? Transport to neighbouring sub-districts was not acceptable for moderate and severe disabilities. What was the turnaround time for compliance?

She said D&R planning and service implementation needed to be at sub-district level for coverage and quality. MLRW was a critical component for coverage, quality and acceptability, so urgent and immediate progress was needed. The retention of civil society organisations (CSOs) in LRS as an initial start towards addressing coverage concerns should be considered.


The unbundling and funding of key PHC services that involved significant health systems approaches, required specific skills not often available in general practice, or required significant inter-sectoral and community engagement. These unbundled services should still intersect and collaborate closely with general rehabilitation services provided within institutions and clinics. The piloting of different aspects of D&R services in different settings was required before final decisions were made. Health care provider/establishment contracts must have specific requirements around the need to budget and provide for D&R services. There were data requirements to do needs assessments and design, and to manage contracting. Should MLRWs be integrated into contracting?

Possible uses of contracting included:

  • Building MDT within the facility -- “making up the numbers” (outpatients, inpatients).
  • Contracting private providers to cover services difficult to access in rural areas in the short and medium term -- e.g. acute care neurological rehabilitation facilities.
  • Contracting in urban areas to allow a shift of DoH workers to under-resourced areas
  • Contracting to free up “DoH rural/PHC experts” to do PHC/CBR instead of “hospital based service.”
  • Contracting local NGOs/NPOs/DPOs to cover services needed but not provided -- for example, peer supporters.
  • Contracting post-community service therapists towards building capacity of rural and LRS workforces.
  • Unbundling specific services.


Ms E Wilson (DA) appreciated the presentations and noted that it was extremely distressing to hear about the state of the healthcare system, particularly in the rural areas. Universal health coverage meant that people would be able to access appropriate quality healthcare services – that was across the board, regardless of who they were and their status. People needed to be able to access quality health services. She referred to the slide on assisted-devices backlogs in the provinces, which showed that very few, particularly in the rural areas, had access to proper healthcare, let alone rehabilitation services. This was extremely concerning. She was glad that the presenters had raised the issue around piloting.

Pilot projects were conducted in relation to the NHI, but the pilots had provided no information or data whatsoever. This was because there were no measurables put into the pilot project. This was something that the Committee needed to consider further. She suggested that more piloting needed to take place, and she was glad that the presenters had emphasised this in their presentation. There needed to be a complete picture of the healthcare needs etc.

Dr K Jacobs (ANC) noted that they had many functions relating to rehabilitation in both the public and private sector, as shown in the presentation. He commented that most of the presenters were employed within the private sector – and this was suggested to be due to a lack of available posts within the public sector. Regarding the concerns raised regarding being recognised within the NHI Bill, he understood the need for that. Could this not be captured within the regulations, rather than the Bill? He queried whether the presenters' suggestion to keep private funding would promote a two-tier system which would in turn exacerbate the existing inequalities. Section 33 of the Bill aimed to prevent a parallel health system. Those who rejected the NHI seemed to support a parallel system. He understood that it was very costly to conduct rehabilitative services, whether one was an audiologist or an occupational therapist etc. It was an expensive field of medicine. The NHI aimed to reduce inequalities by providing quality healthcare to all.

Ms M Hlengwa (IFP) asked whether the children with disabilities, who were highlighted in the presentation as going on wheelchairs to school, went to special or mainstream schools. If they were going to mainstream schools, was there provision by the Department of Education and the Department of Transport for their transportation? She noted that the usual transportation did not cater for wheelchair users. Was this not seen as a priority? She asked whether the audiologists were placed in all hospitals, or only in private hospitals.

Mr T Munyai (ANC) said that the South African Society of Audiologists had suggested that rehab specialists should be placed across all levels of service delivery. A package of services would need to be developed to ensure that services were comprehensive – would this not be decided by the Benefits Advisory Committee, in order to determine cost effectiveness? The presenters made reference to clause 4, which dealt with the eligibility to become beneficiaries of the Fund. Clause 4 provided that the Fund must, in consultation with the Minister, purchase comprehensive service benefits as determined by the Benefits Advisory Committee. He asked whether they had raised the issue of technology – of buying and maintaining durable equipment and devices for audiologists and patients. Were the presenters worried that the Bill was not adequately addressing those matters? Did section 57(3)(d) answer the presenters’ concerns?

In respect of physiotherapy, the presenters had indicated that they wanted to see a private sector medical aid. Were the presenters happy with the current two-tier system, where a huge percentage of money ‘from the government went to the private sector,’ and the majority of the people were excluded? He asked that they clarify whether they supported the issue of equitable healthcare. Did the presenters support the NHI?

Mr M Sokatsha (ANC) asked whether the team was suggesting that the pockets of excellence and expertise within the scope of physiotherapy should be considered in the accreditation and the contracting of services. Did they have an opinion on section 39 of the Bill, which outlined the requirements for accreditation to ensure quality services were provided? Was there a reason why those who delivered ‘excellent’ services would not be accredited, as outlined in section 39 of the Bill? He asked which of the findings and recommendations of the Lancet Commission needed to be included in the NHI Bill.

Dr Jacobs asked to speak about a couple of comments that were made during the presentations. He referred to the statement made by the presenters that rehabilitation practitioners were not allied health professions. All allied health practitioners were registered with the Health Professions Council of South Africa (HPCSA). Was there a section in the Bill that stated that rehab practitioners were allied health workers? What type of practitioners were they? Throughout the Bill, according to his understanding, rehab practitioners were listed with other health professionals.

He addressed the concern highlighted by the presenters regarding the NHI Bill being silent on any financial risk protection of taxpayers, and other contributing streams to the funds. In relation to that, he asked whether section 10(2) did not adequately cover that concern. The Fund needed to perform its functions in the most cost effective and efficient manner possible in accordance with the values and principles mentioned in section 195 of the Constitution, and the provisions of the Public Finance Management Act (PFMA). Was it not the definition of prudence in the use of funds? The reimbursement models for rehabilitation were not clear. Did section 40(3)(f) not deal with information submitted by service providers to determine payment mechanisms arranged for personal healthcare services? Would that not address the challenges once the Bill was passed, once more information available? There was concern that the Bill did not stipulate any corrective action and accountability relating to the timeous submission of audit and financial records, but the PFMA clearly stated when reports should be submitted and corrective action should be attended to by the Auditor General of South Africa (AGSA), as stipulated in section 50 of the Bill. The AG ordered the finances of NHI Fund, and the AG had the power to impose consequences on those who did not comply with the rules.

He noted the concern raised about governance and the suggestions that the NHI Fund should be externally audited. Had the presenters noted that the NHI Fund would become a schedule 3A entity, which would be audited by the AG, who usually out-sourced the audit to external companies? He asked that the presenters to confirm whether they supported universal health coverage, and the NHI specifically.

Chairperson Dhlomo referred to the presentation by the South African Speech-Language Hearing Association (SASLHA). It was stated in that presentation that the Bill did not clarify how clinical professionals would be funded. What specifically did the presenters think was not sufficiently covered in the Bill? The Bill stated that the Fund must transfer funds to the contracting units for primary care, guided by the district health resource allocation and the formula used therein. He wanted to check whether the presenters could comment on that.

The presenters had also stated that the NHI was a funding strategy and not a strategy for access to healthcare. He asked that they provide clarity on that. He referred to section 4.7 of the Bill, where it stated that ‘contracted private providers would be integrated into the primary healthcare services delivery platform in line with the vision of making comprehensive promotive, preventative, curative and rehabilitative services accessible to all, and would be coordinated through the contracting units for primary healthcare. The same principle was applied there.

There was another aspect -- the assumption that accessibility to services was not addressed. He had checked on clause 15.3.3, which stated that the Board should advise the Minister with regard to the development of comprehensive healthcare services to be funded by the Fund through the Benefits Advisory Committee. It covered all aspects, so was that clause not sufficiently covering the concerns raised by the presenters? There was a point made in the presentation that the NHI might exacerbate inequality. He asked that this be explained further. The purpose of NHI was to increase universal access to quality healthcare services in the Republic, according to section 7 of the Constitution, which was embedded in the preamble thereof. This was also captured in the Bill.

There was concern raised in relation to health technology -- that there was a lack of clarity on how it would be paid for under the NHI. The NHI proposed to amend the Health Act of 2003, section 21(d)(2) and replace it with ‘develop a national policy framework for the procurement and use of health technology.’ It did not specify it by name – but it did provide an overview.

Transport costs for a person with a disability could go up to R1 000, which was not always available to the person, resulting in people missing appointments. This was an important part of ‘catastrophic health expenditure.’ It was stated in one of the presentations that ‘it was doubted that the NHI would have financial risk protection.’ One of the principles of the Bill spoke about social solidarity. The fundamentals of the NHI were to reduce and remove that risk from people. It made health a public good. He asked that some of the responses be sent to the Committee in writing, as there was only ten minutes available for responses.


Ms Ramlaul (Occupational Therapy Association of South Africa (OTASA)) said that they welcomed the discussion about the pilot study. With regard to the reimbursement models for rehabilitation, the presenters were not advocating for a two-tier system of payment. There was insufficient evidence of informed reimbursement models, therefore if they were considering products relating to out-of pocket billing that were based on fees for service (which was upfront), how would that work? This was balanced against the need for timeous payment.

She referred to section 23, where they were emphasising a need for evidence-informed approaches. They were not advocating a two-tier system. The presenters would welcome the pilot approach, to enable billing to be a lot clearer and have a lot more detail about what the product would finally look like. They were aware that they were embracing a large area of quality care and healthcare, not just medical care, but were talking about this within the scope of promotive, palliative and preventative rehabilitation.

With regard to the PFMA, naturally the comments she had made with regard to the AG was that the Bill had covered and articulated how the risk could be averted in relation to the audited financial statements. They were trying to emphasise that the articulation thereof might not be sufficient , in terms of the amount of action that was required. This was in relation to the current anecdotal evidence that was provided by the AG, who had said that the quality and integrity of the reporting that was provided in most of the audited financial statements was not sufficient. The Public Audit Act of 2019 would give the AG more powers to have oversight, and needed to be implemented. It was the issue around articulation versus implementation that they had wanted to highlight in the presentation. With respect to economies of scale and the Gini coefficient – they were acknowledging that there was inequality – the presenters were not advocating different tiers of billing.

In the presentation, they had referred to the ‘bottomless scenario’ and the financial risk. This would come with a certain level of indemnity to the provider of the Fund. The first slide articulated the social solidarity. The presenters were behind universal health coverage and the NHI – morally they were in the same breath and scope of how the Bill was enunciated -- but their concern lay in the missing detail. The regulations would not be law. The regulations did not go through a lawful process. They did not need to run the risk that other countries had, of having to compromise and decide what was of a higher priority in terms of the budgets. That was where they wanted a bit more enunciation in terms of the financial risk and indemnity – predominantly from taxpayers. They would like to provide a fuller answer relating to NHI financial risk in terms of section 10(2), and they would send that response in writing to save time.

Ms Ntlhakana (South African Association of Audiologists (SAAA)) addressed the question regarding absorption into the private sector. As audiologists, they should be able to take full benefit of services and cover the greater population of South Africa. Looking at training institutions where they worked in hospitals for training, going into community service, where professionals were absorbed into the National Department of Health, it would not be wise for them to say that they recommended being fully absorbed into the private sector – many of them ended up going into the private sector because of the lack of posts in the public sector. If they maximised existing public health positions, they recommended that more posts be opened for audiologists in the public sector.

The procurement of equipment and devices was sufficiently covered in the Bill, but they recommended that it should be extended. They wanted representation on the Advisory Committee in terms of advising and reviewing the equipment needs and maintenance thereof for audiology testing assessments and assistive devices for patients.

Ms Bezuidenhout (Rural Physiotherapist of the Rural Rehab of South Africa (RuReSA)) responded to the question relating to the scholar transport. This was outside of the Department of Health’s mandate -- it involved the Department of Basic Education. There was a particular concern that the DPOs with whom she worked, had been working with Equal Education and Section 27 to address this. The policy -- at least, the KwaZulu-Natal (KZN) policy -- catered only for buses relating to special schools. This was not right. They had a number of children and adults with disabilities that they had managed to integrate into the mainstream schools. Two of the girls that were shown in the video were scholars who had been hit by cars on their way to school in their wheelchairs because the roads were not safe and there were insufficient public walkways. There was no scholar transport. It was something that needed to be addressed urgently along with many other things within the Department of Basic Education in order to make mainstream schools more accessible to children with disabilities.

Regarding transport issues, she had users who needed to go for non-urgent planned appointments, like neurology or orthopaedic appointments at tertiary and central hospitals. As a result of them being in wheelchairs, they could not use the planned patient transport bus, therefore an ambulance had to be booked to take them. Ambulance services were few and far between in rural areas. She had one person who came to the hospital five times from his home to try and get the ambulance to go to his tertiary appointment. The ambulance left him five times. Each time he came to the hospital, he had to pay R450, because it was an evening transfer. That was R450 multiplied by five that was wasted, as he never got to his appointment. This was why she was quite passionate about making planned patient transport accessible to people with disabilities. It was yet another inefficiency within the system, and it shifted the cost onto the user. It cost R1 200 to get to a hospital on a single round trip from the furthest area, and similar costs were incurred in the Eastern Cape. These people would not come in as a result of the cost. This was why she was passionate about the need to decentralise services. Even with users who did not live that far away, if their wheelchair did not collapse sufficiently, if they had sensory, emotional or behavioural issues, or if they could not control their bowel or bladder sufficiently, public taxis refused to take them. This required them to hire a private car at ten times the cost of a taxi. If one lived 100m off the general taxi route and one did not have anyone to push or carry one that distance, a private car had to be hired. This highlighted the out-of-pocket expenditure in accessing care. It was not at the point of care. It was in accessing the care. This showed the importance of how the services had to be structured.

She appreciated Dr Dhlomo’s comments, and agreed that the Bill was quite specific about rehabilitation and disability services being provided at the clinic and home level. Having worked 20 years in the Department of Health, they were concerned that there would be limited inclusion in planning around how things would work, what would work and who must be involved etc. That was why the presenters wanted to share some of their concerns and experiences. It was not that she did not believe that the NHI could do it -- it was just that greater inclusion allowed for a better system. 

With respect to the NHI perpetuating inequalities that were related to contracting, there was no clarity around what contracts would be entered into – whether it was service contracts, or input or outcome-based contracts. The various contracts had different resource and capacity requirements. If contracting was done badly, was not monitored and there were insufficient objectives put in place, it ran the risk of perpetuating the public sector inefficiencies that currently existed. That was the point she had wanted to make.

Ms Jacobs (South African Society of Physiotherapy (SASP)) stated that the SASP supported the NHI. There would always be people who would be able to afford more than others, and if they were able to afford private funding, they should take the cost off the NHI and carry their own health costs. The presenters were not encouraging a private and public sector, but were trying to reduce the load on the NHI. It would take time to ensure that everyone got appropriate healthcare, and quality healthcare as such.

Chairperson Dhlomo encouraged the presenters to find time and space to share their presentations with the Department of Health.

Dullah Omar Institute (DOI) Presentation

Ms Motlatsi Komote, Research and Advocacy Officer, DOI, presented to the Committee on behalf of the Institute.

Key points

  • The NHI board plays a critical role in respect of its impact on the public finances and an opportunity to redistribute healthcare services to rural/non-urban areas.
  • Parliament is the constitutional site for public involvement.
  • The legislature (Parliament) must play a bigger role in the NHI than currently envisaged

Recommendation relating to governance

  • More debates must be held on whether the Minister/President should make the final appointment(s).
  • Other high level processes that had a significant public impact must have a role for the President instead of a Minister -- i.e. the Municipal Demarcation Board, the Public Protector, the Judicial Services Commission (JSC).
  • In the DOI's view, the President should be responsible for the final appointment(s).

Role of appointment structures and the Minister

- Currently the Minister had a limited role for the advisory panel in the bill.

- The DOI was not in agreement with the ad hoc advisory panel in its current form.

-It recommended an appointment structure with extended powers which would limit the Minister’s role. The panel's composition must be impartial, have knowledge on the particular matter (healthcare) and have the necessary skills and competence.

-Board dissolution -- in terms of section 13(9)(a)(i) and (ii), the Minister has the power to dissolve the Board of the Fund on good cause shown. This was too vague. It was imperative that a list of possible reasons for the dissolution should be provided in the Bill.

-Further, the Bill must require that the information relating to the reasons for dissolving the Board should be made available for public record and scrutiny, to ensure public transparency and accountability.

-The Bill must include that the Minister may dissolve a board only after presenting arguments for this to Parliament.

District Health Management Offices

-There was confusion over the role of DHMOs, similar to that of the role of provinces.

-The bill did not account for the important role that was undertaken at a district level in the provision of healthcare services.

Advisory Committees

-The role of the public was important in all the advisory committees, as stipulated in the Bill.

-These committees should include the Community Schemes Ombud Service (CSOS) and members of the public as health system users.

-They should not mainly constitute government and the private sector.

Role of Parliament

Ms Komote said the DOI recommended that Parliament play a stronger role in the NHI. It had a duty and an active role to play. Lessons learnt had shown that corruption and state capture were rife when mechanisms were not in place at all stages of processes. Clarity had to be provided on outstanding matters, such as the DHMOs and the role of the provinces.


Dr Jacobs stated that the presenter had indicated that there was limited clarity in the Bill on the role of the provinces, other than their delegation as management. The responsibilities of provinces were not related only to those delegated -- as most of them were aware, they had original powers as contained within National Health Act. For example, they were to provide specialised hospital services, which would include infectious diseases and mental healthcare, to coordinate health and medical services during provincial disasters, to provide and coordinate emergency medical services and forensic pathology, as well as forensic clinical medicine and related services. Provinces also provided and maintained equipment and vehicles at healthcare establishments in the public sector. Which constitutional powers of provinces were removed, according to the presenters? It did not seem as if any powers had been taken from the provinces.

Mr Sokatsha requested clarity regarding the role of districts in the provision of health services. Section 36 of the National Health Insurance Bill stated that: ‘the District Health Management Office established as a national government component in terms of section 31A of the National Health Act must manage, facilitate, support and coordinate the provision of primary health care services for personal health care services and non-personal health services at district level in compliance with national policy guidelines and relevant law.’ He asked whether the presenter thought that section addressed her concerns. 

Mr Munyai referred to the presentation where it was noted that the DOI supported the public funded single-payer system, and noted that it was well articulated in terms of the return on investment. In the presentation, recommendations were made in relation to the appointment of the Board, such as the proposal relating to final approval by the President. He was sure that the presenter was aware that the President was not a Member of Parliament. Within their democratic institution, the Minister was appointed with executive powers. Was the Institute proposing that the Constitution be changed? He requested clarity on this.

Ms Wilson said that everyone in the country had freedom of choice about where they wanted to go and who they wanted to see – surely, that included the medical profession. She had been going to her doctor for 20 years, and so had her entire family. He had their entire medical history from A to Z, from when the children were little, and they were all grown up and still went to the same doctor. Did the NHI at any point impact on the freedom of choice for people to go where they needed and obtain the services needed with the professional that they were comfortable with? It had been said that the legalities of the Bill were okay. She requested clarity in relation to the freedom of choice and people's right to choose. Secondly, they already sat with a disaster in terms of the Department of Health -- in the earlier presentations, it had been highlighted that some people did not have access to health care or health services whatsoever. How would this legally impact the Bill?

Chairperson Dhlomo referred to the presentation, where the role of district health in the provision of health services was highlighted. If one considered section 36 of the NHI Bill, it stated that ‘the District Health Management Office established as a national government component in terms of section 31A of the National Health Act must manage, facilitate, support and coordinate the provision of primary health care services for personal health care services and non-personal health services at district level in compliance with national policy guidelines and relevant law.’ Did this not provide sufficient clarity in this regard? He requested clarity regarding the presenter’s view on the role of districts and provinces, as outlined in the Bill. A number of previous presentations had highlighted their diminished role.

DOI's response

Ms Komote addressed the question around the provinces and the districts. She had stated in the presentation that it would not be the main focus of the presentation. She therefore would ideally not like to answer those questions, except to state that there was some confusion in terms of what was found in section 36 and other sections relating to the provinces and DHMOs. She thought that other civil society organisations, whose main focus was around that issue, would refer to it before the Committee.

The Institute was not in any way stating that there needed to be a Constitutional change or challenge to the powers provided to the Minister. A situation should ideally be created where the President made a final recommendation, similar to processes such as the Judicial Service Commission (JSC) and the Public Protector. She was not suggesting that the President should come and conduct interviews or be in charge of short-listing. There should be different stakeholders who would be part of an appointment structure, who would come together to be in charge of the nominations, the short-listing and the recommendations. This would then be sent to the President as a final recommendation, and the President could make the final decision. As previously mentioned, this would be similar to the processes of the JSC and Public Protector. 

The question raised by Ms Wilson it was a difficult one. Both she and Ms Wilson came from a place of privilege, in the sense that they ‘could choose which doctors they went to.’ Her cousins that lived in rural Limpopo had to make use of the public healthcare system, and could not decide which doctor they wanted to see on what day. She noted that the previous presentation had highlighted the issue around the taxis in rural areas, which was a big problem. The majority of South Africans for whom the NHI Bill would provide healthcare services, did not have that level of privilege. The freedom of choice was limited for the majority of South Africans who were in most instances poor, or not from middle income households.

She could not respond on the impact and legality. The NHI Bill would have many consequences for the large majority of South Africans, so they had to be very careful and intentional about the kind of powers they provided to different stakeholders that would be involved in implementing the NHI. Anything relating to the governance issues that were identified, and other healthcare issues highlighted by different civil society organisations, would need to be addressed.

Whilst the Institute welcomed the NHI Bill, they thought that they could not implement it as it currently stood until the issues that were identified were resolved, including and not limited to the role of the provinces and DHMOs. There needed to be more clarity in the Bill. The Institute would be happy to provide input in this regard. 

Additional questions

Dr Jacobs noted the word ‘must’ being used where the presenter was talking about the problems and concerns which were highlighted – that changes ‘must’ be made. Did that mean that the Institute would challenge the Bill should those changes not be included? The processes of public participation had been ongoing, and would be going to the National Council of Provinces (NCOP) for concurrence. Would Ms Komote expect more to be done in that regard?

Mr Munyai said that when the presenter had spoken of the fact that the processes should be the same as those for the judiciary, which was legislated, was she suggesting that they change the Constitution through the NHI Bill? That was how the judiciary was regulated in terms of the separation of powers. Chapter 9 institutions were also independent and regulated within the Constitution, so did she suggest that the Constitution be changed in light of this? To change the Constitution, one needed a two thirds majority in Parliament.

Chairperson Dhlomo said that if one were to elevate it to that level, then one had to follow such a process. Thus they had asked whether that was the presenter’s suggestion.


Ms Komote said that the Institute was in no way proposing that the Constitution needed to be changed. Processes similar to that of Parliament, the Public Protector and the JSC were proposed, where one had different role players coming together to make appointments. This fared well in terms of ensuring that there was no undue political interference in the appointment processes. With respect to state owned enterprises (SOEs), when there was a Minister who had unlimited powers, in terms of the Board, they could hire and fire whomever they chose, as they pleased, without necessarily having to account to anyone. This was quite dangerous. Even the SOE guidelines stated that there should be other role players who were involved in those processes, beyond the Minister playing an autonomous role.

She could not say whether the Institute would challenge the Bill if it were published in its current form. In her personal capacity, if the Bill was in anyway unconstitutional or limited people’s rights, as outlined in the Constitution, then that could open Parliament up to a constitutional challenge, as had been seen in the past.

In terms of public participation, the Institute noted that there had been ongoing processes in relation to the Bill. She acknowledged the Committee’s work to ensure that different members of public society had engaged on the Bill. She commended the Portfolio Committee on Health onthe good work they had done. However, it did not mean that they could not continue to have more engagements around the NHI Bill, as there was no need for them to rush this process. The concerns raised by various civil society organisations should be taken into consideration.

South African Orthotic and Prosthetic Association (SAOPA) presentation

Mr Bradley Beckerleg, Chairman of SAOPA, Ms Heather McCrae, Chief Operating Officer (COO) of SAOPA, and Mr Jan-Hendrik Swiegers, Chairman of the Orthotics and Prosthetics National Rehabilitation Forum, presented to the Committee.

The presenters described the link between the NHI and the education of medical orthotics and prosthetics. Education and health were the most important characteristics of human capital. Both education and good health made individuals more productive. 

They said that “low levels of access to orthotic and prosthetic (O&P) services is hampered by a broad lack of understanding of the benefits and need for these services, as well as the failure of infrastructure to provide appropriate services,” as mentioned in the GATE concept note by the World Health Organisation (WHO). Long-term planning was also needed to encourage professional recognition and retain prosthetic and orthotic professionals for service sustainability, according to the WHO

There was currently a shortage of medical orthotists and prosthetists in South Africa, and access to assistive devices was a challenge. SAOPA therefore proposed a way forward that would include:

  • A staffing action plan;
  • Implementation of MOP community service;
  • An increase in accessibility, and a national need for more O&P centres;
  • An upgrade of current facilities, such as outdated machinery, technology and assistive devices;
  • Implement and ideal hospital/facility framework for O&P centres.
  • Supply chain management (SCM) should be centralised at each facility, and no longer be tied to the hospital to which a facility is attached.
  • Budgets must be individualised per facility – again separated from the hospital to which the facility is attached.
  • 85% of consumable stock should always be available.
  • Implementation of the WHO and International Society of Prosthetists and Orthotists (ISPO) action plan on O&P services and staffing;
  • Lean management implementation.
  • The Durban and Tshwane Universities of Technology, and the Walter Sisulu University, to assist with the above-mentioned feasibility study, to do research and make recommendations.

The presenters raised issues related to the sustainability for affordable healthcare, and asked how the NHI's reimbursement would occur in the future, as there was no current national reference model. Regarding the NHI from a medical insurance management viewpoint, they said there were contradictions in the bill, and they needed clarification on aspects such as negotiated or fixed prices, patients' needs, the Office of Health Products Procurement (OHPP), SAHPRA device accreditation, "health goods” and supply chain management. Other factors were the funders' impact on the private sector, and the referral pathways for orthotist prosthetists as first line practitioners.


Dr Jacobs took over as Acting Chairperson.

Mr Sokatsha asked what the presenters' understanding of equity was.

Mr Munyai asked whether the presenters had any solution or proposal regarding the issues raised, instead of providing only criticisms of the proposed reforms. The presenters spoke about issues of the Constitution – did the presenters not think that the ‘right to life,’ as outlined in the Constitution, superseded all other rights within the Constitution? Did the presenters realise that acts were enabling, and that regulations followed after there was a framework in law?

Dr X Havard (ANC) also asked whether the presenters recognised that acts were enabling and regulations followed after one had a framework in law?

Acting Chairperson Jacobs asked a question in relation to the Money Bill. He had heard the presenters mention that they would need an accompanying Money Bill when the NHI Bill was agreed to in Parliament. His understanding of a Money Bill was that it provided details of how much taxation would be levied, and that this happened on an annual basis. It was based on what National Treasury put forward to Parliament. It was then approved in Parliament. There was an annual Budget Bill for the National Department of Health in the Money Bill. The Money Bill might change on a regular basis, as determined by National Treasury. He did not agree with what had been put forward by the presenter in that regard.

In terms of fees for service billing, did the presenters understand that there would not be a fee for service? The Bill provided for completely different purchasing of a benefit, and not the itemised components of a benefit.

Chairperson Dhlomo said that he got the impression that the presenters were more concerned about how much they would be paid as practitioners, rather than the provision of service. He asked that the presenters clarify whether the issue was more about how much they would be paid versus whether they would be able to provide a comprehensive service to those who needed it. What was the presenters’ understanding of healthcare services? Would it be something one could refer to as a public good, or was it meant to be available to those who could afford it?

Mr Munyai asked whether they regarded the Road Accident Fund (RAF), Workers Compensation Assistance (WCA) and healthcare benefits as part of the social security platform intertwined with the objectives of the NHI? What was their view on the potential for double-dipping, if things remained as they were? Was integrated care not supporting the integration of road-related injury care in the NHI benefit package? Did the Association support the NHI? Did the presenters not agree with equitable healthcare and social solidarity? There was currently too much money in the hands of private medical aid schemes, yet the majority of the poor population remained excluded due to the two-tier system of healthcare. Did the Association believe in the two-tier system? The NHI offered one healthcare funding scheme to cover everybody.


Mr Beckerleg said that those in attendance representing the Association were all practitioners, thus a lot of the remarks were made based on the advice they had received from their attorneys.

Mr Lupiwo Mduzana, Board member, Health Professionals Council of SA (HPCSA), said that their understanding of equity was promoting equal opportunities and fair treatment. It also involved eliminating unfair discrimination. As a profession they supported equity, so the Association had presented a comprehensive approach.

Mr Beckerleg said that SAOPA supported the Bill and believed in equal and fair healthcare for all South Africans. Their biggest concern was the implementation of the Bill. It needed to be done correctly. The reference to the Money Bill was simply to highlight that clarity was needed in terms of funding.

The presentation had highlighted a number of existing challenges within the profession. As practitioners, they interacted with their colleagues in the public sector on a daily basis, and shared their frustrations relating to a lack of budget. If the NHI were to be implemented and there was not a sufficient Money Bill or a way that the funds for the NHI would be implemented, patients would suffer because they would not get the treatment that they deserved or required. A prosthesis was not just a prosthesis, different categories were established and needed by different amputees for very specific reasons.

There were a number of limitations imposed by the Compensation for Occupational Injuries and Diseases Act (COIDA). These were frustrating from a practitioner’s point of view because patients, irrespective of demographics or background, were unable to achieve their prosthetic potential because of the limitations. As practitioners, they were concerned that the NHI would impose those limitations across the broader spectrum of orthotics and prosthetics in South Africa.

Funding from a private perspective was not as comprehensive as what it was often believed to be. Almost all his patients had extreme co-payments when it came to prosthetics, and this was often the case with the orthotic devices. This was also due to the limitations imposed by funders. There may be excess funds available in the private medical funding industry, which might come from different departments, but not from an orthotic and prosthetic perspective. There was limited funding, even from the private sector.

Mr Mduzana stated that they had noted the questions asked by the Committee and would provide comprehensive answers to the questions in writing. The Association supported the NHI. Their priority was not payment, but to service those with disabilities.

South African Society of Anaesthesiology (SASA) presentation

Dr Lance Lasersohn, President of SASA, said the NHI Bill could not be considered in isolation. Factors such as the cost of healthcare and human resources had to be taken into account. The lived experience was that there was mismanagement, corruption, maladministration in the healthcare sphere, as well as an absence of regulatory policing, a failure to address the HR (time) crisis, no increase in production/recruitment/retention, while fragmentation was pervasive in all sectors. He also referred to challenges with HR economies of scale. While health professionals supported UHC, interpersonal trust was limited, and corruption and mismanagement had to be addressed and dealt with.

He said the NHI Bill provided a legal foundation for UHC, and funding to enable economies of scale. However, it contained preconditions that may threaten quality patient centre care, threaten access to care, enable fiscally unsound principles and override independent regulatory oversight.

Further risks were that the Bill failed to address the requirements that would enable UHC, quality measures and values were ill-defined, there was a massive cost of establishment, and fiscal detail was lacking for the achievement of high quality care.

SASA favoured a step-by-step social compact. The NHI/UHC required a foundation first, where key components could be addressed and trust established with decisive action to deal with corruption and financial management and administration. There had to be bold economic steps to increase the gross domestic product (GDP), where investment would be paramount, and aggressive HR development in healthcare needed to be implemented.

In the area of HR development, the government had to attract learners to consider healthcare, revise and review incentives, bursaries and remuneration, increase training capacity, retain and  attract skills, enable and prioritise registration to work reciprocally, and address administration urgently.

The decision to implement the Bill must concentrate on strengthening healthcare. A solid foundation would enable a solid Bill, and would unify the health asset.


Chairperson Dhlomo asked that the presenter comment on the matter of the Presidential health compact in light of the presentation. That compact had suggested that they needed to ‘fly the aircraft’ as they built it. Things would be fixed as they went along. Could the NHI be implemented within the timeframes detailed in the Bill, considering that there were certain obstacles that needed to be fixed as they went along? The compact spoke of a staggered approach, a step-by-step approach -- did the presenter have a challenge to this process?

Mr Sokatsha asked whether, in the current context, medical aids sanctioned professionals? His understanding was that the medical aids did – not for professional matters, but for any abuse of the system. Did the presenter propose that the IT systems should be detailed in the Bill? He noted that the National Health Act, section 74, described the current statutory requirements for health IT systems.

Acting Chairperson Jacobs requested clarity regarding the migration of doctors from the public sector to the private sector. He commented on the inequity in the number of anaesthetists between the sectors. What was the reason for that? Could funds be attracting and promoting the migration to the private sector? In the current context, did medical aids sanction health professionals? There was an understanding that they did, not for professional matters but for abuse of the system. Did the presenter think that the IT system should be detailed in the Bill? Did the presenter think that money spent in the private sector was well spent, considering the report of the health market inquiry?

Chairperson Dhlomo said that it was understood that the human resource (HR) issue was a big challenge that the Department faced. When could one state that a facility had an adequate number of doctors and nurses? Did the presenter think that they could start the process of the NHI, or would the presenter like all those challenges sorted out? The current system of unequal access was there – it had been acknowledged. Should there be adequate human resources before considering implementing the NHI? What were the issues that the presenter would like to see revised in the NHI Bill? There was an understanding that there were challenges in both the public and private healthcare sector. Was there any thinking in that regard? Was the money spent in the private healthcare sector considered to be well spent?


Dr Lance Lasersohn introduced Ms Natalie Zimmerman, Chief Executive Officer (CEO) of SASA, who had been involved in the drafting of the Presidential health compact on behalf of the Society. The Society understood the imperative to ‘build the plane as it flew.’ It would require innovation and collaboration to do so.

Ms Zimmerman said that there had been attempts to address the problems within the healthcare system collaboratively between the public and private sectors. As a society, they needed to address the issues in the healthcare system collectively. There were faults and flaws and needs for improvement in both the public and private sectors. The Presidential Health Summit had not achieved the objectives it set out to achieve in addressing some of the critical flaws in the healthcare system as a whole. She agreed with Dr Lasersohn that they needed to learn as they flew. In implementing that process, it needed to be understood where the focus should be and what needed to be built ‘as they flew.’ She noted that HR was amongst the most time consuming challenges to 'build as they flew.’ There needed to be a collective vision that everyone was committed to. That would take work.

Dr Lasersohn said it was well acknowledged that the country needed to introduce national healthcare, and this could not wait until the GDP went up and enough human resources were equipped in the system. He realised it was quite difficult to have everything in one place in terms of bills and regulations. The Bill needed to incorporate something to the effect that, as the system increased its human resources, they could deliver different types of services. The Bill would perhaps require other departments to deliver in specific spheres. For example, the Department of Higher Education and Training (DHEY) had to deliver X, and this would be held to account in the Bill. These were just innovative solutions that may or may not be possible.

SASA recognised that the NHI spoke to the timeframes and staggered approach. The problem was that in some respects, the timeframes were already in the Bill – but it was not known whether the timeframes would be achievable. He suggested it might require intermediary steps that helped assess whether they could move to the following step. For example, if they were not achieving step 2, there needed to be strategies to make that happen. He realised it was difficult to include this in the Bill, as it would become a 5 000 page Bill, but other documents could be referenced to the Bill.

It could be stated that until the country addressed the GDP and deficit in trust, systems of transport, for example, could be put in place to ensure that patients in absolute need would be transported to centres where they could get the primary or tertiary care they needed. This could be done instead of stating that clinics would be established that may or may not be able to function presently.

The Society’s key issue with the Bill, as it stood, was that there may be unintended consequences if the Bill was ratified and rolled out without making sure all of the steps were in place. In terms of the specifics that needed to be revised in the Bill, the overarching specifics were outlined in the few slides he had presented in the presentation. Specifics were outlined per clause in their 59-page submission. The Society was more than happy to present that in detail to the Committee at another time.

Ms Zimmerman said that what the Society had tried to do in the written submission was to provide alternative wording that addressed the concerns they had. The submission did not just highlight what was not adequate, but the Bill could be made adequate to address some of the potential unintended consequences.

Dr Lasersohn addressed the question relating to the private sector in terms of whether it was delivering as it should. There was no question that there was no perfect system anywhere in the world. Universal healthcare systems had failings, and the private sector system had severe problems. There were very good regulations, but there was a failure in regulatory oversight and implementation of the inspectorate. For example, if one considered private healthcare facilities, in many ways they needed to self-regulate, as there was no regulator of those facilities. As a Society if they went to the Health Professions Council and stated that they had a particular issue that was infringing on the ethical rules for them as clinicians, the HPC would state that the facility was not their member. If one went to the National Department of Health, they would state that they did not govern the private sector facilities. However, the Department gave them a licence to practice.

The private sector could be better regulated – that was the first issue. If one looked at other territories that had private sector facilities, they were well-regulated. Facilities in other territories had to ensure they had the right nursing staff ratios and the correct qualifications were in place. There was an HR constraint, which meant that many private facilities compromised on those things. Sometimes they compromised for reasons of not being able to get the staff, but sometimes they compromised because of profit agendas.

Both the public and private sectors had failings, and he did not believe they were getting the best value for the US$1 500 being spent per capita, of those insured. He also did not think they could spend $576 to $700 to achieve the quality they needed to achieve. As the country moved to a unified health asset, in service of equity, there should not be compromises relating to quality.

There was a lot of media attention around medical aids that had started their own fraud, waste and abuse sections inside their administrative companies. It was not the medical aid scheme that was outsourced. They sanctioned health professionals from the fraud, waste and abuse perspective. The same administrators had managed care organisations. Managed care organisations had also started treading the thin line of supercession – where they were told how to treat patients, without having examined them. It did happen. It came back to the issue of regulation. If there were strong regulators that actually were well-resourced and had the qualifications and inspectorate, it would not happen, as it would be curbed by the regulator. What they found was that without adequate regulation, private facilities, medical aid schemes or administrators had started doing their own regulation because there was nowhere to turn to. That was a bit of an ‘open day,’ as it were. There was no one who provided oversight, and that oversight should be done by a regulator.

He understood that IT system information, in terms of how it worked and how much it cost, could not be contained within the Bill. By the same token, if the Bill prescribed how people would deliver services, the contracting of services and registration on the IT system, there would need to be consideration of how much that would cost, the roll-out and whether or not the inadequacy of the system would compromise the ability of a patient to access care. What they had seen in both the public and private sector in the roll-out of electronic health records, was a definite indication that patient care was being compromised. There was not adequate consideration of the consequence of rolling out IT systems and the requirements of human resources in the IT sector. The system needed to be stable.

They had submitted a survey to the Health Market Inquiry regarding migration. This highlighted why specialists moved from the public to the private sector among their membership that had participated. Remuneration was an important factor as to why specialists moved from the public to the private sector, but it was not the only reason. Public sector mismanagement was also one of the main factors that made specialists leave the public sector. Working conditions were also highlighted as a significant factor. In terms of the pull-factors to the private sector specifically, remuneration was one factor, as well as better working conditions and access to equipment and drugs. The survey results were available on the Health Market Inquiry’s website. This could be supplied directly to the Committee if necessary.

Ms Zimmerman said that in terms of HR moving from the public sector to the private sector, at the moment there was a dire shortage of posts. The Society had more members that would like to stay in the public sector on completion of training, but there were not necessarily posts available.

To know when they had enough HR, the National Department of Health had been working on a human resource strategy for health. This needed to be finalised, as it answered some of the questions as to how many people they needed. There were also clear numbers in training facilities through the Health Professions Council of South Africa (HPCSA) for the intern training programme, and the work done by the clinicians. This stated that if one was going to offer a certain service and there were two theatres, one needed x number of professionals in anaesthesia and access to Y number of specialists, not necessarily on site, in order to provide a safe service. That work had been done, and those numbers were known. That needed to be built into the plans. There was no need to wait until they had some mythical or magical numbers, but they did have to have targets that they were really committed to working toward achieving.

Regarding the question about IT, part of the commentary made on the Bill itself was that there was a lack of clarity as to what belonged in the NHI Bill as a funding mechanism, and what would belong in something like the National Health Act. The IT system would belong in the National Health Act, and would need to be implemented from there. Some of the proposed changes were related to where the responsibility lay.

Regarding the fraud, waste and abuse of the medical funders and their efforts, she agreed that in the absence of strong regulators other people would start to regulate. The clinicians also needed to be more adequately regulated. The most that those organisations could do, was to claw back the money that they had paid them in the past or try to state the following clinical pathways that should be followed. They did not have the regulatory authority to regulate whether one practiced. That sat with the regulator. It disabled what one was trying to achieve with a strong regulatory environment.

Additional question

Mr Sokatsha asked whether SASA supported a national health insurance model as presented in the Bill. He asked that they make no reference to universal health coverage. Was SASA aware of the regulatory tool that was already in the public domain and was called the ‘Health Normative Standards Framework?’ His understanding was that health establishments and providers were required to comply with this.


Ms Zimmerman said that SASA had no problem with the funding model. It was a universal fund, but the Society had concerns as to how it would be implemented and do so effectively. They were aware of the normative standards, and had contributed considerably to their formulation. The standards were good and existed -- it was the policing and applying of the standards that was problematic.

Dr Lasersohn said that in terms of an NHI model, when one considered working systems in other territories that had a universal or single payment model, there was a private tier that serviced what people were willing to pay more money for. Those were quality systems that worked with an NHI model. The issues could be addressed through collaboration, using the private and public system. If they could get one health asset, they would be able to do better than they were currently doing. They could work together under a single payment model, as they did in some of those territories. People that migrated went to areas where there was a single payment model. People would often leave a system because they did not feel they were able to provide the best quality care.

Occupational Therapy Association of South Africa (OTASA) presentation

Prof Patricia de Witt, Senior Lecturer: University of the Witwatersrand, and Mr Elvin Williams, Lecturer: University of Cape Town, presented to the Committee.

Their general comments were that key aspects of the reform package, such as addressing wider social determinants of health and capacitating generally weak existing governance structures, remained unaddressed in the Bill. The WHO defined health as a ‘state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity,’ and this definition recognises the impact of social determinants on the achievement of health and therefore affirms health as a human right. More than just the absence of symptoms was needed to consider health in its broadest definition.

Referring to the funding, they said the Bill states that the ‘funding and functions of organs of state in respect of health services under legislation contemplated in sections 77 and 214, read with section 227, of the Constitution’ (e.g. the RAF and COIDA), as well as the provinces (which currently fund healthcare services), would remain unaffected by the NHI. However, in clause 53 and the schedule of the same Bill, these two laws were proposed to be amended. This required clarity, as it would have an impact on the provision of effective and efficient occupational therapy services through COIDA and the RAF. What had to be clarified was:

  • How and what services would be funded.
  • How would reimbursement for services occur

Clause 5(1)(f) mentions that the Fund must ‘ determine prices annually after consultation with health care providers, health establishments and suppliers.’ This seemed like the system used by the RAF and COIDA for codes and tariffs. The process of getting the fees to be reimbursed by the NHI Fund should include professional groupings or associations, and by definition would require exemption from the Competition Act for the service providers.

OTASA supports the price negotiation models proposed by the Health Market Inquiry.

Monitoring of registration and licensing

Clause 5(1) states that the Fund will ‘monitor the registration, licence or accreditation status, as the case may be, of healthcare providers, health establishments and suppliers.’ The HPCSA and the Nursing Council of South Africa are responsible for regulating the registration of health professions and determining the standards of professional education and training in the country. The same applies to the various provisions made for complaints, so the NHI Fund cannot exercise an overlapping and duplicative jurisdiction with statutory bodies and others, such as criminal bodies, in the case of fraud or corruption.

Certificate of Need (CON)

The accreditation of providers by the NHI Fund to the CON was a system created by sections 36 to 39 of the National Health Act. The NHI Bill refers to accreditation and certification, where certification refers to the CON. Not being accredited by the NHI Fund would mean that one's CON would not be granted or could be withdrawn. No person would be able to practice occupational therapy in South Africa without a CON, and then without servicing the NHI. The same would apply to occupational therapists (OTs) working in medico-legal matters.

Reimbursement of services provided

To implement the multi-disciplinary practices referred to in the definition of ‘primary health care’ in the Bill (section 1), and the ‘all-inclusive fees’ (section 41(3)), amendments to the Health Professions Act would be required. This process had not started, but without that, neither the primary care nor the hospital-case based NHI models could be implemented.

Closing remarks

OTASA welcomes universal health coverage as a human right. Health and health service provision could not be considered only from a medical point of view. There were social determinants of health which required a whole society approach, and this included the rehabilitation of professionals.


Mr Sokatsha asked whether OTASA agreed that the RAF and COIDA were part of the social security platform. Healthcare benefits covered under the RAF and COIDA were intertwined with the objective of the NHI, which aimed to provide a social protection platform. What was the view of OTASA on the potential for double-dipping if those funds were not consolidated? What were the presenters' fund proposals relating to these reforms. In terms of the accreditation of providers, what was the view of the presenters on section 39(2) and the role of statutory councils?

Acting Chairperson Jacobs asked a question in relation to the certificate of need. Had the presenter considered what was said in the Bill in the section on the definition of "certified" that was linked to the OHSC, and not the certificate of need? Did the group realise that the NHI Bill must be read with the National Health Act and its amendments? Should the Bill describe the end points or operational matters that should be in the regulations? Should all of the HPCSA regulated professions, of which there were 88 disciplines, be represented on the Benefits Advisory Committee? What was the presenters' view of statutory councils, such as nursing and pharmacy, being represented? In terms of understanding the difference between financing personal healthcare services compared to non-personal services, where did they position funding for the training of healthcare professionals within the spectrum?

Ms Hlengwa referred to the presentation where the presenters had spoken about the Road Accident Fund. Why was the Fund not accessible to those who applied without lawyers?

Ms Havard asked that the presenter describe how supply-chain management fitted into the overall aim of the Bill. How did this fit this into the Office of Health Products Procurement, outlined in chapter 7 section 38 of the Bill?

Chairperson Dhlomo said that the presenter had referred to the Bill of Rights, where everybody had the right to have access to health. It became a legislative requirement of the government to do that. Later on, the presenter had alluded to asylum seekers, asking whether they should define emergency health services -- or were they suggesting that the asylum seekers should get more than emergency care? Who were the presenters perceiving as being left out in terms of the right to access healthcare? He asked whether they were familiar with the Presidential health compact and how it worked. The OHSC had indicated that not all facilities would be accredited on day one. Were the presenters suggesting that the system could not accommodate an approach where a staggered accreditation process was applied? In terms of the NHI comprehensive health benefits definition, did the presenters think that had been left out? What was not fully covered in that process? He asked whether the certificate of need was the same as accreditation. Were they familiar with the Health Market Inquiry that looked at the certificate of need as a tool to distribute healthcare services?


Prof De Witt said that they had linked the certificate of need to registration. As they understood it, people would be required to register according to where there was a need. There may be a greater need in some areas, depending on the distribution of staff, to have one component of registration.

Mr Williams addressed the question in relation to the RAF, COIDA and double-dipping. Of course, those funds and services were absolutely needed. Historically, it could not be ignored that there had been irregularities and delays for people accessing care. While the funds were amalgamated, there needed to be consideration of the processes that would enable access to services, or that would disable or disempower patients from accessing quality care services. This was borne out of feedback from therapists who were working on the ground with persons with disabilities, and who were struggling to obtain compensation. It could not be ignored that while the Bill was talking about progressive realisation and implementation, there were currently systems that were not functioning well.

The Association was aware of the Presidential health compact. It had been involved in the implementation of the compact and the readying of the profession for NHI. As an Association of just under 4 000 members, challenges around RAF and COIDA were on their agenda. Part of the reason they were highlighting this to the Committee was for their support. Here was a small organisation that was contributing substantially to the health and wellbeing of citizens. There were challenges within the system. While they were talking about progressive realisation, what would this mean for the person on the ground? What did this mean for a healthcare provider that was still working in a system that could be very disabling and limiting in terms of the provision of services?

Regarding the need for the Benefits Advisory Committee and the Ministerial Committee to have representation of all professional associations, this was what the Association was advocating. All their professions had professional bodies that were part of the HPCSA, and decisions could not be made for the persons that they served and for their professions without there being consultation with the professional bodies. Persons with disabilities needed to be included on the advisory committees. People who the Bill intended to serve and impacted, needed to be represented.

He responded to the question regarding who was not being seen in terms of the Bill of Rights. When they spoke about emergency care in relation to asylum seekers, what constituted emergency care? Rehabilitation professionals were not traditionally part of emergency care service provision. However, most patients would require rehabilitative services after initial surgery etc. Their comment was around how to ensure that persons who were categorised as asylum seekers, and their children, would have access to services beyond initial emergency care. How was the Bill making provision for that? What was the thinking around the provision of services beyond emergency care? They were in support of universal health coverage and the Bill. The Association’s concerns were related to how, in terms of all the interventions of realising the implementation of the Bill, access to services was being prioritised. How were vulnerable groups, communities and provinces being prioritised in the progressive realisation of the Bill?

Prof De Witt said that the Association was working with the OHSC around providing a set of standards which spoke to the needs of professions. The Association was working hard with them, so that when services were assessed, facilities were considered in terms of what should actually be there, because it was different from what a doctor or nurse might need. Those standards were not actually in place. The Association had completed a national survey and were putting together a report for them.

South African Society of Cardiovascular Intervention (SASCI) presentation

Dr Hellmuth Weich, President of SASCI, referred to the Health Market Inquiry, and said the HMI had investigated what was “wrong” in private healthcare, and had proposed reforms that would ready it for the NHI. Two of these reforms were important for the NHI:

  • Health Technology Assessment (HTA) and the setting of treatment protocols, including coding as an independent body.
  • A health outcomes organisation (as an independent body).

He said that money made systems more efficient, and reducing this driver reduced productivity and increased the potential for corruption.

Referring to teaching hospitals, he said the emphasis was on service, and asked how they would be funded. Specialist training was currently funded via grants from the National Treasury. Based in the provinces, most trainees and lecturers were co-employed by the province and the universities -- how would the NHI fund this? He added that teaching medicine significantly slowed down service.

According to Section 27 of the Constitution, access to healthcare should be realised through principles of “reasonable measures” and “available resources.” This required strict pathways, strict adherence, and no room for outliers, who were often the most vulnerable. To solve this, one had to protect the principle of evidence-based medicine (EBM) in the Bill, which was in the NHI White Paper.

Dr Weich asked what access to care would be in an environment where medical schemes could provide only “complementary cover.”  What could medical schemes provide -- was it per diagnosis, or per type of treatment? For instance, if the NHI provided aortic valve stenosis care, could a scheme provide it, or not? Or, if the NHI provides only open heart surgery, and not a transcatheter aortic valve implantation (TAVI), could schemes provide a TAVI, and would that be financially feasible? What would this mean for high-end procedures?

SASCI's major concerns embraced lack of governance, academic medicine, centres of excellence, strict adherence to rigid pathways, how private healthcare would feature, and whether South Africa could afford it. Still outstanding was key information from NHI pilot sites, the National Treasury financing paper, and the availability of basic infra-structure.


Chairperson Dr Dhlomo chaired the meeting hereafter.

Mr Sokatsha asked whether the presenter was concerned that with the improved primary healthcare there might be an increased demand for tertiary care. Was it not important for the health system to have a good sense of what was needed and hidden amongst the poor and unemployed?

Dr Jacobs asked what specific governance SASCI wanted to see implemented, which was not in the Bill currently, to tackle the corruption. They had been hearing about corruption a lot. In the context of their lived experience, what did they want to see implemented? Why did the Society think that the NHI was not a solution to the dysfunctional two-tier system, as indicated in slide 14 on functional environments?

Chairperson Dhlomo said his understanding was that the NHI had a primary healthcare approach. What they would see as a consequence of the NHI would be an increase in the burden on the tertiary health services. He had failed to understand this, and requested more clarity in that regard. What was ‘academic medicine’ -- was he referring to academic training and excellence? Surely, this applied across all specialties. What was his take on other similar systems, such as the British National Health Service (NHS)? The NHS had been implemented post-war, when there were not enough resources. The primary imperative was to save lives. Both in Japan and the United Kingdom (UK), that had been implemented.

He asked whether the presenter was able to access the report on the pilot sites. 8.5% of the country's GDP was spent on health services. Half was spent in the public sector, and the other in the private sector. That was not enough to provide healthcare for the country. How did the presenter see this, compared to other countries with a similar GDP? The Bill proposed an incremental approach in a staggered manner, which touched on the OHSC and the ideal hospital presentation. The presentation had proposed that the country start with a limited roll-out, and he asked for clarity in this regard -- in what way would it be limited?


Dr Weich responded to the question regarding improved primary care leading to an increased need for secondary and tertiary care. He had seen this first hand in their setup. In their division, outreach programmes had been setup. Two of the doctors had gone out to the smaller hospitals and the patients had greater access from there, without needing to come to Cape Town. A huge burden of untreated disease had been uncovered -- people with really nasty conditions, who had previously just waited in a queue and not got seen. The number of specialised procedures they had performed had gone up dramatically. There was a study to show how everything had gone up.

Although there was a lot of disease at the primary level, one could prevent complications. If one had better treatment of hyper-tension, HIV and tuberculosis (TB), one prevented the bigger complications later on. If one were under-serving primary care, one would just uncover disease that had always been there and required tertiary care. The need for tertiary care was unknown. He thought the country was currently doing well in terms of the number of specialists they had, compared to comparable countries. If they were to uncover disease, they would need to deal with it.

There had been a question about governance, and from a practical point of view, if one gave a facility money to provide a certain service, there needed to be very clear outcomes that needed to be fulfilled. There needed to be structures in place that would look at things like the health technologies assessment. If one gave someone money, they needed to be able to state what they had done with it.

When he referred to academic medicine, he was specifically speaking about teaching hospitals, which were currently funded in a specific manner. The Bill did not clearly state how the teaching hospitals would be funded. Things happened a lot slower when it came to service provision in teaching hospitals, because one had to take one's time to do procedures, see patients in the clinic, and do three or four ward rounds with students so the conditions could be explained to the team, so that they could learn from it. It was a completely different environment -- one had to do research and teaching. At most of the tertiary level hospitals in South Africa, teaching took place.

He responded to the question about the pilot sites, and said they could learn a lot from the pilots. If everything was perfect, then they did not need to discuss them any further. If there were mistakes made and lessons to learn – if it was made public - then they could learn from the mistakes. A partial roll-out could be implemented to learn from mistakes before it was built up to comprehensive care.

Regarding comprehensive care, he proposed that they start the NHI at a primary care level -- focus on primary care and sort out the problems. Once they had that rolling and figured out how it all fitted together, they could move on to the remaining tiers and implement them in a staggered way.

Additional questions

Dr Jacobs asked whether the presenter was suggesting that the private sector should be used as the first platform to implement NHI – he had also heard the presenter say that primary healthcare should be used as the first platform. How did one relate that to equity and social solidarity? Was the presenter supporting the approach of a single unified healthcare system? Was he not concerned about fragmentation as they went forward wanting to give everyone equal access to quality healthcare?


Dr Weich clarified that he had referred to primary healthcare, not private healthcare. With regard to fragmentation, he was not sure whether Dr Jacobs was referring to what he had mentioned earlier -- whether there would still be space for expensive procedures to be done via private funding. There were a lot of things that could not be fixed in relation to the Bill, and one was social inequality in the country. There would always be people who could afford private cover, but he did not know how that would figure at this stage, as it was presently uncertain.

Cancer Association of South Africa (CANSA) presentation

Ms Zodwa Sithole, Head of Advocacy at CANSA, Ms Elize Joubert, CEO of CANSA, and Prof Michael Herbst, CANSA Board member, presented to the Committee.

They said that the concerns raised in our 2018 Bill submission were still relevant, and would be inclusively referred to in the presentation. The Bill was considered along with the Medical Schemes Amendment Bill, the Health Market Inquiry recommendations, and        Universal Health Coverage (UHC) as part of the Sustainable Development Goals (SDGs) to be achieved by 2030 as defined by the WHO as a system whereby all communities and individuals had access to quality care health services without suffering financial hardship

They conveyed a message from "The Elders," who were independent global leaders working together for peace and human rights, established by Nelson Mandela. They had participated in a panel discussion on 2 September 2019 at the Charlotte Maxeke Hospital, Johannesburg, hosted by the Minister. of Health. Its recommendations, which CANSA supports, were:

  • SA must tackle corruption in its health system. Many countries implemented NHI during periods of economic crisis;
  • Investing in health is investing in the economy – the outlay of a publicly-funded, single payer system would give a return on the monies spent;
  • One could not cover all sectors at once - a gradual approach was needed to guarantee eventual success of the NHI;
  • There must be a systematic process, but this could not happen from one year to the next. It must be built up, step by step;
  • They had to develop protocols (what was to be done and covered financially) for each type of disease diagnosis, and must cost it before implementation;
  • Participation of stakeholders involved was very important to develop the implementation plan;
  • Prevention was also important to decrease the burden of disease, so the budget for primary health care must increase to assist in lessening the treatment impact of preventable disease;
  • Waiting lists ought not to be beyond three months maximum, to ensure the success of NHI services;
  • Chile had started off with three pathologies (diseases) in year one; five in its second year, etc, until 56 diseases were covered over a period of 20 years;
  • The NHI needed to be implemented step by step. Individuals could claim against the government if it did not fulfil its NHI promises.

CANSA pointed out that the Act was to establish and maintain a National Health Insurance Fund, but their concern was that the Bill did not provide detail on the funding of the NHI system, except that this was a function of the National Treasury. CANSA was of a view that there was no clear funding strategy, and the NHI would have potential constraints for the foreseeable future if sources of funding were not well planned for due to weak macroeconomic conditions, other fiscal pressures on government, and the burden of diseases increasing exponentially. They had seen from the centralised control over COVID-19 vaccines and the centralised control of vaccination and vaccination sites, that the central government had found it difficult to effectively provide a COVID-19 vaccination programme. How would the “Fund” be able to provide a complex, sustainable health service?

CANSA's recommendations for the NHI Act were:

  • Clear plans, with clear multiple funding streams were needed to ensure the sustainability of the services;
  • Management of the health funding must be strengthened across to all the different diseases, with no disease being discriminated against
  • The clear pointing out of sources of funding and management thereof, would ensure the sustainability of funding for health care services.

For the Fund to attain its objectives, measures should be in place to:

  • Properly re-engineer the health services;
  • Harmonise the strategy and operations according to the National Development Plan (NDP);
  • Improve the governance and accountability for a more responsive service system;
  • Facilitate collaboration of internal and external stakeholders to improve health outcomes;
  • Improve labour relations, to be aligned to patient-centredness;
  • Ensure cost coverage, as the Bill states that the user of the Fund is entitled to receive an accredited health care service provider or health establishment free at the point of care;


The process of certifying and accrediting contracted service providers should be inclusive of civil society representation to ensure the provision of equity and efficiency in funding, by actively purchasing health care services, medicines, health goods and health-related products from properly certified accredited service providers.

Regarding the advisory committees, CANSA's concern was that the Bill required that only the stakeholders committee required representation from civil society and patients. Their recommendation was that civil society should fulfil the role of watchdog by holding the public servants and the government accountable, and should be included in all advisory committees. Consideration must also be given to including individuals from organisations with a focus on cancer and expertise in all committees.

Function of the Fund -- Recommendations:

  • A risk management system must be in place, and quality improvement and management systems must be properly in place and reviewed regularly;
  • Credible civil society organisations with track records could be of benefit in being involved as external quality assurers;
  • The Fund must enter into contracts for the purchase, procurement and supply of health care services, medicines, health goods and health related products with health care providers that are accredited;
  • Systems must be credible and ensure continuity of service provision through delivery of sufficient quantities and quality to meet the needs of users;
  • Suppliers must guarantee that there will be no interruption to supply for the duration of the contract, as this would be detrimental to the health of the patients;
  • The Bill must clearly state the provision for cancer treatment, with no delays and interruptions;
  • Back-up plans for service providers need to be in place to avert any possible stock out and to prevent treatment interruptions.

Referral pathways

  • Referral pathways must be realistic and be well known to the services providers, health department personnel and the users;
  • Referral pathways must be improved, especially for the rural communities in relation to cancer services, to prevent delays and interruptions in treatments;
  • Effective referral systems from the community to the health care facility were essential to save lives and ensure quality and a continuum of care;
  • The effectiveness of referral systems depended on multiple factors that involved clients/community members, community health workers (CHWs) and facility-based health care workers.
  • Each stakeholder was dependent on the other, and could form either a barrier or a facilitator of referral within the complex health system;
  • Transport services for patients also needed to be considered to assist patients to honour their appointments as per given schedules;
  • The Fund must improve access to screening for cancer to improve early detection through proper provision for screening in the referral pathways;
  • Patient navigation systems should be introduced and supported by the Department of Health to prevent cases falling through the cracks.

CANSA said the Bill must ensure that the service providers were well informed about cancer signs and symptoms, with emphasis on early detection and treatment to be able to refer patients appropriately. If this was not improved, the user would be denied referral from his or her health care provider, leading to late diagnosis when patients had been through the health system at earlier stages of the illness.            When cancer care was delayed or inaccessible, there was a lower chance of survival, with greater problems associated with treatment and higher costs of care.

CANSA advocated a comprehensive package of benefits for cancer patients, which provided screening/diagnosis and treatment and care, with palliative care throughout the illness trajectory

Governance in the NHI

The governance structure of the NHI Fund was of importance, as it would be responsible for financials and decision-making processes. CANSA found that governance of the fund was largely on the Minister of Health. The board of the Fund must be accountable to Parliament, rather than the Minister. There was a concern that the Minister would not be able to adequately perform his/her other duties, as it seemed that the NHI would take up all of his/her time.


Ms Wilson said she thought there were reasons for concerns. According to the South African Medical Research Council, over the last three years there had been a 30% increase in the number of cases of cancer. Her concern was that very little was being done in the cancer environment to deal with this. One of her major concerns was that there were about ten cancer hospitals in the country -- ten facilities that were able to offer chemotherapy and radiation in the public service sector. In Limpopo, there was only one hospital that dealt with this, the Polokwane Hospital. For a long time the bunker was not working, so people’s radiation was severely compromised as they could not continue within the right periods of time in order to get treatment. Cancer was more aggressive when given the chance to recover.

Many members of the private sector had offered their services to the public sector, in terms of oncology services, treatment or surgeries. She mentioned surgeries specifically, because she knew this was important. There was a stage in Limpopo where there was a 12-month backlog on cancer-related surgeries. If one had cancer and operations could not take place within a short period of time – 12 months was too long – that was like a death sentence to a cancer patient. She had lost her father to cancer, so she understood how these things worked. In terms of the NHI, the people in the private sector who had offered their services to the public sector had actually been turned away. One of the reasons stated for turning them away was that the Department could not afford them, or did not have the budget to pay them for their services.

It was very concerning. The country was not moving to a system where there would be centralised purchasing and payments. Her fear was that this could possibly be exacerbated. Given the high mortality rate relating to cancer, the Country needed to be doing more, and there were people willing to help but they were turned away because there was no budget to pay them. Many of them had said that they were offering their services at a very reasonable rate. She requested their comment on this. Would the NHI not exacerbate an already bad situation? Would it assist? The Committee was all for universal health coverage – it was about how it was done where it became problematic.

She was glad the presenters had mentioned the patient navigation systems. Aa tremendous amount of money had been spent in this country on human immunodeficiency virus (HIV) and tuberculosis (TB). Extensive navigation systems and follow-up systems had been put in place, whereby patients were alerted to the need to pick-up medication or arrange appointments, but she had not seen this in the case of cancer. HIV and TB once under control, were under control. Cancer needed to be put in the same bracket. It was still a cause of thousands of deaths every year. She did not understand why it was that they were not giving cancer the same emphasis or importance as they did to HIV/Aids and TB. Her opinion was that cancer was being severely neglected in the country.

In light of the regulations that the NHI proposed, it did need to be a phased approach. The NHI could not just be applied tomorrow and work -- it needed to be a phased-in approach. Her concern was what the priorities were of that phased-in approach. There were massive budget cuts in primary healthcare. If one did not have primary healthcare, vulnerability was created to the more vicious diseases. There had been huge cuts in infrastructure budgets, which meant that the proper radiation equipment, the establishment of bunkers, and the extension of cancer treatments, would become limited further. On top of that, they had seen huge budget cuts in terms of resourcing of personnel. All they saw now was one chain linking to another chain, but she was not seeing the shackles coming off -- she saw them getting tighter. Was the NHI going to assist in this regard, or would it exacerbate the problem?

Mr Sokatsha asked whether the presenters were suggesting that, based on the experience of the vaccination roll-out, they did not want to see the government playing a prominent role in the implementation of the NHI.

Dr Jacobs asked a question in relation to taxes, directed toward the NHI. Were the presenters suggesting that it be earmarked, as reference had been made to the sin taxes? Were the presenters proposing that sections 48 and 49 of the Bill be further elaborated? In terms of cancer treatment not being comprehensively covered – if this was the presenters' view – which cancer treatments did the presenters think would be outside of the NHI Bill or benefits? Currently, the National Department of Health provided cancer treatment for patients. He was certain that the intention was to do the same within the NHI.

The presenters had mentioned that the point of access to healthcare must be accompanied by improvements in the quality of healthcare. It was agreed that there must be an improved quality of healthcare. The Bill stated in section 39(4) that the contract between the Fund and accredited healthcare service providers, or health establishments, must contain a performance expectation and needs in terms of the management of patients and the volume and quality of services delivered, as well as access to service.

To address corruption in the health system, the Special Investigating Unit (SIU) had identified corruption, and was dealing with it decisively. Furthermore, within the Bill, in section 20 subsection 2(e)(1), there was a requirement that the NHI Fund establish an investigating unit within its national office for the purpose of investigating complaints of fraud, corruption, criminal activity, unethical business practices and abuse relating to any matter affecting the Fund, or users of the Fund.

Concern had been expressed in the submission that the Bill did not provide details of the funding of the NHI, except to say that it was a function of the National Treasury. Could it be that in section 48 of the Bill, the presenters did not notice that it made provision for the sources of income of the Fund in terms of clause 48, that the South African Revenue Service (SARS) would undertake all revenue collection relating to the Fund, including the collection of any health levies, if applicable. The Treasury would, in consultation with the Minister of Finance and the Fund, determine the budget and allocation of revenue to the Fund on an annual basis. The sources of funding were listed in section 49 of the Bill and section 8 of the Memorandum of the Bill, which outlined the financial implications. Therefore, there was a funding strategy, but the presenters were welcome to elaborate on their view in that regard. Regarding the vaccinations, most people who were vaccinated in the public sector had been pleasantly surprised about how good the service was.

Ms Hlengwa said that the presentation had been a real eye-opener for the Committee. The presenters had referred to an ineffective response to COVID-19 in terms of the vaccines because of the centralised control. What suggestion did CANSA have for the NHI, since the provincial governments were also facing challenges such as budget cuts. Instead of looking at the COVID-19 response, which was an unplanned occurrence, what lesson did CANSA suggest that the government could learn for better implementation of the NHI.

Dr Havard asked a question relating to the funding of the NHI. What did the presenters want to see added to the Bill in terms of the financing strategy? What was unclear?

Dr Dhlomo said that over the weekend, the Committee had visited Gauteng and had been appraised by the leadership of the Charlotte Maxeke Hospital, where the challenges alluded to in the presentation relating to cancer patients had been highlighted. In the evening, the Committee had had a meeting with the Minister and Member of the Executive Council (MEC). Subsequently, on the Monday, the Committee was aware of the progress that the Minister and MEC had made in that regard. If one delayed intervening in terms of chemotherapy and radiotherapy, challenges resulted. There was assistance coming in from the Steve Biko Academic Hospital, but that had to be added on, until they got the Charlotte Maxeke Hospital back in action. Something needed to be done urgently, and it was being addressed.

It was stated in the presentation that registration might be cumbersome, based on the registration for the COVID-19 vaccinations. There was information that there were close to 50 million South Africans who were registered on the patient registration system in facilities, mainly clinics, in preparation for the NHI. It had taken place even in far-flung areas. If there was a challenge in that regard, they needed to hear what the presenters proposed.

He referred to the Presidential health compact, and wanted to check whether the presenters were familiar with it. It was an enabler for the NHI – it actually spelled out that until x and y were in motion, it would not be easy to implement the NHI. Did the Association want a multi-payer system? Was that what they were indicating in their presentation?

The Committee noted that their call was for a risk strategy. He asked what the statement was regarding the ‘freedom of choice being limited in the Bill.’ He said that it was heart-warming to hear their reference to the statement made by The Elders. They had shared their experiences in various countries with the Committee at the beginning of the NHI process. He was happy to hear the presenters state that they were the Elders of South Africa. The Committee had listened to the Elders of other countries, and now to those of South Africa.


Prof Herbst said that collectively CANSA was part of the Elders -- they were 90 years old this year.

Ms Joubert said that they had shared the observations highlighted by the Committee in terms of the challenges. 80% of the population relied on the public sector, but 80% of the resources for oncology were based in the private sector. The Association wanted to see that situation turned around.

There had been a question asked in relation to public private partnerships. As CANSA, they supported public private partnerships -- of course, within prescribed protocols. The Association believed that the Bill should make provision for that. They did not think the NHI would immediately be able to cover all diseases. Cancer treatment was very expensive They had seen that with non-communicable diseases, there were budget cuts every year. There was no funding. That was a turnaround that the Association wanted to see.

The Association supported a single payer system. They were concerned that if the funding was not there to give equality to everyone, in the meantime, as a phased approach, the NHI should look at public private partnerships. There should be prescribed protocols in place for that.

There had been mention of navigation. They had successfully applied navigation in the past. It was a pity that the government was not supporting the Association and other cancer civil society organisations with funding for navigation. It was costly, and they could not expect people to volunteer. People came in from the deep rural areas, they sometimes did not even know what cancer was. The Association had to assist in helping them to navigate through the systems. There were many defaulters because of no navigation. The Association supported the suggestion that navigation should be opened up to other diseases.

Some of the questions related to the lessons learnt from COVID-19, and there were many examples. The Association had a footprint across the country -- they were based in communities, and could assist when there were distributions that needed to be made. It could only be central; the government must contract in public private partnerships to help them execute the functions of the Fund.

Prof Herbst addressed the question relating to the investigating unit that was provided for in the Bill. Although that was so, if one read that section of the Bill, it made the NHI the referee as well as the player. The Association was highlighting that it could not be the player and the referee at the same time. The NHI could not be investigating itself.

Ms Joubert said that in terms of the funding strategy, prioritisation of funding was the kind of detail they were looking for in the Bill. The Association did recognise and acknowledge the fact that if the Bill came into play, priorities would need to be decided. The Elders had recommended that they should be very clear about where to start and how to phase in and how to cost what everyone would do. Currently there were cuts in non-communicable disease budgets – that was not equality, and that was their concern.

The Association was well aware of the health compact -- it was part of the patient user group, and had contributed to the compilation of the compact. She hoped it was monitored very stringently. They had observed that COVID-19 had put many things on the back burner. That was their concern – in the face of unexpected issues arising, they were sidelined.

Eventually the single payer system was absolutely what they wanted to go for. When the NHI could not offer certain treatments, there must be options for people to access them via other sources in the meantime until everything was covered.

Ms Sithole stated that through the lessons learnt from COVID-19, she could not stress the training of healthcare workers enough, particularly in terms of palliative care. For patients in the intensive care unit (ICU), whose families could not be with them, healthcare workers who were trained in palliative care would be able to be with those patients during those last moments when their loved ones were not with them. There was a palliative care policy, and the Association was advocating for it to be implemented because the training of the healthcare workers was outlined in that policy. There was a long delay in starting treatment after being diagnosed with cancer, and during COVID-19 that delay had been worse. It was important to make sure that the cancer machines were serviced and functioning.

The Association had also learnt the importance of having online counselling for patients' families. This was so important, because they were desperate. Transport was a big issue, in that cancer patients' immune systems were very low, and there was concern about exposing them to COVID-19. If there was a transport system for those patients, it would be beneficial.

Prof Herbst stated that they had all seen how the budgets to provinces had been cut. This was why they were picking up on and referring back to the Committee the issue of funding of the NHI. The Bill had made a provision that Treasury was responsible for the funding of the NHI. It was Treasury that was cutting the budgets of provinces and other services throughout the country. What assurances did they have that Treasury would not do exactly the same with the NHI? When things were a little bit tight, the first place to cut would be the NHI. Did they have an assurance that it would not happen?

Closing remarks

Chairperson Dhlomo thanked the presenters for their contributions. The Committee would take them into consideration as they refined their processes going forward.

The meeting was adjourned.


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