National Health Insurance (NHI) Bill: public hearings day 21

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08 December 2021
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary


NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee held public hearings on the National Health Insurance Bill. Three organisations made oral submissions: the Public Service Accountability Monitor (PSAM), South African Disability Alliance (SADA) and South African Federation for Mental Health (SAFMH). All three organisations supported the move toward universal health coverage but expressed concern about certain provisions, gaps in the legislation and proposed a number of improvements to the Bill.

PSAM focused on concerns about the governance and organisational structure contained in the Bill, including the extent of power given to the Minister of Health. It highlighted that the Bill did not take into account the existing governance failures. The issues of corruption and maladministration were highlighted and it was suggested that there needed to be sufficient transparency and access to information. It recommended that the Bill take guidance from the Global Initiative for Fiscal Transparency when enacting the legislation. Issues of procurement were outline. In pursuit of better development outcomes and economic growth, sound public procurement and contract management was essential, particularly in preventing further corruption. PSAM proposed that the Draft Procurement Bill be considered in as far as broader questions of reform were concerned and the alignment and structuring of the National Health Insurance Bill.

A Member asked how strong the current governance and accountability measures were given the risk of corruption. The Chairperson highlighted the existing measures in place to address corruption. Clarity was requested about the Organisations support of the current two-tier healthcare system. It was asked if the massive cost of National Health Insurance would stifle innovation in the healthcare sector. Clarity was requested about the organisation’s proposed timing for the implementation of National Health Insurance. Some Members felt that the recommendations made about the Public Finance Management Act were beyond the scope of the Bill and the Committee. It was asked if the Organisation was concerned about the single-purchaser model and its impact on competition.

SADA was concerned about the definition of ’disability’ not being listed and the impact this had on the provision of services and identification of discrimination. It proposed that persons with disabilities needed to be represented within the various governance structures under National Health insurance, as the lived experience of patients allowed for the comprehensive provision for their needs on the ground. Issues of corruption, mismanagement and lack of capacity in the healthcare system were highlighted. Concerns about the funding of National Health Insurance and the shortage of healthcare workers was emphasised. There were concerns that certain therapies, technologies and diagnostic tests would be considered too costly under National Health Insurance and access to these services would be impacted. There were existing challenges in the healthcare system, including shortages of medicines and staff as well as poor administration systems which had resulted in the loss of patient records. This would likely carry through to the National Health insurance system, if not addressed. A number of concerns were raised about the provision of care and referrals as well as issues that might prevent access to care, such as the lack of a formal home address.

A Member stated that the challenges highlighted in the presentation emphasised the need for National Health Insurance to be implemented. Clarity was sought about a claim that there was a lack of consultation on the Bill and if persons with disabilities should be excluded from the referral system. A Member highlighted that a number of stakeholders wanted to be represented within the governance structures and this would likely be dysfunctional. Concerns around access, particularly for person with disabilities in rural and township areas were highlighted. It was emphasised that the Committee needed to take issues of access and inclusion seriously when considering the Bill.

SAFMH’s key proposals included mental health being a priority package within National Health Insurance and a conditional grant to earmark capital bridge-funding for over a 15-year period to scale up sufficiently. It recommended that funding and investment needed to go towards community-based mental health services. Efforts needed to be supplemented by other national and provincial governmental departments.

Committee Members pointed out that the financial implications of the Bill would include a conditional grant for mental health and that a conditional grant could not be a pre-condition for the implementation of National health Insurance. A Member suggested that the Federation engage further with the Department on mental health provision and budget as well as the proposed 15-year conditional grant.  Concerns were raised about the number of monitoring indicators proposed. The Federation had critiqued the licensing system across the board. It was asked if the Federation was in agreement that the National Department of Health, the Office of Health Standards Compliance and the National Health Insurance accreditation process needed to be aligned, taking into account the need on the ground.

The Committee considered and adopted its first term programme for 2022. The programme highlighted that the Committee would resume public hearings on the bill on 18 January. The Committee agreed to finalise dates for the other scheduled items later.

Meeting report

Opening Remarks
The Chairperson stated that the Committee would be receiving oral submissions from the Public Service Accountability Monitor (PSAM), South African Disability Alliance (SADA) and South African Federation for Mental Health on the National Health Insurance (NHI) Bill.

Public Service Accountability Monitor (PSAM) Presentation on the NHI Bill
Ms Zukiswa Kota, Programme Head: Monitoring and Advocacy, PSAM, presented the organisation’s submission on the NHI Bill.

Governance & Organisational Structures
PSAM highlighted a number of concerns about the governance and organisational structures outlined in the Bill. It stated that the NHI needed to be implemented in a manner that promoted accountability, should allow for increased transparency and responsiveness and support more effective, efficient, equitable, and inclusive access to health services. The Bill did not take sufficient consideration of the existing systemic governance failures; some aspects were likely to replicate weaknesses or fail due to existing dysfunctional/weak governance mechanisms. The need to strengthen health system management was emphasised. PSAM endorsed other organisations concerns that the Bill provides the Minister with too much power and that the Board of the Fund were not sufficiently independent.

Access to Information
Section 32 of Constitution recognised everyone’s right of access to information held by the State. Good governance and accountability were supported by increased levels of transparency. Corruption and maladministration thrived where access to information was restricted. Timely access to information was valuable, increasing meaningful participation and providing feedback about the services offered was important. PSAM encouraged the drafters and reformers of the current NHI Bill to take guidance from the Global Initiative for Fiscal Transparency (GIFT) Principles of Public Participation especially when considering access to information and before enacting this proposed legislation

South Africans were entitled to fair, equitable and efficient public procurement processes. Public procurement was a necessary strategic development instrument to promote good governance. Procurement should embed the effective and efficient use of public resources, which would ultimately result in higher levels of service delivery. Given the ever-increasing focus on sustainable development, the role and focus of public procurement had evolved from a predominantly technical and administrative process to a series of processes built around efficiency, transparency and accountability in using public resources. In pursuit of better development outcomes and economic growth, sound public procurement and management of contracts was essential. Establishing a transparent, fair, prudent and efficient health sector procurement system was vital. An estimated R27 billion (equal to more than one-third of the 2021/22 health budget) was lost to corruption annually. In September 2021, the Special Investigating Unit (SIU) reported that R14.8 billion of COVID-19 spending from April 2020 to June was being investigated for procurement irregularities.

PSAM encouraged the Committee to consider aspects of the Draft Procurement Bill in as far as broader reform questions were concerned to consider parallels between the proposal for NHI and structures proposed in the Procurement Bill. Specific mention was made to aspects of PSAM’s written submission on procurement issues.

(see PSAM’s presentation and written submission for further information)

Ms H Ismail (DA) asked what the risk of corruption was and how strong the accountability measures were under the Bill’s current governance and organisational structure. To what extent did the Bill allow for equal access to quality healthcare? Was this an all-inclusive Bill or did much more need to be done to make it all-inclusive? How sustainable was the Bill in its current form? Would the massive cost of the NHI system stifle innovation in the healthcare sector?

Dr X Havard (ANC) asked if PSAM differentiated between strategic opportunity and procurement, per the definitions in the Bill.

Mr M Sokatsha (ANC) asked, in light of all the concerns that were raised in the presentation, what was PSAM’s view on the timing of implementation of NHI. Should the move toward universal health coverage be implemented once all the issues that were raised had been addressed. He asked a question about clause 36 of the Bill. PSAM stated that the current model of service delivery should not be disrupted; was PSAM satisfied with current access to quality healthcare services and suggesting that the status quo continue?

Mr E Siwela (ANC) said PSAM appeared to believe that transparency of the single exit price for medicines and negotiations could not co-exist – what informed this view?

Mr T Munyai (ANC) said based on the presentation, he got the impression that PSAM was against everything, if not most of the proposals, made in the Bill. Would PSAM suggest that the status quo be maintained in the healthcare system despite the challenges? The inequalities were evident in the current system, as well as the lack of access to good quality healthcare for South Africans. Was PSAM against the Minister of Health as an accountability authority? Having the Minister as an accounting officer was consistent with the democratic outcome and structure of the unitary government. Who did PSAM suggest be held accountable for implementation of the NHI? The lack of transparency was emphasized as well as inadequate governance and accountability being areas of weakness in the Bill. The Minister as the executive was accountable for certain aspects of the Bill. What was PSAM’s recommendation about how this should be addressed. He requested clarity on PSAM’s proposal for that.

PSAM seemed to make recommendations, such as changes to the Public Finance Management Act (PFMA) and procurement systems, which could not be done through the NHI Bill. All supply chain processes were regulated or formulated through the PFMA. It was irrelevant to attempt to make recommendations to changes of supply chain management to the PFMA, through the NHI Bill. If PSAM had a different view, he asked that it be clarified. He noted the mention of the investigations done by the Special Investigating Unit. What was PSAM’s view on Non-Governmental Organisations (NGOs) that were funded by foreign organisations to ‘undermine the policy and sovereignty of the Republic?’

Ms A Gela (ANC) noted that the presentation highlighted gaps in the Bill – what was the PSAM’s view on these gaps being addressed in regulations? Were the concerns about access to information not addressed in clause 34(2) of the Bill which stated that the Protection of Personal Information Act (POPIA) and the Promotion of Access to Information Act (PAIA) must be accurate and accessible to the Department and the Fund or to any other stakeholder legally entitled to such information. If PSAM was against the Minister of Health as the accountability authority, who did PSAM suggest should be held accountable for the implementation of the contents of the NHI Bill. PSAM highlighted a few areas of concern, namely procurement, access to data and governance. Was it PSAM’s view that the Public Procurement Bill needed to address issues around preferential procurement procedures and good governance and the PFMA needed to address concerns about accountability, procurement and governance practices. In the case of information data, was PSAM in agreement that PAIA would give guidance on how certain information would be accessed. She asked if the National Health Act, the Consumer Protection Act and the Constitution would further address PSAM’s concerns around governance.

Ms M Hlengwa (IFP) asked for clarity about the concern raised in the presentation that NHI must be implemented in a manner that promoted accountability. She asked for more information about the proposed instruments to promote good governance. It was said that oversight should be increased and monitoring [Ms Hlengwa lost connection 53:55].

Ms E Wilson (DA) asked a question about procurement and the single purchaser proposal, that government would become the single purchaser of medical resources. Did PSAM find that concerning? She was concerned about this; there was such thing as competition that was monitored by the Competition’s Commission. Even if the PFMA was in place, it had been overridden by people as high as Ministers – how would this affect the general medical supplies? There were obviously very big companies and very small companies. All companies contributed to the economy and the medical services of the Country. Would the single purchaser system put these companies at risk, as put forward in the NHI?

Ms Hlengwa asked which bodies PSAM had been referring to in the presentation that needed to provide increased oversight and monitoring – was this the Committee or Department? The presentation spoke of equitable and inclusive access to health services – she asked for clarity on that.

The Chairperson noted the concerns raised by PSAM about corruption. He asked if PSAM was aware of clause 20(2)(e) of the Bill, which established an investigating unit within the national office of the Fund for the purposes of investigating complaints of fraud, corruption and other criminal activity. This clause, combined with the SIU led anti-corruption forum, and other mechanisms to prevent corruption indicated efforts of anti-corruption. Did PSAM agree? He asked if PSAM supported the establishment of a single fund or multiple fragmented funds. Did PSAM subscribe to the concept of funds following functions? If so, how would PSAM, propose this to be structured if it supported the establishment of a single NHI Fund.

Mr Munyai asked if PSAM was aware that the implementation of NHI was underpinned by Vision 2030 of the National Development Plan (NDP), which envisioned that by 2030, every South African should have access to equal standard of care, regardless of their income and that a common fund should enable equitable access to healthcare. Was PSAM comfortable with the current two-tier system, which reinforced the inequality of care according to income and wealth?

Ms Kota replied that it would be a major disservice to PSAM and her colleagues to not emphasis the following point, PSAM was in support of the implementation of NHI. The principles that underpinned it were central to addressing inequality in the country and central to the work that PSAM was involved in to contribute to eliminating gaps and reducing inequalities. PSAM did not want the status quo to continue; that would be ‘devastating.’ The submissions made on the NHI Bill were not to detract or shut it down but rather to strengthen it and the provisions contained therein. She emphasised the need for the Sustainable Development Goals (SDGs) and the 2030 Agenda to be met. The weak provisions in the Bill would likely see the country talking about an unequal health system and a two-tier system in 2030. There were positive aspects to the Bill, PSAM’s submission spoke to the weaknesses as this was important for the reform process and improvement of the Bill.

PSAM was not questioning the governance structures that were aligned with the Constitution, specifically the ambits of the ministerial powers. PSAM was questioning the extent of power that sat with the Minister of Health, as things stood in the Bill. That was problematic. It was problematic when a board was unable to make decisions and was inadequately provided with the powers and responsibilities to effect fair decision-making, proper oversight and consequence management. Alternative structures had been proposed. It was not that PSAM felt that the Minister could not be an accounting officer in the context of the NHI.

The ant-corruption measures outlined in the Bill were important, that was an area that was positive. PSAM did recognise them as anti-corruption efforts. What was of concern were the structures. The proposed monitoring and oversight was of procurement processes and delivery of services in the context of the NHI. Competitive bidding in the procurement space was an important question. In principle the provisions within the PFMA, Treasury regulations and the draft Procurement Bill dealt with the role of the State in procuring goods and services, which was fundamental. As things stood, PSAM was not questioning the State’s responsibility for procuring in the public service. The provisions were not in support of adequately providing for competitive bidding – that was where the concern was. PSAM was not advocating for the State to limit its procurement duties. The inclusion of non-government observers in the process of bid-evaluation and adjudication was potentially a valuable additional layer of accountability and transparency. Those were some of the suggestions being made by PSAM rather than taking away the procurement responsibilities from the State. 

She noted Mr Munyai’s statement that the NHI was not the place to advocate for procurement reform; that it belonged in the PFMA. The submission put forward spoke specifically to the procurement arrangements in as far as the NHI was concerned, given the details contained in the Bill. It was not that PSAM was advocating for, in this instance, the reform of the PFMA or procurement more broadly but rather the considerations around the different structures and capacity issues. In the context of the NHI, the assumptions that were made in the Bill were likely to replicate the same procurement irregularities that were being seen. It may not lead to an adequate improvement of health procurement, as things stood.

The reason the parallel systems of reform were raised in the Draft Procurement Bill, in the NHI context, was not to suggest that the Portfolio Committee or Department of Health had a role to play in the reform of that – but that these should be complementary processes. PSAM made a submission to Treasury on the Draft Procurement Bill, which had many fundamental problems. PSAM had noted that each of these processes did not seem to be speaking to each other. When PSAM spoke about reform more broadly it was about public finance management holistically. Observations about procurement in the NHI belonged within the context of the NHI and the discussions about how to improve that to ensure that quality, equity and transparency were met.

She responded to the question asked by Mr Munyai about the sovereignty of NGOs in South Africa. It was important in any context, particularly where there were engagements between oversight entities, parliamentary committees and outsiders to be open about their mandate and agenda. She was unsure where the question was coming from. There was not necessarily a link to independently funded organisations, that had a social justice mandate and who wanted to see the betterment and development of the country in respect to inequality, poverty and unemployment and the funding of those organisations by foreign donors. It did not necessarily mean that submissions, such as this, were opportunities to undermine the sovereignty of decision-making or governance in South Africa. She was happy to respond to specific questions about that.

Each aspect that PSAM raised was about increasing accountability. For example, by ensuring a broader and more diverse set of actions in the context of procurement processes it would bolster procurement processes by ensuring that there was adequate communication and mechanisms between the different provincial entities, district and national. This was another way of promoting good governance. The proposals made that dealt with the delineation of roles and responsibilities more clearly within the Bill attempted to ensure accountability in those processes. PSAM’s submission covered how to bolster accountability as well as meaningful, strong governance and decision-making processes. PSAM made specific proposals around the elaboration of clause 57 of the Bill which covered transitional arrangements. Those proposals were trying to pre-empt potential problems in the system, particularly capacity at the provincial level. On page eight of PSAM’s written submission there were a number of proposals made. Some of the questions asked by Members were answered in that section of their submission.

The proposal made on the requirement of the Fund to establish an information platform was outlined on page nine and ten of PSAM’s written submission. She offered to come back to Members in writing on any other questions she had not answered. By making proposals on the Bill, PSAM was not attempting to close down the process of NHI development, it was to strengthen the mechanisms and provisions made in the Bill.

The Chairperson stated that PSAM could respond in writing to any remaining questions that were not answered.

South African Disability Alliance (SADA) Presentation on the NHI Bill
Ms Kelly du Plessis, Chief Executive Officer (CEO) and Founder of Rare Diseases South Africa, presented SADA’s submission on the NHI Bill to the Committee.

SADA highlighted concerns about the definitions, particularly the definition of ‘disability,’ which was not listed. It was suggested that there was a lack of consultation with the disability sector in drafting the Bill. It was proposed that there needed to be persons with disabilities represented on the various governance structures of NHI.

Major concerns
SADA’s major concerns centred around overall corruption and mismanagement within the Department of Health, the funding of the NHI, shortage of healthcare workers (more than 83 000) and severe shortage of rehabilitation services, such as therapeutic personnel. Issues around the backlogs with the South African Health Products Regulatory Authority were highlighted as well as ineffective recording keeping. The State would be the sole-purchaser of medication and procurement and prioritise primary healthcare. Valuable therapies, health technologies and diagnostic tests would likely be ruled out as too costly. Access to Specialist for diagnosis and intervention was extremely serious, including paediatric neurologists, there were only 26 in South Africa.

State hospitals were facing a shortage of medication, staff, linen and other resources. The extremely poor administrative system resulted in a loss of patient records. This meant that tests had to be repeated numerous times, people died while waiting for medical help and infection control was so poor that HIV and TB patients simply succumbed and died. State hospitals were facing a shortage of medication, staff, linen and other resources. Daily reports showed elderly, disabled and acute patients lying on dirty floors in the utmost discomfort.

Questions about how NHI would accomplish challenges
How would people without a home, an Identification Document (ID) and home address be accommodated? Members with an NHI card would be allowed about three visits to his/her chosen clinic/GP per year. How would travelling outside their district be accommodated?
Treatment without referral to private facility would be paid from one’s own pocket.
No clear guidelines how persons with disabilities and their families from rural areas would be assisted when referred to one of the ten State hospitals as they would be in need of accessible transport and accommodation. It was proposed that there should be a specific fund allocation for disability and rare diseases. Would there be an inclusive employment package for disabled people in the NHI network? How would NHI rectify the situation and provide efficient and sufficient healthcare to people / patients with intellectual disabilities? - Let’s remember Life Esidimeni. How would NHI address the current substance abuse situation? The Promotion of Equality and Prevention of Unfair Discrimination Act, 2000, section 10 outlawed hate speech on, among others, the basis of disability. How would the NHI contribute to the protection of the rights of persons with disabilities?

(See Presentation)

Mr Munyai stated that the challenges raised by SADA, such as the Life Esidimeni tragedy and challenges of shortages of medicine, demonstrated that South Africa was one of the most unequal societies. These challenges highlighted the need for NHI to be implemented so that all South Africans, including those with disabilities, had access to healthcare. The current two-tier system displayed perpetual inequalities. A number of shortcomings were identified in the quality of healthcare in South Africa, as outlined in the presentation. The word ‘quality’ appeared more than 38 times in the NHI Bill; this suggested that the Bill addressed this issue. For example clause 10(1)(k) of the Bill stated that the function of the NHI was to ensure that the care services providers, health care establishments and suppliers were paid in accordance with the quality and the value of services provided at every level of care. Was this not an indication that the NHI was a vehicle to improve the healthcare systems?

He noted SADA’s concern about the lack of consultation – this was of great interest. The process of developing NHI policy reforms started in the early 1990s and gained momentum again in 2009. The White Paper on NHI, which formed the basis of the NHI Bill, was widely consulted, as well as the NHI Bill which was published for comment for six months. He asked if SADA was able to submit their comments. He stated that the issues of service provision highlighted by SADA were not issues that needed to be covered by the NHI Bill.

SADA had raised concern about the referral system proposed in the Bill. Was the recommendation from SADA that persons with disabilities should be excluded from the referral system requirements? How did SADA see this different system working, if this was the case? How could these systems be accommodated in the Bill? Some doctors in hospitals had disabilities; he suggested persons with disabilities were active players that were not necessarily excluded.

Mr Sokatsha noted the presentation indicated that persons with disabilities should be represented in a number of the NHI structures. The Committee had repeatedly heard during the public hearings that various stakeholders should be represented in the NHI structure. Would these structures be functional if the Bill added all the proposed suggestions – was it not better to ensure that the Department of Health consulted with all stakeholders on an annual basis per the National Health Act? Various concerns were raised in the presentation about the quantity of services to be provided under NHI. The NHI Bill did not outline services to be delivered but defined ‘comprehensive services’ as healthcare services that were managed to ensure a continuum of health promotion, disease prevention, diagnosis, treatment, management and rehabilitation in accordance with the needs of the users. Did this address SADA’s concerns?

Ms N Chirwa (EFF) stated that SADA’s concerns were pivotal in the discussions that the Committee should be having about the NHI Bill. The implications of the referral system were much more serious for people that were living in townships and rural areas, as they did not have the freedom of having a Medforum down the street. The ableist proposals in the NHI Bill should not be thought of as what the Committee primarily represented. The Committee was there to defend the people and not necessarily a Bill that did not serve the people in the way that it should. If a person with disabilities in a rural area got into a situation at night, when clinics were closed and hospitals were three hours away, it could not be said in the same breath that there was equitable access to healthcare. It could not be considered universal healthcare coverage if in rural and township areas services were only open during working hours. This should be part of the conversations the Committee was having. Who was it equitable for? Who was it accessible to? [Unclear audio 1:52:53]. Healthcare should be for everyone, that was why she primarily wanted to appreciate the presentation and deliberations by SADA. How then did one deliberate and view the NHI Bill if SADA was noting the inadequacies in addressing or covering persons with disabilities? It took five years for children in Limpopo to access hearing aids. How were these issues being addressed in the Bill? The Bill did not cover the issue of infrastructure. The current circumstances in public healthcare facilities was one that catered for persons without disabilities – these facilities were not necessarily accessible enough for persons with disabilities.

Dr Havard noted SADA was of the view that it had been prevented from providing inputs and comments on the definitions in the Bill. What made SADA think that?

Dr S Thembekwayo (EFF) acknowledged the concern about the listing of disabilities and the impact of that on inclusion in the NHI Bill. It stood to be considered in further discussions by the Committee, as it was very important. SADA had said that the funding was not clear in the NHI Bill. Did clause 48 and 49 of the Bill not provide enough information about the Fund as well as clause 35 and other clauses referred to within? What needed to be clearer?

Ms Gela stated that she would communicate Mr Siwela’s questions as well her own, as he was having connectivity problems. SADA raised concerns about the referral system proposed in the Bill. Was SADA suggesting that persons with disabilities should be excluded from the referral system requirements? If that was the case, she asked for clarity how SADA saw the different system working and most importantly how it could be accommodated in the Bill. Given that medicine registration was regulated through the Medicines and Related Substances Act, and the South African Health Products Regulatory Authority (SAHPRA) had put measures in place in 2018 to address backlogs in medicine registration, how did SADA believe that the Bill could address medicine registration issues, when these were already being addressed in the Act? She appreciated that SADA wanted to see equitable and accessible access to quality healthcare. Did SADA accept that systems and legislation already existed, for example the National Health Act and the Office of Health Standards Compliance (OHSC) – did SADA accept that the NHI Act would allow the Fund to provide a guide that would ensure that the services contracted and the right of all persons were met in accordance with the Constitution.

Ms Hlengwa stated that she was largely covered by Dr Thembekwayo. SADA had suggested that the NHI Bill did not list disability – what list? Or were there categories that needed to be listed in the Bill? SADA had raised an important issue about paying for the healthcare in the public versus private sectors – as many persons with disabilities could not afford to pay with their disability grant. What was SADA’s suggestion on this issue?

The Chairperson noted that persons with disabilities were covered in clause 6 of the Bill, which was dedicated to the rights of users of the NHI. Clause 6(e) of the Bill stated that users were not to be unfairly discriminated against, as was provide for in the Constitution and the Promotion of Equality and Prevention of Unfair Discrimination Act. Did this clause address SADA’s concerns? A suggestion was made in the presentation that it should be mandatory for people with disabilities to be included in the pricing committee. There were important criteria to use in constituting such a committee, which would mainly focus on skills. Why did SADA believe that people living with disabilities in general would provide additional value to the deliberations of that particular committee?

Ms du Plessis responded to the questions about quality. The fact that ‘quality’ was included a number of times in the Bill did not mean that it addressed the problem. The definition of ‘quality’ was different when one was looking at it from a payers’ perspective versus receiver perspective. This was evident in aspects, such as the seating requirements for a disabled person – which needed to be re-evaluated every six months for a growing child. That was not accounted for in the existing system. This showed that the existing system had an idea that quality healthcare involved providing the child with a seating device – however quality from the patient’s perspective involved that it be re-evaluated every six months. Thus, there was a difference in how ‘quality’ was defined from the payer and receiver perspective.

She explained that SADA did have the opportunity to submit comments – but in the event that she had been deaf and blind it would have been challenging to participate in that morning’s consultative process. Special accommodations would have needed to be made – it would have needed to be asked for – whereas those accommodations should be automatically offered. It was not that the system did not allow for them to do it – it was not expanded to allow for input from a variety of disabled individuals and therefore excluded some individuals from the process.

She responded to the referral systems question and if persons with disabilities should be excluded. Persons with disabilities should not be excluded from that. SADA was proposing that the referral systems needed to be expanded. There needed to be a mechanism of escalation in the referral system where necessary. This had not been seen in the existing system and SADA would like to see that allowance within the NHI framework. Persons with disabilities needed the option to escalate and increase the referrals timeframe. At the moment it was lengthy, particularly for those coming in from rural areas. Unfortunately, the compounding impact of those lengthy referrals had a negative impact on the patient’s quality of life while waiting.

SADA proposed that problems should not accumulate for a year before being given the opportunity to be addressed and ventilated. That was why SADA was adamant that all elements of the NHI structures needed to have patient representation. It was not about the quality of services, it was about the extent of services. It was not that services were not there – the extent of services needed to be expanded. At the moment a patient who required long-term speech therapy might only get seen by a speech therapist once a month or once every two months. SADA would like to see them being treated optimally – so that if more contact time took place in a six-month period, extended speech therapy might not be needed. The current system was set in stone – it was not a one size fits all approach. While SADA understood that this was what the Bill intended to do – SADA would like to see how it intended to do it. This was why SADA’s ability to provide input into the various committees was so important. There were certain things only understood because people lived with the conditions all the time – which might be left off the minds of those who were not living with the challenge every day.

The existing referral system was a very long process. SADA would want to see mechanisms for escalation and ways in which urgency could be put forward where necessary. She responded to the question asked by Dr Havard, SADA wanted to see expansion and further inclusion within the system. At the moment inclusivity was probably ranked at one or two and SADA wanted to see it move up to an eight or nine. SADA did not want persons with disabilities to be set aside – there was no intention or desire to be further marginalised. There should not be discussions about disabilities being in its own sector -it should be included. It should get to the point where accommodations for persons with disabilities was as easily discussed or administrated as was any patient sector.

Was the funding model outlined in the Bill practical in the current economy? There was such a low tax base in South Africa. There had been a complete drop-off in contributions to private schemes recently and those private scheme members would need to move across to the NHI – there was a decrease. SADA’s comment was not around how, it was around practicalities and if it would address, serve and bring in the amount of funding that was required to fulfil all the services that were necessary.

The current system was working but not necessarily efficiently – that was what SADA wanted to see change. There needed to be inclusivity to the point where it was forgotten that disability was ever a separate sector.

COVID-19 had displayed the need for urgency, with both treatment and the provision of vaccines. The pandemic had brought about a lot of awareness about stigma, isolation, the need to think out the box, that some patients needed more than others. SADA would like to see those escalation processes being retained going forward.

The NHI could be an overreaching guide if it was driven by the patients’ needs. That was why patient input into the system was so important. It was impossible to develop any kind of guideline around a complicated health issue without understanding the needs of the patient on a daily basis. If patients were not included in those processes – there would simply not be the knowledge or insight that was needed to develop guidelines that would essentially be inclusive and provide the necessary framework.

‘Disability’ had not been defined, when someone was being excluded on the basis of disability – what did that look like? That was what SADA needed to see. ‘Disability’ needed to be included as a definition in the framework so that it was clear what was included and excluded from that ‘box.’

At the moment, SADA understood that any further burden on disabled patients was simply not an option. Persons with disabilities were burdened enough. There was an average of eight percent disability in South Africa. When the employment numbers were down to eight percent then it could be re-evaluated and when education was inclusive in so far as persons with disabilities had access to education it could be ascertained if persons with disabilities could contribute to the Fund. With the education statistics being as low as they were at present, as well as employment ratios being where they were – affordability was not possible. SADA would like to see some concessions made for how persons who were impacted by disability would be expected to contribute toward the Fund.

The mandatory inclusion in committees was based on skills. Persons with disability added value by ensuring that those looking for solutions had an in-depth understanding of the problem. One could not understand a healthcare issue unless one had lived with it. One needed to have an understanding of the day to day lives of those patients and the impact of the conditions. That was valuable input required in the committees, if one was going to see a truly inclusive and equitable NHI.

South African Federation for Mental Health Presentation on the NHI Bill
Ms Bharti Patel, Director, SAFMH, presented the Federation’s submission on the NHI Bill.

A medium-term conditional grant earmarked for investments in the mental health system in advance of a fully implemented NHI was recommended in the investment case report. The grant would need to be monitored wisely into contextually-relevant, evidence based mental health services for population mental health. This specifically included inter-sectoral community-based mental health services, expanded primary healthcare mental services and prevention and promotion interventions. Other government departments needed to be worked with to ensure that their policies and budgets augment the NHI mental health benefit packages for successful implementation.

Medium-term conditional grant for mental healthcare services
A 15-year conditional grant was proposed to allow for bridge-funding to support adaptation of services and capacitation of provinces. For specific costs and Return on Investments (ROIs) refer to the Mental Health Investment Case Report (MHICR). The Department should undertake an explicit priority setting exercise for the NHI packages of care to review which packages and benefits were included and the reasons for inclusion. This should be informed by a needs-based approach (e.g. burden of disease, treatment gap, inclusivity etc). There was a need to invest in inter-sectoral community-based mental health services, expanded primary healthcare services and prevention and promotion interventions. This was outlined in detail.

Key proposals
Key proposals included mental health being a priority package within the NHI and a conditional grant to earmark capital bridge-funding for over a 15-year period to scale up sufficiently. Funding and investment needed to go toward community-based mental health services. Efforts to be supplemented by other national and provincial governmental departments.

Expected Outcomes
Health gains included 2.2 million years of healthy life restored, 44 000 deaths avoided. The universal school SEL programme would avert more than 415 000 cases and more than 89 000 healthy life years would gained.

Economic gains included ~R124.5 billion over the 15-year scale-up period while human rights gains included accessibility, the fivefold increase in the number of persons in need who would receive care and government work to address the wrongs of the past (e.g. Life Esidimeni) and investment in human-rights based mental health care.

(See Presentation)

Mr Munyai noted SAFMH had suggested that before NHI was implemented, the country needed to establish a conditional grant for 15 years. Was SAFMH aware of the financial implications of the NHI Bill, which would include a conditional grant for mental health? Was SAFMH’s concern about the size of the budget rather than establishing a conditional grant? Issues of mental health occupied centre stage on a national level in the current ANC led government. NHI was geared to provide access to all people, regardless of mental status and socio-economic condition. Was the Federation comfortable with the current two-tier health system, which did not address the healthcare needs of all people? One needed to have significant wealth to access good quality healthcare under the current system. Some of the challenges raised were precisely why NHI was needed.

The view that suggested that grants were needed to implement NHI was subjective. Some people wanted a basic income grant for all. One could not state for example that the basic income grant be the pre-condition for the implementation of NHI. The debt to Gross Domestic Product (GDP) was not in a positive situation. Besides that, it was believed that NHI would help everyone, including those with mental healthcare needs. The past did not only include the Life Esidimeni case it went back earlier before 1994. If one looked at the recommendation of the Commissioner, it would have given SAFMH the clarity that those issues justified the need to be resolved by the NHI.

Mr Sokatsha thanked SAFMH for putting forward an investment case. He noted the offer to help the Department of Health in ensuring that their mental health policies and budgets were appropriate for the needs of persons with mental health illness. The Department was present in the meeting. He encouraged SAFMH to work with them to address the needs of persons with mental health challenges. The request to include NGOs and traditional healers as service providers was noted. Clause 39 of the NHI Bill set criteria for the accreditation of service providers, this included producing proof or certification of being registered with the Council, as a professional meeting the care provision standards, adherence to treatment protocols etc. All of these were done to ensure the quality of health services met health criteria.

Dr Havard stated that NHI was aimed at funding integrated and comprehensive services. Was SAFMH not concerned about the proposal for a 15-year conditional grant? There was a challenge in having too many indicators at a high level. All the programmes had detailed indicators that were not in overall national [ unclear audio 3:12:8]. Was that not a bad way to monitor mental health services and outcomes?

Ms Gela asked if SAFMH had engaged the Department of Health on the proposal for a 15-year conditional grant and the investment case. What was the response from the Department, if such engagements took place? Did SAFMH support the NHI Bill and its objectives? What intervention was SAFMH involved in as part of the promotion and prevention of mental health problems rather than the ‘corrective’ approach. She noted that prevention was not an integral part of the SAFMH’s presentation – why was that?

The Chairperson noted that SAFMH was critiquing the licensing system across the board – was SAFMH in agreement that the National Department of Health, the OHSC and the NHI accreditation process needed to be aligned, taking into account the need on the ground. He asked a question about clause 15(3)(a) of the Bill which made provision for the development and funding of comprehensive healthcare services. What made SAFMH believe that mental health was not covered in that description? If any amendments were to be made in the Bill to the above – what would SAFMH propose?

Ms Patel responded to Mr Munyai’s question. SAFMH was aware of the conditional grant; however the size of the budget was very small. It was fortunate that the Department of Health had already been proactive and commissioned the investment case for mental health – that was forward thinking. The question of affordability was a relative question. When one looked at the Convention on the Rights of Persons with Disabilities, the International Covenant on Economic, Social and Cultural Rights – one knew that one could not go to progressive realisation of those rights. There needed to be plans that addressed those rights immediately. One needed to be realistic about the human rights treaties that had been agreed to. Mental health had always been neglected. SAFMH was in favour of the NHI Bill but wanted to enter this piece of legislation proactively, making sure mental health was covered. South Africa had a wonderful Mental Health Care Act – there was however never a budget allocated to it. The rights around mental illness were never realised. In 2013 the Mental Health Policy Framework was adopted, that was also critiqued, because provinces could not implement anything in those policies because there was no funding allocated to those pieces of legislation. That was what SAFMH was trying to guard against.

Ms Donelo Besada, Senior Scientist at the South African Medical Research Council (SAMRC) representing the SAFMH, responded to a number of questions. SAFMH was aware that there was a grant allocation in the NHI for mental health; it was a very small amount and was initially put in place to decrease the backlog of forensic assessments within the hospital systems. Engagements with provinces had indicated there was some limitation in capacity to absorb that. The provinces were struggling to access the grant as it required sign off from provincial heads of health as well as the Members of the Executive Council (MECs). There needed to be capacity building across the provinces in order to facilitate timely access to those grants.

The investment case, what was estimated for the initial Medium-Term Expenditure Framework (MTEF) period, was not asking for a lot more money than what was currently being spent for mental health services. What preceded the development of the investment case was a national costing exercise in order to understand what was currently spent on mental health services. The findings from that costing exercise revealed severe inefficiencies in how that money was being spent – with a heavy focus on the hospital levels. Only eight percent of expenditure was going toward the primary healthcare level, with 45 percent of expenses going toward specialised psychiatric hospital care. Given the 90 percent treatment gap – that money was not being efficiently spent. Approximately five percent of the health budget was being spent on mental health services. There was still a considerable treatment gap. SAFMH called for the assurance that the money would be spent more efficiently in the first MTEF period. That was why the conditional grant was being proposed so that expenditure could be monitored to ensure that it was redirected toward the primary healthcare level. 

In the long-term SAFMH would like to see the integration of mental healthcare service delivery. SAFMH did not want a vertical system of service delivery, particularly in recognising the severe comorbidities that existed between mental health and other kinds of priority conditions in the country, namely Human Immunodeficiency Virus (HIV), Tuberculosis (TB) and chronic conditions. The risk was that without dedicated funding in the short to medium term to scale-up mental health services, it would be neglected within a broader service delivery model looking for integrated services. The generalist workers needed to be trained and dedicated funding needed to go toward that. At the moment there was no comprehensive development of district mental health specialist teams, which would be key to ensure supervision and support to the primary healthcare level. SAFMH was asking that the money was reprioritised effectively. The money that was currently being spent was an appropriate amount. Over time, while services were scaled-up, more money would need to be dedicated toward mental health. Hopefully with the NHI contributions there would be a growing budget.

SAFMH recognised the budgetary constraints currently in South Africa, which was why it called for the efficiency in spending. The costing study also revealed that there was a significantly high level of readmission rates – that was largely due to a lack of primary and community-based services. 18 Percent of current expenditure was going toward re-admission rates, which was as high as 25 percent across all the hospital levels. The idea was that lost expenditure could go towards service delivery.

Healthcare workers were certainly inundated with a lot of information system monitoring. SAFMH was not calling for a huge list of indicators. At the moment the indicators that existed did not allow for the monitoring of service delivery nor coverage nor the quality of service delivery. For HIV where there were a considerable number of indicators one was able to monitor the cascade of care – that was not present with mental health services. One of the issues with the previous Mental Health Policy Framework was that there were no indicators linked to the plan in order to monitor service delivery; the plan therefore stayed as an ambitious framework for service delivery without real implementation or monitoring of services.

The two-tier system was one of the reasons SAFMH supported the move toward NHI and the Bill, which tried to reduce the inequalities across the public and private sectors in recognising that there were a lot of resources that lay within the private sector. This was particularly true of human resources for health where people could be contracted from the private sector to the public sector. Some early initiatives of public-private partnerships had been seen and needed to be developed further as the Country moved toward an NHI model. Even in the private sector there was considerable out-of-pocket expenditure for mental health services. There was a lack of financial protection for mental health even in the private sector. there was interest amongst private sector providers to start piloting public-private partnerships.

SAFMH had engaged with government, where the investment case was presented to the Mental Health Directorate and to the Acting Director General, at the time, as well as the Deputy Director General for Primary Healthcare services and Treasury. It was now awaiting review for the upcoming MTEF meeting the following year, where it would hopefully get approval. A fifteen year period was picked for modelling the investment case which would allow for an incremental approach to scale up mental health services in recognition of budgetary constraints. Very modest scale-up targets were used. SAFMH recognised that there would always be opportunity costs. This was why the treatment package that was recommended in the investment case needed to be analysed within the broader requirements of a basket of care for the NHI and the budgetary implications of that needed to be considered.

Ms Patel responded to the question about prevention; one of SAFMH’s key focus areas was around awareness and prevention. By creating awareness around mental health issues, the idea was to break the stigma about mental health. SAFMH promoted and encouraged that the Bill focus on prevention services within the conditional grant being proposed. The licensing of health establishments – these guidelines spoke a lot to the tertiary health establishments. It did not really speak to the needs of those residential care facilities that were managed by community-based organisations. It needed to be tailor-made for what was affordable and doable for community-based organisations to provide community residential care. SAFMH had engaged with the Department of Health on the licensing guidelines – that was still in discussion. It had not been done that was why there were so many unlicensed NGOs, where the care of people could not be monitored. There were a lot of human rights violations that took place within those unlicensed facilities. 

Mr Munyai stated that the distribution of budget was not made by any organisation but was made by the Minister of Finance. The Committee would want mental health to receive more money – but that was how it worked.

The Chairperson asked what made SAFMH believe that traditional healers and practitioners were not covered in the Bill.

Ms Patel stated that within the NHI Bill, NGOs appointed many social workers and traditional leaders also played a role in community based mental healthcare. The recommendation was that traditional leaders be recognised as essential staff for mental healthcare. She stated that SAFMH would provide a script to the Committee of the presentation, so that the detail of the presentation could be considered. SAFMH looked forward to engaging with the Committee going forward.

Consideration and Adoption of Minutes

Minutes of 1 December 2021

In the meeting held on 1 December 2021 the Committee held public hearings on the NHI Bill and considered and adopted meeting minutes.

Ms Gela moved to adopt the Minutes.

Dr Havard seconded the adoption of the Minutes.

The Minutes of 1 December 2021 were adopted.

Minutes of 1 December 2021
In the meeting held on the evening of 1 December 2921, the Committee received a briefing by the Ministry and Department of Health on the Omicron variant.

Mr P van Staden (FF Plus) moved to adopt the Minutes.

Ms Gela seconded the adoption of the Minutes.

The Minutes of 1 December 2021 were adopted.

Consideration of Programme for 2022
The programme for 2022 was presented for consideration. The Chairperson outlined a number of reports, workshops and items that would need to be attended to in the new year. There was a lot of outstanding work; the Committee was under obligation to deal with these matters as soon as possible. This would take place toward the end of January 2022. The Committee would be starting earlier than when Parliament officially resumed, with the NHI public hearings on 18 January 2021. He had made this request and was awaiting approval of that. He was bringing it to the Committee to be agreed upon.

Ms Gela noted that there was still a lot to do on the NHI hearings and supported the Chairperson’s proposal to start early on 18 January 2021.

Mr van Staden supported the proposal. He asked that the Committee speak about the other outstanding matters in the programme and that the dates for those items be set so that it would not be forgotten about.

The Chairperson stated that the reason dates had not been set was because the Committee was hoping to complete the NHI public hearings by the end of January 2022. The Committee was hoping to take six to seven organisations per day and get that behind them. Then the Committee would be able to deal with the other work and dates could be set for those items.

Dr Thembekwayo supported starting on 18 January 2022. The other dates could be decided over WhatsApp.

Mr Munyai supported the start on 18 January 2022.

The Chairperson wished Members and the Parliamentary support staff a Merry Christmas and well over the festive season.

The meeting was adjourned.

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