National Health Insurance (NHI) Bill: public hearings day 24

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28 January 2022
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary


NHI: Tracking the bill through Parliament

The Portfolio Committee convened in a virtual meeting to engage with the Competition Commission, Commission for Gender Equality (CGE) and Solidarity on their National Health Insurance (NHI) Bill submissions.

The Competition Commission disagreed with the proposed exemption from the Competition Act as stipulated in the NHI Bill and submitted that the exemption should be dropped. The blanket exemption would have a negative impact on the provision of universal health care services as envisioned by the NHI and could lead to collusion amongst private health care suppliers. It argued that the Competition Act provided for adequate mechanism to protect NHI Fund activities.

The Commission for Gender Equality supported the NHI Bill but cautioned that the Bill would only be effective if the shortcomings highlighted in the CGE submission were addressed. The key concern was the lack of clarity in the Bill in addressing the needs of marginalised communities, including CGE constituencies such as the LGBTIQA community. The CGE was of the view that the Bill should be clear from the onset to minimise the opportunities for legal action which could delay the implementation of the NHI.

Solidarity submitted that the Bill should be withdrawn as it was unaffordable, unnecessary and unworkable. A viable alternative to the NHI would be to fix the clinics and public hospitals who were in essence providing universal health care. The solution to the poor quality of health care services was a matter of governance and management and not a funding issue. Solidarity was planning to challenge the Bill in the Constitutional Court.

Meeting report

Competition Commission (CC) submission
Mr James Hodge, CC Acting Deputy Commissioner, said the Competition Commission understood that a unified health care system would be beneficial for the country but it was not clear why exemptions were needed as the Competition Act contained an appropriate mechanism to protect NHI Fund activities.

Private health care providers would have to contract with the NHI Fund, as the single purchaser. This would create opportunities for collusion amongst private health care providers, which was the domain of the CC. This was also the key concern of the CC. Cooperation between the NHI Fund and the CC should be facilitated through a Memorandum of Understanding (MOU) to ensure a cooperative working relationship.

The CC submitted that the blanket exemption should be dropped because it was inappropriate and exposed the NHI to unnecessary risks. In the interim, the mechanism in the Competition Act would apply.

The Chairperson appreciated the submission and called on Members to engage on the issues.

Ms E Wilson (DA) said the CC submission definitely provided food for thought. The role of the Minister of Health as the sole accounting officer or “literally the king of NHI” was problematic. In light of the Zondo Commission and Special Investigating Unit (SIU) reports as well as the Digital Vibes debacle, she raised her concerns about the powers of the Minister to appoint the board and committees, considering the level of collusion that occurred. She would welcome a suggestion from the CC on the way the matter should be dealt with and if Parliament or the Portfolio Committee on Health should be involved. The matter was a big concern in light of the recent reports. She was concerned about the NHI Bill not meeting constitutional muster taking into account the numerous exemptions and the contradictions to the Competition Act.

Ms H Hlengwa (IFP) thanked the CC for the detailed submission. She asked if the Committee could be provided with examples of the proposed appropriate alternatives that would protect the public from the great risk of the blanket exclusion of the Competition Act in the Bill. Examples of prohibitions within the European Health Care sector were also requested.

Mr M Sokatsha (ANC) welcomed the submission. On the comment in the submission about the design elements of the NHI being unclear in the Bill, he advised the CC that this Act should be read in line with other pieces of legislation. All laws apply unless stated otherwise. The exemption of the Competition Act would not lead to the exemption of other laws that regulate the implementation of the Act. The CC was requested to explain how a single public purchaser would function under a free market system and what the alternative would be.

Ms Gela (ANC) welcomed the submission and asked if the CC acknowledged that other mechanisms were available to address corruption and collusion or if they viewed the Competition Act as the only way to prevent corruption.

Ms M Clarke (DA) thanked the CC for the submission. Considering the lack of prosecutions despite what had been uncovered, she asked how the risk of collusion could be mitigated and the issue of collusion across state contracts including in Health Care, be addressed. She asked if the CC would agree to form part of an oversight role as an independent ombudsman for the NHI. She asked in what way the registration requirements of the Bill would result in unequal access to health care services; if the Bill made provision for recommendations for the registration process for a member without a physical address; if the Bill adequately covered access to health care for indigent women and in what way the Bill provided for a person seeking urgent health care services or would the Bill delay access to health care services. It was her opinion that the MOU between the Fund and the CC would be helpful to ensure a close and cooperative relationship. She asked if the CC would recommend that this be factored into the Bill.

Ms X Harvard (ANC) enquired if the Health Market Inquiry (HMI) recommendations, where necessary, could be implemented in parallel with the incremental implementation of NHI.

Mr T Munyai (ANC) said the comments in the submission appeared to suggest that low and considerate prices were not considered acceptable under NHI. He asked what the CC proposal was for services for the poor under the environment of the two-tier system or if the CC wanted the status quo to remain. Adverse findings were made by the HMI such as the overcharging of non-medical costs as outlined by the Inquiry. He asked if Mr Hodge was aware of the Inquiry gazetted by Minister Patel and how the CC planned to address the findings. It appeared to him that the CC wanted universal health care without the NHI.

Ms N Chirwa (EFF) acknowledged the very important issues raised in the submission and asked what an appropriate exemption would be that would not jeopardise what the NHI was trying to achieve. If vigilance against corruption was part of the reasons for the CC recommendation about the blanket exemption, then it should be stated overtly and not in vague terms. Ms Chirwa recommended that the Legal Department of Parliament be called on to clarify the exemption and the effect it would have on other legislation. It would be a mistake for the Committee to engage in a conflict during deliberations on such an important bill without having absolute clarity and relying on the interpretation by Members and people making submissions.

Mr E Siwela (ANC) asked if the exemption meant that any supplier to the Fund would be exempted from the Competition Act and what wording would the CC propose to ensure the mandate of the Fund was fulfilled.

The Chairperson noted the recommendation about the National Department of Health (NDoH) taking into account the HMI findings given the similarities in the proposed reforms. He asked if the CC considered the recommendations applicable to the public sector or to the future unified health care system. He asked for the position of the CC on the milestones and timelines for the implementation of the recommendations as stipulated in the draft NHI Act, considering competing interests and budget allocations.

Competition Commission response
Chief Legal Officer of the CC, Mr Bakhe Majenge, replied to the legal questions. The exemption concern was not about corruption in the NHI Fund but about the collusion by the private health care providers, which by necessity would have to contract with the NHI Fund as the single purchaser.

In terms of the wording, Mr Hodge said the CC suggestion was not to include it in the Bill because an appropriate mechanism existed in the Competition Act. If exemption would be required in the future, it could be adequately addressed by the Competition Act.  

Mr Majenge replied to Ms Wilson that the ministerial role was a policy and legislative matter within the domain of Parliament and policy makers. It was outside the domain and regulations of the CC. The constitutionality of the NHI was similarly a policy and legislative matter which would have to be tested. The obligation to take legislative measures to achieve the right to health care was provided for in section 27 of the Constitution. The NHI could be viewed as the objective through which universal health care could be achieved. The CC supported the NHI and was not opposed to it. The key concern was the blanket exclusion of the Competition Act which would have ramifications and unintended consequences.

Mr Majenge explained the Competition Act provided for alternative pathways to achieve exemptions of certain elements of the work of the NHI, short of blanket exemption. For example, exemption on a case-by-case basis were provided for in section 10 of the Competition Act. The Competition Act was recently amended to make provision for block exemptions by the Minister of the Department of Trade, Industry and Competition. One of the most successful exemptions granted to date dealt with the exemption granted to the National Hospital Network in giving bargaining power to smaller hospital groups.

Mr Hodge provided specific examples of exemptions. The National State of Disaster sought to coordinate services of health care providers to enable them to respond to the pandemic in terms of adequate distribution of treatment protocols, allocation of staff to hotspots, sharing of information from testing facilities and the ability to move staff between clinics and hospitals. Exemptions that were issued aimed to allow funders to negotiate collectively to bring down prices which have some parallels to what the NHI is trying to achieve. Another example of an exemption was in the petroleum industry which allowed refineries to share pricing information with the Minister with the broader objective of securing energy supply to the public. In order to temper market power in the Health Care industry, prohibitions on mergers and acquisitions of pharmaceutical companies were granted. The major concern was about private suppliers which might gain market power in the NHI including global pharmaceutical companies which remain within the CC jurisdiction.

Mr Hodge did not regard the comment about the design elements being unclear, as a criticism. The CC suggested that it would be preferable to determine if exemptions were required or if any part of the Competition Act restricted the NHI objectives, once regulations were in place. The exemption process had been accelerated through the pandemic and involved engagement with different stakeholders and ministers to understand the particular problems and determine if exemptions were required.

Mr Hodge reiterated that the CC concern about how a single payer and buyer would function under NHI, was about health care providers that would supply the single buyer. While there had been a single purchaser in the public health system, it did not prevent abuse through collusion, even during the pandemic. The objection was therefore not about one payer but the competition amongst suppliers to the NHI. Mr Hodge expressed the hope that this response would address the questions about the CC concern.

Mr Hodge replied to Ms Gela, stating the focus of the CC was mainly on collusion in procurement. The CC had worked closely with other partners on abuse of PPE procurement. Cases that involved corruption were investigated by the SIU while the matters of abuse in the private sector were referred to the CC for investigation and prosecution.

In response to Ms Clarke’s concern about the lack of mechanism to address collusion, Mr Hodge said the CC had existing advocacy and training programmes in place with organs of state. The detection of collusion was done through a range of tools to identify similar directors, similar pricing and handwriting styles. A global move towards digital detection pools was taking place that would enable the flagging of collusion trends through the power of big data, for example, the rotation of big bidders for repeat work.

Mr Hodge replied that it was not a requirement in terms of legislation for the CC to have an oversight role but the CC engages with many agencies through MOUs and would recommend a MOU for engagement with the NHI Fund.

Ms Harvard was requested to repeat her question. She asked if the implementation of the HMI recommendations could occur along with the incremental implementation of the NHI.

Mr Hodge thanked Ms Harvard for the clarification and agreed that HMI recommendations could be implemented in parallel with the NHI. Some of the recommendations provide for adequate competition amongst private health care providers that would benefit the NHI as it takes over the role of single payer. In terms of the competing interests and budget allocation for the implementation of the HMI recommendations, Mr Hodge said some of the recommendations did not require public funding. An engagement was necessary to determine which recommendations would be a priority and what was achievable within the transition period. A lengthy transition period would mean continued engagement with the private sector.

Mr Hodge replied to Mr Siwela that it was not the position of the CC that the exemption would provide a better option to achieve universal health care. The CC supported the objectives of the NHI and therefore deemed it necessary to highlight the fact that the current exemption posed a risk to the NHI. National health systems provide greater equality and access and had been successful in other countries.

Mr Hodge stated that a series of recommendations, to address adverse findings, were contained in the HMI report. An executive summary of the HMI report was available on the CC website and could be made available to the Committee. A discussion with the NDoH about prioritisation of recommendations and funding would be welcomed.

In response to the questions by the Chairperson, Mr Hodge explained that the HMI recommendations were quite extensive and affected both the demand and supply sides of the system. Problems in the private health care sector would impact on the public health care sector. Some adverse findings already had an impact on the public sector through GEMS, the scheme through which government employees were funded. To ensure improvement in health care services for all, the CC would welcome engagement with the NDoH and NHI Fund. Lessons were learnt during the pandemic through some of the coordination and forums that were in place.

Mr Majenge restated the point made by Mr Hodge that there was no contradiction between the recommendations of the HMI report and the initiative to implement universal health care system. The CC viewed the two as reinforcing each other.

The Chairperson thanked Mr Hodge and his team. The Committee was looking forward to further engagement. Referring to the requested engagement with Parliament Legal Services made by Ms Chirwa, the Chairperson replied that legal opinion would be sought. Also the follow up processes after the public hearings would involve obtaining a legal opinion from the State Law Advisor.

In conclusion, Mr Hodge reiterated the support of the CC for the NHI initiative and objectives and its willingness to work with the NHI Fund, within the framework of the Competition Act, where exemptions were required as it offered a more flexible option without denying the opportunity for an exemption to occur. The CC would recommend that the existing exemption be removed from the NHI Bill and that suitable options, where appropriate, should be identified through engagement between the CC and the NHI Fund. 

Commission for Gender Equality submission
CGE Legal Officer, Mr Moeng Dilthage, said the CGE supported the Bill but needed to highlight shortcomings that were not catering for the needs of the CGE constituencies and other marginalised communities.

Access to health care services for residents in rural communities was not a consideration in the Bill. The referral system did not consider factors such as the limited financial means of rural residents to access health care services in urban areas. Inadequate infrastructure in rural areas was a concern as it encroached on the right to dignity and privacy of rural women.

The CGE would prefer that the Bill provide clarity about the mechanism for complaints, especially for the LGBTIQA community who relied on a complaint system. To alleviate any exclusions in terms of enjoying the benefits of the system, the Bill should be clear and inclusive and not left open to interpretation by various stakeholders.

The CGE submitted to support the Bill but emphasised the gaps needed to be addressed for the Bill to work effectively for all communities.

The Chairperson found the submission interesting and invited Members' engagement.

Mr Chirwa said the concerns in the submission were previously raised by the EFF and she found it refreshing to hear similar sentiments from the CGE that were often missed by other organisations. These concerns related to the referral system, infrastructure and access to services which indicated that people from townships and informal settlements would not necessarily benefit from the Bill. Issues of exclusion of women, marginalised groups, the LGBTIQ community and people with disabilities were identified. She questioned its support for the Bill despite these points of conflict emphasised by CGE.

Ms Chirwa raised the disturbing forced sterilisations and the developments that had been taking place under the ANC government. CGE played a pivotal role in seeking justice for this crime against humanity. She was however concerned that CGE were sending people who had been violated to collect evidence from the perpetrators for CGE to continue with investigations. The lives of the victims, who are mainly black females, were being put under jeopardy when they are required to collect files from the places where they were subjected to trauma. She blamed CGE for not defending their report on this matter and said this issue would have been flat on its face, had it not been for the intervention of the EFF.

Ms Gela said it appeared CGE preferred that access to health care services within the NHI should not be coordinated from primary care to higher levels of care. The use of the referral system would ensure cost effectiveness and long-term sustainability of the NHI Fund. Although emergency medical services (EMS) was covered in various clauses of the NHI Bill, the submission seemed to suggest that EMS were not accommodated in the Bill in particular for members of marginalised groups. She asked why CGE believed that individuals from their constituencies would not benefit from EMS.

Ms Ismail (DA) asked if CGE was concerned that the NHI would not be effective due to the shortage of facilities and health care workers. Was CGE proposing that health care services must be specified in the NHI Bill. Was CGE of the opinion that tragedies such as Life Esidimeni, were not covered in the Bill? She asked if CGE would recommend that the private sector or entities be included in the NHI Board to ensure diversity, improved accountability and services. The submission gave the impression that the NHI was not offering adequate quality health care services for all. She asked if it was the opinion of CGE that the Bill was not inclusive and not sustainable and if CGE would therefore not support the Bill considering the concerns raised in its submission.  

Mr Sokatsha noted that CGE was seeking clarity on how the Bill would prevent discrimination in terms of the Promotion of Equality and Prevention of Unfair Discrimination Act. He asked if the mechanism in clause 43, clause 6(k) and clause 6(l) had been considered and if it would not strengthen the position of clause 6(e). Further detail about mechanisms was stipulated in various clauses of chapter 9 of the Bill.

Ms Harvard asked if CGE would be satisfied with a women’s health policy that would include all the issues raised in the submission.

Mr Siwela requested CGE to expand on the points made on clause 4 of the Bill about treatment that may not be funded under the NHI. CGE seemed to believe that clause 4 discriminated against the provision of health care to transgender and intersex persons as well as girls and women. He sought clarity on which specific parts of the Bill excluded the categories of users CGE represented.

Mr Munyai appreciated the valuable input by CGE and noted the concern about street dwellers. Clause 5 of the Bill made provision for a person who wanted to register as a user to provide biometrics and other prescribed information including fingerprints, photograph and proof of habitual place of residence. These provisions could be elaborated on to cater for the circumstances of street dwellers. The same applied to travellers in terms of the Immigration Act. He understood that roles not in the Bill would be covered in the regulations. He asked if CGE was comfortable with the two-tier system to continue to persist. He asked the view of CGE about the 8% of the private health care system accessing over R400 billion from the fiscus to cover 16% of the population while the rest was excluded from these benefits.

The Chairperson acknowledged the anxiety expressed by CGE about exclusion from necessary health care services to the LGBTIQA community. Clause 25 of the Bill stipulated that the Benefits Advisory Committee would have representation of different stakeholders. He asked if it was not possible that when such exclusions happened, CGE would have access to the mechanisms in clauses 6(e), (k) and (l) along with complaints mechanism outlined in Chapter 9 of the Bill. CGE was asked how the Bill could be improved to represent the LGBTIQ community.

CGE response
Mr Dilthage confirmed the CGE support for the Bill and stated that the challenges highlighted at this stage was with the intention for further negotiations. He replied to Ms Chirwa stating that there were many aspects involved in the forced sterilisation matter. The request for more detail was made only when complainants provided incomplete information such as the date or the name of the hospital. CGE would struggle to do investigations or come to a conclusion and make a finding in the absence of all relevant information.

The referral system was important in the allocation of resources and would support the long-term sustainability of the NHI. The concern was with the referral of patients from rural to urban areas as rural people would in most cases not have the resources to reach urban areas.

Mr Dilthage replied that the mechanism in the NHI Fund must prevent discrimination but some clauses of the Bill did not cater for everyone as stated in the Constitution. Discrimination on the basis of gender and sexual orientation was a concern. The Bill indicated that some roles would be covered by the regulations but CGE proposed that all roles should be catered for in the NHI Act. The focus of CGE was to achieve coverage for members of the previously disadvantaged group and for the NHI to cater for the needs of everyone. No one should be excluded, based on the environment where they lived.

Ms Mamello Matthews, CGE Legal Officer, asked if any questions were unanswered.

The Chairperson replied that there would not be another round of questions but he would grant CGE an opportunity for closing remarks. He thanked both CGE representatives.

Ms Matthews said the general sense from Members' questions was about CGE position as it pertained to the Bill and the submissions that were made. She confirmed CGE’s support the Bill. The gaps identified would impact on how well this piece of legislation would work and how it would benefit the entire community. On the question why CGE was overlooking the benefits in Chapter 9, she replied CGE would want to solve problems before they occurred especially for the LGBTIQ community that had to rely on a complaint system. Ideally the legislation should be as clear and inclusive as possible to alleviate any exclusions from enjoying the benefits of the system. It was made clear in the submission that CGE supported the Bill. It was an important Bill and therefore it must be as clear as possible from the onset to prevent having to approach the courts for interpretation of certain clauses that could be interpreted differently by different stakeholders. The Bill would work well if gaps were addressed from the start.

Solidarity submission
Mr Connie Mulder, Head of the Solidarity Research Institute, was pleased to finally have the opportunity to address the Committee. From the perspective of Solidarity, the Bill was unaffordable, unnecessary and unworkable. There was no fiscal space left to implement NHI as the economic position of the country deteriorated drastically. Mr Mulder compared the situation to wanting to buy an Airbus while only having funds to buy a car.

An adjustment of the figures in the 2010 White Paper, by Prof Jannie Rossouw of Wits in 2019, showed an estimated funding gap of R236 billion. It was inconceivable that, based on this estimated shortfall, the Bill was still being considered. Solidarity submitted that it could not support the Bill and would initiate legal action to challenge the Bill.

The Chairperson thanked Mr Mulder and said the Committee was now aware of what to expect in terms of actions from Solidarity.

Mr P van Staden (FF+) said the submission from Solidarity provided the information that the Committee needed to know. He asked if Solidarity was able to provide the Committee and Parliament with an alternative model that would provide better and affordable health care.

Mr Sokatsha asked if Solidarity differed with the National Institute of Communicable Diseases (NICD), Human Sciences Research Council (HSRC), Medical Research Council (MRC) of South Africa and the World Health Organisation (WHO) survey on the burden of disease and its importance on health services. Solidarity seemed to present a negative argument about the NHI with no reference to specific elements in the Bill. He asked if it was the position of Solidarity not to support universal health care and therefore there was no need to refer to the Bill.

Ms Gela said the goal of the NHI was to expand population coverage. She questioned if Mr Mulder had read clause 2 of the Bill in which the purpose of the NHI Fund was stated. She asked if Solidarity submitted comments on the Green and White Papers when presented by NDoH for public comment.

Mr Munyai asked if Solidarity acknowledged the discriminatory nature of the current system and if the status quo of the two-tier system should be allowed to continue. He asked if the right to equitable access to services was not a concern to Solidarity. Mr Munyai spoke of an accident which involved himself and his brother. He was offered the services of an ambulance, which he refused because his brother was not able to get the same service as he did not have medical aid.

Ms Clarke said everyone was aware that the current system had failed most people in the country. She asked how Solidarity would be able to provide universal health care considering the feasibility of such a system. An alternative model would be an interesting prospect. The public participation process was an aspect that was missing and which needed attention.

Mr Siwela said Mr Mulder indicated that the NHI was unaffordable therefore further discussion is academic. He asked if Solidarity expected the Committee to accept the finding that was based on studies and a sample of 1 410 members of Solidarity.

Ms Wilson stated that in principle we did have universal health care in South Africa. Nothing was preventing any person from going to a clinic to access health care when it was required. What the country needed was quality health care based on three pillars, i.e. availability, accessibility and equity. The priority should be on upgrading the current system. In terms of the Zondo Commission report and the horrific PPE corruption in the SIU report, Ms Wilson reiterated her concern about the Minister having the sole responsibility to appoint NHI Boards and Committees. The single buyer system would stop innovation should it be considered. Ms Wilson asked if the Bill met constitutional muster.

Mr Harvard asked what Solidarity would propose to give effect to section 27 of the Constitution which made provision for health care for all. She enquired if the views of Solidarity were based on its own work.

Ms Ismail acknowledged the submission saying it was good to hear from all stakeholders. The existing health care system was not working efficiently for all communities due to the high levels of corruption in the system.

She was anticipating the input of Solidarity on alternatives that could be put in place. Health care workers who had been studying hard and working hard, were not getting value for money due to the lack of opportunities. She asked if a feasibility study was done on alternatives that could make progress with the aim to provide for quality universal health care.

The Chairperson found the statement by Mr Mulder that no research and technical analysis was done to support the two-tier system, challenging. If Solidarity had developed a benefit analysis, it would be welcomed if the information could be shared with the Committee. Mr Mulder was asked what should happen to poor people if the dual system should persist. The judgement was based on the ideology and interest of Solidarity and not considerate of the broader society. He requested Mr Mulder to comment on the ethics of the Bill and to disclose the data source on which the calculation of the shortfall of R236 billion in NHI funding was based. In light of the legal challenge that was being prepared by Solidarity, the Chairperson asked if Parliament should continue the process of reviewing the Bill.

Solidarity response
Mr Mulder replied that Solidarity explicitly stated it was not satisfied with the status quo but disagreed with NHI as the solution. A single fund with a single purchaser would not work and would have a negative effect on the health care system.

Mr Mulder sympathised with Mr Munyai about the situation with the accident where the ambulance service was not offered to his brother. He acknowledged the massive governance and corruption issues in the public health care system. The outcomes in the Western Cape were far better compared to Gauteng which supported the argument that the problem was a management and governance one and not a matter of funding. Action was needed for the public health care system to work better. The priority should be to fix the roof and not to demolish the whole house.

Mr Mulder responded to Mr van Staden that the Solidarity proposal was for more medical schemes to be introduced which would bring about more competition. This would side-step the option of a central fund that could be plundered. Extensive work on viable options had been done by Prof Alex van Heerden of the University of the Witwatersrand (Wits).

Mr Mulder replied to Ms Gela that universal health care did exist but the poor quality of services should be addressed instead of changing the Private Health Care system. Some of the public hospitals had clean audits which was an indication that public health care could work. He confirmed that Solidarity had been part of the legislative process from the start and had made written submissions on the White and Green Papers.

Mr Mulder disagreed with Mr Siwela that data was selectively chosen to prove that NHI was unaffordable. It was stated in the Bill that funding would take place through taxation. The 2010 values in the White Paper had not been adjusted. The shortfall of R236 billion was based on updated figures, determined by Prof Jannie Rossouw of Wits. In terms of the unworkability factor, Mr Mulder explained the sample consisted of 1 410 health care workers who were members of Solidarity. From the perspective of Solidarity, it was a valuable sample as it was not possible to obtain the opinion of the entire health care population.

Mr Mulder agreed with Ms Wilson that the Bill was not going to address the quality of services in the current health care system. Monopoly purchases would not lead to proficiency, given our history of corruption where officials were found to plunder money even in times of a pandemic. Solidarity was extremely concerned and proposed that South Africa should follow the examples of other countries and decentralise as much as possible. Mr Mulder reiterated that the Bill would not meet constitutional muster.

In response to Ms Harvard, Mr Mulder said section 27 of the Constitution was not the matter as an extensive public sector health care system, which was well funded from taxpayer money, already existed. The system just needed to be fixed and not rehauled.

Mr Mulder replied to Ms Ismail that the focus was not on specific issues in the Bill because the starting point of a single payer was wrong. Alternatives were presented in the submission.

Mr Mulder replied to the Chairperson that the status quo was not sustainable but NHI was not the solution. The issue was not the distribution of funds but rather a matter of governance. A viable option was to fix the current system. He agreed that the judgement of Solidarity was driven by ideology but stated that the NHI was also based on ANC ideology. It was almost reckless to steam ahead with the Bill considering that it had not been properly costed. Solidarity was of the opinion that the Bill should be withdrawn as it would not extend health care. Solidarity was still in consultation on the legal challenge and would be ready for the Constitutional Court hearing.

The Chairperson thanked Mr Mulder and his team for the submission and for clarifying matters.

Mr Mulder concluded that the Bill was unaffordable, unnecessary and unworkable and would not extend access to health care.

Concluding remarks
The Chairperson said the submissions for this week were complete and offered Mr van Staden the opportunity to raise the matter about emailed submissions.

Mr van Staden asked if the fire at Parliament had an effect on the delivery of email submissions to Parliament. He wanted to know where the email submissions could be located and if Members could be informed about the manner in which this system was working.

The Chairperson noted the question and said he would revert to the Committee with an answer on 8 February 2022.

The meeting was adjourned.

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