National Health Insurance (NHI) Bill: public hearings day 25, with Deputy Minister

Meeting report

Opening Remarks
The Chairperson made brief opening remarks. The apologies were noted.

A moment of silence was observed for Prof Eddie Mhlanga, Chairperson of the National Committee on the Confidential Enquiries into Maternal Deaths.

The Chairperson noted that Prof Eddie Mhlangu was a dedicated public servant in the health sphere, who had done a lot of work in the field of maternal health in South Africa.

The Chairperson noted that 99 oral submissions had been heard on the National Health Insurance (NHI) Bill to date. The last of the submissions would be heard by 22 February 2022.

Presentation by the Democratic Nursing Organisation of South Africa (DENOSA)
Mr Simon Hlungwani, President, DENOSA, made brief introductory remarks to their submission presentation on the NHI Bill.

Mr Daniel Kwena Manamela, Deputy General Secretary, DENOSA, presented the organisation’s key concerns about the NHI Bill. It was emphasised that DENOSA supported the objectives of the NHI Bill.

Definitions and funding
A number of definitions were highlighted for inclusion in the Bill, this included the definition of ‘National Health Insurance,’ ‘complementary health benefit services,’ and ‘universal health coverage.’ It was emphasised that there was a need for clear regulation on the implementation of the Bill. Evidence showed that the private health sector was well funded through private schemes while the public sector was depleted but serviced most of the population of the Country. Due to corruption, fraud and user preference the funds should not be channelled to the already capacitated private sector. In light of the corruption and poor governance at public entities. There was a lack of detail in the Bill with about how the fund would tackle elements of corruption. There should be a detailed process outlined, in the regulation that would be operationalising the Act.

Coverage
Concerns were highlighted about the lack of sufficient coverage of asylum seekers and illegal foreigners, particularly that coverage was limited to emergency medical services and for notifiable conditions of public health concern. Issues around the role of the Minister were highlighted, particularly in light of the huge failures in the public health system currently.

Representation on Committees
The need for diversified committees was emphasised, as well as broad expertise of all skills and knowledge to inform the benefits. Nurses were a huge workforce that took care of patients in the private and public sectors and had knowledge and skills. The labour movement represented the majority of workers in the Country who used public service and had knowledge and skills required to advise.

Shortage of employment opportunities
Current issues around the shortage of positions was highlighted. Training of the workforce had dropped which was not in line with the Primary Healthcare reengineering. Nurse production had dropped significantly with one intake per annum. Several nursing colleges had closed with those remaining unaccredited to offer new qualifications.

(See DENOSA’s presentation)

Discussion
Ms H Ismail (DA) asked if DENOSA thought the Department of Health had adequately planned for NHI, given that the pilot projects were not an effective tool for determining if NHI would work. Did South Africa not already have universal healthcare? There were public healthcare facilities that were available to everyone who chose to use them. Was NHI not simply re-inventing the wheel? Due to budget constraints and other factors, both doctors and nurses were experiencing difficulties in being placed by the Department. With the current infrastructure crisis, most of the healthcare facilities were facing challenges. Would NHI really work given this situation? Would there be adequate healthcare if it was not first ensured that there were enough healthcare workers in the system and healthcare infrastructure was improved before NHI was implemented.

She highlighted that the Office of Health Standards Compliance (OHSC) currently could not manage to oversee 20 percent of the country’s healthcare facilities. Under NHI many of the clinics would need to be closed, due to not meeting compliance standards. This would lead to decreased access to healthcare facilities. Given that the Health Ombudsman could not oversee and ensure compliance currently – how would it manage to ensure compliance under NHI?

Currently, there was already around R104 billion in medical negligence claims – would the situation not be worse under NHI? Would the NHI be providing a health-barrier based model in its current form? Did DENOSA think the NHI Bill met Constitutional requirements?

Ms A Gela (ANC) highlighted that the NHI would correct the current imbalances in the healthcare system. NHI would be a good move for South Africa, people would be treated equally, no matter their status. NHI would address the issues faced by the Department of Health. DENOSA had suggested that there was a need for clear regulation of the private sector. She asked that DENOSA provide more clarity on that; what were the key areas that needed to be regulated? DENOSA had concerns about healthcare service coverage for illegal foreigners and asylum seekers; she asked what DENOSA proposed, to cover these groups.

Mr M Sokatsha (ANC) stated that DENOSA had raised important issues about the emergency medical services. He noted that the NHI Bill defined ‘emergency medical services’ as ‘services provided by any private or public entity dedicated, staffed and equipped to offer pre-hospital acute medical treatment and transport of the ill or injured.’ Clause 35(4)(a) stated that ‘emergency medical services provided by accredited and contracted public and private health care service providers must be reimbursed on a capped case-based fee basis with adjustments made for case severity, where necessary.’ Did those clauses not address the concerns of DENOSA?

Mr T Munyai (ANC) asked if DENOSA was worried that clause 17(a) might lead to the denial of care for users. Was the leadership aware of clause 6 of the Bill, which outlined the rights of the users and stated that users would ‘receive necessary quality healthcare services free at the point of care from an accredited healthcare provider or healthcare establishment upon proof of registration with the Fund. The health patient registration system would ensure that all users were registered to access healthcare within their catchment areas. Services would be portable – there would not be area coverage issues. He asked if DENOSA was aware of clause 40 of the Bill – did clause 40 not address their concerns? DENOSA had highlighted problems with the role of the Minister, specifically the appointment of the independent board, as outlined in clause 12 of the Bill. He asked if DENOSA was aware of clauses 18, 19 and 21, as well as other clauses, in the Bill where provision was made for the Minister to consult with the Minister of Finance, the Portfolio Committee and require approval from the Cabinet before implementation of any recommendations. If the structures were not adequate to provide oversight of the actions of the Minister – what other structures did DENOSA propose be included in the Bill? Did DENOSA want to change the Constitution, specifically the current constitutional role of the Minister?

Ms N Chirwa (EFF) asked if DENOSA thought the issues of infrastructure (i.e. refurbishment of hospitals and clinics) were addressed in the Bill – and what DENOSA would propose on that. Over the previous few days the issue of hospitals in Gauteng not meeting certain standards, had been highlighted.

People living in townships, informal settlements or rural areas would still be subjected to the current public health system without improved access. She highlighted that these areas would still be under-resourced under NHI, unlike urban areas. She suggested it was partly due to the referral system proposed in the Bill. Patient’s first had to go to their nearest point of care. What was DENOSA’s position on the fact that the NHI did not address the issue of infrastructure? The majority of the funds would be directed to carrying the cost of the NHI Fund and not necessarily dealing with the issues present in the current healthcare system.

She highlighted the issue of security of healthcare workers. She had received complaints about security when on oversight visits to clinics and hospitals. Many healthcare workers were physically assaulted and abused by community members. This had not been highlighted in the presentation, despite it being an issue that nurses’ complained about a lot. There were communities that saw the incapacity of healthcare facilities and placed the blame on nurses who were violated on their way to and from healthcare facilities. There had been a number of recommendations to the National Department of Health on how to ramp up security. This had clearly fallen on deaf ears; one of the proposals was to introduce the biometric system in pharmacies. During the oversight visit, nurses complained about there being an excessive influx of people to regional and district hospitals, which put a lot of strain on nurses. This was largely due to there being insufficient/inadequate infrastructure in some areas, which saw an overburdening of some facilities.

She asked for more information about the training and absorption of community healthcare workers under NHI. What role did DENOSA envision having under NHI? She noted that the issue of documentation was highlighted in the presentation; she asked for clarity about DENOSA’s position on illegal immigrants. She asked that DENOSA keep in mind that the issue of documentation was not only isolated to illegal immigrants. There were many South Africans who were flooding Home Affairs branches every day, who did not have documentation. There were issues of abandonment after birth, lack of literacy about the processes of registration and persons who were homeless etc. What was DENOSA’s position on documentation?

Dr S Thembekwayo (EFF) asked what services would not be included under complementary health benefit services. She noted that it was stated that the regulations were unclear on implementation – she asked what DENOSA’s proposals were on this. Clause 4(2) of the Bill stated that ‘an asylum seeker or illegal foreigner was entitled to’ – what was not clear about that clause? Clause 5 provided clear information about registration for all users – she asked what was unclear about it.

The Chairperson welcomed the Deputy Minister Dr Sibongiseni Dhlomo to the meeting. He noted DENOSA’s concerns about clause 8(2) of the Bill and the suggestions made about the members of the Benefits Advisory Committee. DENOSA seemed to suggest that the proposed role of medical schemes, as stated in the Bill, should be removed completely. He reminded DENOSA about clauses 33, 58, 6 and 25. Clause 33 stated that once NHI was fully implemented, as determined by the Minister and issued in the gazette, medical schemes could only cover services not reimbursed by the Fund. This was supported by clause 6(o) of the Bill. He asked if DENOSA was familiar with clause 58 of the Bill, which proposed amendments to the Medical Schemes Act – would that amendment not provide the legislative oversight of complementary cover to be provided by the schemes? What was DENOSA’s view on the issues of choice, specifically where medical schemes were concerned? He noted the suggestion that a representative of the nursing fraternity and organised labour needed to be included on the Benefits Advisory Committee. Should representatives from every health profession be appointed to the Benefits Advisory Committee – if DENOSA proposed this – why should it be done?

Mr Hlungwani replied that the public health system in South Africa was designed to deal with a certain size population. DENOSA believed that the current health system in South Africa was designed to deal with the health challenges of 1997. The current system was outdated. At some point South Africa had a population of about 46 million people. There were presently about 60 million people in the country - the health system had not evolved. In 1997 the disease burden was low and the country did not face the same challenges, such as the Human Immunodeficiency Virus (HIV), serious chronic illnesses nor COVID-19.

The pilot project showed that the country had performed dismally. This suggested that more needed to be done to ensure that NHI was successful. The challenges seen in the pilot project should not discourage the country from forging ahead and addressing the issues indicated in the pilot project. One could only learn from the pilot project.

Systems development would include planning, management and maintenance. He highlighted the state of infrastructure and the balancing of the needs for maintenance and health services, such as the case of Johannesburg’s Charlotte Maxeke Hospital. There needed to be serious commitment to address systemic issues and maintenance issues. It provided an opportunity to plan properly. Planning for 46 million people would not work, as there were about 60 million people in the country, on top of undocumented persons.

DENOSA agreed with the standardisation of access to ensure there was a better system. He highlighted the lack of sufficient cancer diagnostic services and infrastructure, particularly in outlying areas. Issues of access could not only be considered in urban areas, where there were a greater number of facilities, it needed to be considered in rural areas as well. The NHI system should try to distribute services all over the Country and provide access to the private sector. This meant that one would not have to rely on one’s income to get access to those services.

COVID-19 had taught the country that there could be collaboration between the private and public sectors. This could be learnt from. Where there were gaps highlighted by the OHSC and Health Ombudsman, resources needed to be pumped in. DENOSA believed that the tender model of providing security in hospitals did not work. Security personnel needed to be trained sufficiently to deal appropriately with patients accessing care – DENOSA suggested that training of government security needed to take place to provide security at hospitals. Security was a serious concern, as highlighted by Ms Chirwa, there were rapes and stabbings.

DENOSA was worried about the shortage of health professionals. Many nurses completed a four-year degree or diploma and thereafter they underwent community service for one year. After this, those nurses were let go as there were limited opportunities for employment. When one considered the disease burden in South Africa, including what the World Health Organisation (WHO) released in the State of World’s Nursing Report 2020, it had stated that every country needed to grow its health sector, including nursing by 8-10 percent. There was regression in the intake of nurses. In the year 2030, there would be a shortage of health professionals – as found by the Report. If one considered the number of people being trained for critical care currently, one would realise that the country was way behind what was acceptable. It was a concern.

If one went to the poorest of the poor in the country, many of those hospitals were designed during apartheid for poor Blacks, such as Tembisa Hospital in Johannesburg. Many health professionals were being blamed for such problems, when in fact there were systemic problems. The community health workers that were let go, were nurses that could be assisting the human resource shortages. DENOSA was assisting pharmacology graduates who had qualified and were awaiting placements. To become fully fledged pharmacists, graduates needed to do an internship; community service opportunities were needed for them to be used in either the public or private sectors. There were systemic challenges that should be addressed in conjunction with realising NHI.

He stated that he ‘was not being xenophobic’ in stating that when one considered the number of people giving birth in some hospitals, 80 percent of them were women who specifically came to South Africa. The challenge was created by porous borders. If there was no well-functioning Southern African Development Community (SADC) nor country with systems that worked. The NHI should provide an opportunity to address all the systemic issues until NHI was fully functional.

Mr Manamela responded to the questions about the inclusion of organised labour and the nursing fraternity in the committee structures of the NHI. This was simply DENOSA’s proposal, that the two areas be represented. DENOSA was not proposing that the Constitution be amended. The issues of complementary cover needed to be clarified, particularly clause 33 of the Bill. He noted clause 58 of the Bill, it was not clear and he suggested it needed to be listed. DENOSA had wanted to stress the issue of undocumented foreign nationals as an issue that needed to be looked into. DENOSA understood the registration of users – but what happened when persons could not produce certain required documents?

DENOSA did not believe there would come a time when the country would be ‘ready’ to implement NHI. The discussions about universal healthcare dated back many years – it took the will of leadership to implement NHI. There was no universal health coverage nor universal access in the Country currently. There was already a shortage of services, NHI would not make the situation worse. It was understood that there would be cross-subsidisation – although he noted that it had not been outlined how it would be fully funded.

Presentation by the Young Nurses Indaba Trade Union
Ms Lerato Mthunzi, President, Young Nurses Indaba Trade Union, presented the Union’s submission on the NHI Bill to the Committee. The need for a ‘one-tier’ system was emphasised

Funds
The pool of funds collected by the NHI needed to be monitored through oversight committees that would be watchdogs. The committees must be autonomous, independent and should not report to the Minister. This was informed by the fact that the Bill, in its current form, the Minister was NHI and could decide who served, who did not and overrule the Boards. The risks that existed were significant and opened the Fund up to looting and corruption. The need to phase out medical aids needed to be clearly stated.

The private sector
The Union stated that NHI should not be disguised as a method of privatizing South African healthcare. It needed to remain the sole responsibility of public health. Healthcare was not for profits and therefore, tiptoeing around the private healthcare sector should be discouraged at all costs. External private service providers were made too comfortable in the Bill. Their operations were enhanced. The Union would not support the NHI in those sections that was giving service providers more solidified operations. The NHI must be bold to state that when it was implemented, there must be a clear pathway of phasing out medical aids. The NHI needed to seek to offer comprehensive, equal service to all. Phasing out of medical aids as primary service providers must be achieved. The eradication of ‘elites forming their fund and disguising it as things that are not covered by NHI must be rejected.’

Inclusion of Youth & Women
The Union emphasised the need to involve young healthcare professionals in the planning and oversight committees as well and the Boards. The need to include women was highlighted.

(See Young Nurses Indaba Trade Union’s Presentation)

Mr Rich Sicina, General Secretary, Young Nurses Indaba Trade Union, made brief concluding remarks to the presentation.

Discussion
Mr Sokatsha noted the organisation’s concern about the definition of ‘emergency medical services.’ The Bill defined ‘emergency medical services,’ as ‘services provided by any private or public entity dedicated, staffed and equipped to offer pre-hospital acute medical treatment and transport of the ill or injured.’ If this definition was not sufficient, could it not be defined further by the Benefits Advisory Committee, as outlined in the Bill, or in the regulations? He noted that the Union recommended that any procedure deemed to be cosmetic needed to be subjected to special authorisation. Was the Union aware of clause 25 of the Bill, which spoke about the Benefits Advisory Committee? The Benefits Advisory Committee would be tasked with determining the NHI service benefits.

Ms Ismail asked if the Department of Health had adequately planned for the NHI. Given that the pilot projects were not an effective measuring tool for establishing if NHI would work, she suggested it had been a waste of money, as there were no actual pilot projects in the Country that determined if NHI would work. Did the Union believed that NHI would work? NHI was a funding model, would the NHI be providing health value-based healthcare to citizens?

There was a major issue with the placement of nurses and doctors in the current context – would the situation be better under NHI? Should the healthcare system not be fixed before NHI was implemented to ensure that there was effective service delivery to the country. The fact that the Health Ombudsman could not manage to monitor 20 percent of the country’s healthcare facilities was concerning. Under NHI there were certain compliance requirements for healthcare facilities to operate. How would this work? Would there not be a situation where 90 percent of the country’s health facilities would need to be shut down? Would this not hamper service delivery and the availability of healthcare services to citizens? Would the NHI work, given the number of issues in the system?

She noted that corruption was highlighted in the presentation; would the single purchaser, single buyer model, be effective or would it cause a monopoly, which would in-turn increase prices of medicines and possibly open up opportunities for looting and corruption. What would the Union recommend be included in the Bill to eliminate this risk?

She highlighted the R104 billion in medical negligence claims; would this not be worse under NHI? How would the NHI cope without the private sector functioning in parallel? She noted that the risk of corruption had been noted in the presentation – what should be included to strengthen the accountability measures in the Bill? COVID-19 was mentioned in the presentation as well as the way the country had dealt with it. It needed to be acknowledged that the private sector played a huge part in the COVID-19 struggle – did this not highlight that the private sector was an important role-player in providing professional healthcare to the Country? Would the NHI work without the private sector being there?

Dr X Havard (ANC) stated that the presenter made a comment that the Bill sought to deliberately exclude women from participating in South Africa’s health system and NHI. She asked that the Union clarify which clauses of the Bill contained such information and/or on what was the basis this view.

Mr Munyai said it appeared that the Union believed that some provisions of the Bill, particularly clause 2, sought to further fragment the healthcare system - when in fact such provisions sought to provide users with avenues to access services not covered under NHI. Did the Union believe that costs associated with services that were not essential, such as cosmetic plastic surgery, should be paid for by the NHI Fund? He noted the concerns about the accountability of the Fund - what was the Union’s interpretation of clause 50 of the Bill, which dealt with the role of the Auditor General (AG)? This was a constitutional body that was responsible for looking at those matters. What role did the Union anticipate Parliament playing in its oversight role in holding the NHI Fund accountable? Should the country continue with a two-tier system, of which the private medical schemes received 8 percent of Gross Domestic Product (GDP)? This was equivalent to over R400 billion, yet the rest of the population did not have access to that kind of money in the public sector. Should there not be an integrated system, wherein the entire population needed to be served, regardless of their socio-economic status?

The Chairperson asked if the Union was concerned about clause 8(2) of the Bill, which provided basic healthcare benefits. Clause 15(3)(b) of the Bill stated that the Board must advise the Minister on any matter, concerning the development of comprehensive healthcare services to be funded by the Fund through the Benefits Advisory Committee. Was the Union aware of clause 39(8) of the Bill which contended that the Fund could withdraw or refuse to renew a healthcare service provider or health establishment if it was proven that a healthcare service provider had failed or was unable to deliver the required comprehensive healthcare service benefits.

He noted that the Union had expressed concern about medical schemes claiming from the NHI Fund, and the proposal that the medical schemes should not claim from the NHI Fund and that their role needed to be made redundant. Did the Young Nurses Indaba Trade Union not agree with clause 33 of the Bill which stated once NHI had been fully implemented, as determined by the Minister through regulations in the gazette, medical schemes could only offer complementary cover of services not reimbursable by the Fund? What about those arguing for some level of choice?

In the Bill, the Minister had certain functions, including the appointment of board members, most if not all of these could only be implemented after consultation with other structures, such as the National Health Council, the Board and National Treasury. What made the Union think that the Minister would ‘own’ the NHI Fund? What other structures should the Minister consult with?

Ms Mthunzi noted that the dispute was not about the definition of ‘emergency medical services.’ The definition was very clear in the Bill. The inclusivity of all health categories was important, which would apply to emergency medical services as well.

She responded to the questions about the role of the Advisory Committee, which would advise the Minister, in line with clauses 33 and 39 of the Bill. The Minister was given ‘way too much power’ over the NHI. The healthcare system had been plagued with ministers, looting and corruption. Those checks and balances were important. The Union was not suggesting that the Minister should consult other committees; the Union was proposing that what was contained in the Bill was inadequate. There needed to be an external body that needed to be included for the Country to have peace of mind. The Union did not think the wheel needed to be ‘re-invented’ – it should be a comprehensive system that covered everyone adequately.

When it came to complementary cover – it was not clear what complementary cover was nor were complementary services mentioned. Currently the system offered primary to tertiary care and that needed to be maintained - everyone needed quality improved healthcare services.

The non-essential services should not be issues of debate. One only had a choice, if one had money. If one did not have money, one did not have a choice. It should not be a question of ‘choice’ - one should have access to quality healthcare. It was a right to every citizen of the country. The Union supported NHI, but did not support the Bill in its current form. What happened to those who did not have access to healthcare services currently? Should those patients wait until the healthcare system was fixed – while others could afford and did have choice? The NHI was the first step, with its imperfections, it was something that the Country could start working on.

If there were committees in the national framework which had oversight of how provinces regions and districts ran, with clear accountability, it would lessen the load on regulatory bodies, such as the South African Nursing Council (SANC) and the Health Professions Council of South Africa (HPSA). Currently, there was no capacity. No one accounted to National Government under the current structure. As a healthcare worker, the only difference between the public and private sector was that the private sector played a role in segregating and denying medical care – hiding behind medical aids etc.

The Union was not stating that the Bill in its current form was excluding women. Women at all levels were excluded in occupying positions of authority and ensuring that the healthcare system moved forward – despite women being in the majority. These disparities needed to be addressed and bridged under NHI.

For the privileged who had access to medical aids, one wanted to stay with the medical aids – but that would not correct the system. One could wean it off – ‘make everyone who had money comfortable,’ but then one would really be ‘playing games.’ The Bill was very generous to the Minister, affording one human in the country too much responsibility. Currently the regulatory authorities, in line with the Nursing Act, were advising the Ministers. She noted that the recommendations made by the Health Ombudsman, for example, never got implemented.

Mr Sicina noted the question from the Democratic Alliance asking why the health system was not fixed before NHI was implemented. The Union wanted to move away from the two-tier system. He highlighted that Blacks in South Africa, due to the history of the country, did not have sufficient ownership and economic freedom etc. The health system was in its current situation because people in positions of authority had money. Those people would not make use of a clinic nor public hospital when sick, waiting there from 8am to 4pm before being attended to by a doctor. This was why one system was needed that would force everyone to stand up when things went wrong. The poor were suffering currently because the public healthcare system was neglected.

Ms Ismail asked that the presenters, when responding, not refer to politics. Members were asking questions as Members of the Committee, and not necessarily as party liaisons. She agreed with Mr Sicinia that all South Africans were equal – despite past presidents and deputy presidents going outside of the country to seek medical care. It showed that there was not sufficient assurance that South Africa’s healthcare system would provide sufficient healthcare to them. She clarified her earlier question, she asked if there would be adequate healthcare under NHI, as NHI was principally a funding model.

Presentation by Genetics Alliance South Africa
Dr Helen Malherbe, Former Chair of Genetic Alliance South Africa, and Ms Kelly du Plessis, CEO and Founder of Rare Diseases South Africa, presented the submission made by Genetics Alliance South Africa to the Committee. In 2020, Rare Diseases South Africa absorbed Genetic Alliance South Africa into its operations, expanding their mandate to include congenital disorders, however the submission on the Bill was given by Genetics Alliance South Africa prior to this change.

The presentation focused on issues of definitions in the Bill, access to healthcare, fund income, coverage, continuation of care, referral pathways, rights of fund users and progressive realisation. A number of ambiguous terms, included in the Bill, were highlighted. This included active purchasing and progressive realisation, amongst others. It was highlighted that the NHI did not effectively prove for nor uphold Constitutional rights of those with congenital disorders and rare diseases.

Fund Income and Coverage
The Fund was the single public purchaser and financier of health services in the South Africa. There was no reference to the mechanism by which the fund would be financed; this needed to be clarified and detailed. A provisional funding framework should have been in place (i.e. a means to financially provide for the scheme) prior to the drafting of the Bill. The financial burden imposed on families affected by congenital disorders and rare disease was already immense (full time care, loss of earnings). If families were required to pay toward the NHI Fund from taxable earnings, this would further decrease the amount available to obtain appropriate complementary cover, placing them at further financial risk. This may result in vulnerable groups paying for a mandatory service that did not provide for their needs and additional costs for private services not provided through NHI. The issue of a small tax base was highlighted, particularly concerns about the sustainability of the Fund.

Accreditation
Concerns were raised that 85 percent of public hospitals and clinics were not accredited to participate in an NHI system because they were unable to comply adequately with basic healthcare norms and standards, such as maintaining proper hygiene and having medicines available. These problems required improved operational and financial management.

Accountability & Corruption
For South African citizens to truly benefit from a universal health coverage system there was a need for stronger accountability for wrongdoing and accountability amongst political and civil servants involved in the operation of the fund. Failure to do this would directly impact the entitled user/beneficiary’s right to life and to have access to health care services.

Summary of Position
The Genetics Alliance of South Africa and its membership did not believe that the draft Bill could be accepted in its current format. Genetics Alliance of South Africa requested that comments were addressed and shortcomings rectified through further consultation with the various stakeholders and groups. True universal health coverage was where citizens could access health services without incurring financial hardship: a system of protection which provided the equality of opportunity for people to enjoy an attainable level of health. Such a healthcare service should be available to all registered users, and include promotive, preventative, curative, rehabilitative and palliative health services, regardless of socio-economic or health status of those persons at no cost impact to the registered user.

(See Genetic Alliance of South Africa’s presentation).

Discussion
Dr Havard noted the concern that the Bill, in its current form, did not effectively provide for the constitutional rights of South Africans affected by common or rare congenital diseases. She asked if Genetics Alliance South Africa was aware of clause 25, which spoke about the role of the Benefits Advisory Committee. This would include membership of persons with different skills, expertise and representation of patients’ rights.

Mr Sokatsha noted that Genetics Alliance South Africa argued that there was no reference to the mechanism by which the Fund would be financed. He noted the request for a provisional funding framework. He asked if the organisation was aware of the funding framework that was proposed in the White Paper. Had Genetics Alliance South Africa read clause 49 of the Bill? This clause dealt with the chief source of income for the Fund.

Mr Munyai said it appeared that Genetics Alliance South Africa was seeking clarity about clause 33, as it related to NHI service benefits and complementary cover by medical schemes. Was Genetics Alliance South Africa aware of clause 33, which spoke about complementary cover that did not include the benefits covered by the NHI Fund? Was Genetics Alliance South Africa aware of the definition of ‘complementary cover’ as outlined in the Bill? It was defined as follows, ‘third party payment for personal healthcare service benefits, not reimbursed by the Fund, including any top-up cover covered by the medical schemes, registered in line with the Medical Schemes Act or any other voluntary private health insurance Fund.’ Was Genetics Alliance South Africa aware of clause 8 of the Bill, which proposed amendment of the Medical Schemes Act, for alignment with the Bill?

Genetics Alliance South Africa outlined the situation of economic hardships, following COVID-19. He noted that the most industrial countries were hardest hit, where hospitals were overwhelmed and resources were not limitless. To suggest that the country needed the money in order to implement NHI –what had been the source of funding for other such policy implementation? He emphasised that tax had been a part of all of them. The challenges of the two-tier system were well-known. Those that could not get assistance, were excluded based on socio-economic conditions. Private medical schemes however, were receiving over R400 billion and were covering only 12 to 16 percent of the population. The rest of the Country did not enjoy those benefits. Did Genetics Alliance South Africa support the two-tier system?

Ms M Clarke (DA) asked if the NHI would be able to have enough healthcare professionals in the system to deal with patients who suffered from rare diseases. Many health professionals did not agree with the way the Bill was structured in its current form. Did Genetics Alliance South Africa think that the medico-legal claims would dissipate under NHI? Billions of Rands were being claimed against state hospitals for malpractice. Should there be health experts that served on the Board as well as civil society? She asked if Parliament should be the watchdog over that Board in ensuring that the Board was capable and performed its role as required. Should Parliament have the role of appointing representatives onto the Board, instead of the Minister?

She asked if the Bill in its current form would pass constitutional muster, specifically the rights of persons. Five out of 696 health facilities currently complied to the 80 percent compliance requirement set by the Department of Health. She highlighted the implications of this. Clause 5(5) determined that in order to register as a user of the Fund, a person was required to provide their biometric information and an identity card, original birth certificate or refugee identity card issues in line with the Refugees Act. Many of those eligible to use the Fund may not have birth certificates or identity documents. Should the Bill make provision for persons who were unable to produce birth certificates or identity documents to become users of the Fund? Many children did not have birth certificates; she had found this to be the case when on oversight visits to schools in her constituency. Schools battled to ensure that Home Affairs came to the school to ensure there were adequate legal documents in order to access benefits. Should this be provided for in the Bill?

The Chairperson noted Genetics Alliance South Africa’s concerns about clause 7(2)(d) of the Bill and the referral pathways. The NHI White Paper stated that patients who needed to be treated by specialists or in hospitals, would need to be referred by primary healthcare providers. This meant that except in emergencies, patients could not go straight to specialists or hospitals. He noted that current practice included coordinated care for persons with chronic diseases.

He noted the suggestion that the Committee should consider the Health Market Inquiry recommendations. He highlighted the referral pathways outlined in the Health Market Inquiry. What made Genetics Alliance South Africa believe that persons with congenital disorders, and rare diseases, would not be catered for under NHI and that the Benefits Advisory Committee would not specifically accommodate for this in the benefits package?

He noted Genetics Alliance South Africa’s concern about the provisional funding framework that needed to be put in place prior to drafting the NHI Bill. Had Genetics Alliance South Africa considered clauses 48 and 49 of the Bill, which spoke about sources of funding? Had Genetics Alliance South Africa considered what was contained in the Memorandum of Objects accompanying the Bill, specifically clause 3(2) that spoke about sustainability and affordability of NHI; clause 8 spoke about financial implications of the State. He asked if Genetics Alliance South Africa’s had familiarised themselves with Chapter 7 of the 2017 NHI Bill funding framework?

He noted the statement that most healthcare providers were in the private healthcare sector. That was why there was a proposal in the Bill that services should be purchased from both private and public providers. The NHI Bill provided for comprehensive health services that covered all users irrespective of race, wealth etc. He asked for Genetics Alliance South Africa’s view on that. Concerns were raised in the presentation about clauses of the Bill that dealt with the medical schemes. A point was made in the presentation about the powers of the Registrars covered in the Medical Schemes Act – that was how the Registrar could limit benefits to users. How were the patients with rare diseases accessing healthcare services, when even in the current private sector patients seemed to have access challenges and the Medical Schemes Act had provisions that made it difficult for these patients to access the care they needed?

Ms M Hlengwa (EFF) noted the presentation highlighted that the burden of congenital and rare diseases was increasing, but was largely unseen as there was a lack of empirical data. The scale of this health issue was therefore completely under-estimated. This had a knock-on effect on services and access to relevant care. Was there any data on the scale of the health burden of these diseases, so as to understand the impact and need for the provision of such services.

Ms Ismail asked if Genetics Alliance South Africa thought additional pilot projects should be carried before the implementation of NHI, specifically taking into account chronic and ‘special needs’ patients. Did the Bill provide adequate healthcare to the country? She noted the issues raised about the referral pathways – did the Bill infringe on the rights of patients? Was it constitutionally incorrect? Should the Bill only be implemented once the issues in the healthcare system had been addressed? Genetics Alliance South Africa highlighted that the OHSC could not cope –the OHSC only monitored up to 20 percent of facilities. Most of the facilities were in a pathetic state – would Genetics Alliance South Africa recommend that the infrastructure and resource issues be addressed prior to the implementation of NHI? 

Ms du Plessis stated that Rare Diseases South Africa and Genetics Alliance South Africa were in no way supportive of a further divide in equity by means of the system. Genetics Alliance South Africa had seen that there could be great care provided in the State system, there was access to multi-systemic teams and referrals within the team. Patients were often treated at one centralised point, which made communication easier amongst the healthcare team. She noted that referral systems had improved. Knowledge was often far superior in the public sector to that of the private. There were significant access challenges in the private sector. The difference was that the private sector had the ability to litigate, as a result, patients were not able to advocate as well as in State facilities. In many State facilities, issues came down to budget. In the private system, the funding was largely there, however one needed to jump through many bureaucratic hoops to access funding. Rare Diseases South Africa and Genetics Alliance South Africa were in no way supportive of a dual healthcare system.

The Benefits Advisory Committee needed to have extensive consultation with and include civil society. There needed to be patient representation. Patients would not be given the opportunity to participate under the proposed structure. Many conditions were not isolated to healthcare problems, but had larger implications on social support, education, disability in the work place and general accessibility. This was why various comments were made about the Benefits Advisory Committee. There needed to be some form of patient representation, either patients advisory groups or similar.

Genetics Alliance South Africa was aware of the provisional funding framework and White Paper – however it was still insufficient. A large proportion of the financial funding pool would come from existing taxpayers – the tax base in South Africa was exceptionally small. How would that tax base be increased? It would be impossible to take that same pool of funding and expect those taxpayers to do more. There was an understanding that the congenital disorders and rare diseases patients would likely not be able to contribute to both public and medical schemes. Thus, there needed to be assurance that there would be the same level of benefit outside of the payment – this was the point being made. Under the current system, when one applied for comprehensive benefits – there were still access issues to innovative and high-cost technologies – which was unfortunately the only treatments that were available. There was not always a benefit of choice, in cases there was only one treatment option, which might be expensive. Genetics Alliance South Africa was unsure how access would be improved, if there were currently challenges to access comprehensive cover. The system needed to move forward and not stagnate. How would this situation be financially viable under NHI?

COVID-19 had taught everyone what it was like to be a ‘rare disease patient,’ in the sense that people had experienced isolation, stigmatisation, denial of opportunity to work and the economic impact resulting from a condition. People had experienced loss and being better caregivers in their own home. There had been an increase in awareness about picking up new infections and being immune-compromised in one’s everyday life. Most importantly there been awareness about what it was like to unite as a global community toward benefiting others. Everyone had waited for the vaccines to become available – and had wondered about the development and approval of them. Everyone was more enlightened, with the difference being that rare diseases were not going to go away. The majority of rare diseases patients were in it for life.

She responded to the question about there being enough healthcare professionals in the system. There was enough academic knowledge, however there was not sufficient continuation of that knowledge nor services or plans in place to ensure continuation of that type of knowledge. Genetics Alliance South Africa would like to see improved training and collaboration amongst tertiary clinics and hospitals etc. Care depended upon the entire ecosystem of knowledge and care.

If a patient had been properly engaged and included in the decision-making process throughout, patients were less likely to take any form of legal action when outcomes were not reached. In many cases of medico-legal claims, it was where patients were not consulted sufficiently and felt bitter and agitated about the outcome.

Patient expertise were critical on the Advisory Board, particularly where there was sufficient holistic knowledge. The suggestion of Parliamentary oversight of the Board was considered a positive suggestion. There needed to be improved accountability and oversight of the functioning of those Boards. Genetics Alliance South Africa felt that there were elements of the Bill that would pass Constitutional muster. It was not to suggest that the Bill intended to be unconstitutional, but not enough was being mentioned or being included in the framework to ensure the rights of vulnerable persons. Accommodations needed to be made for registration, if an ID card was required – certain efforts needed to be made to ensure those services were available and accessible to vulnerable communities. There needed to be ways to allow for registration i.e. where fingerprints could not be provided due to amputation etc.

The existing public healthcare system was not entirely different from the referral system proposed in the Bill. The private sector however was different. In the State sector, various referrals were needed. Genetics Alliance South Africa was not against the referral system. Genetics Alliance South Africa encouraged referrals, however referrals sometimes did not take place or were so complicated and labour intensive that it discouraged people from making a referral. That was an issue currently experienced. The timeframes for referrals were often not conducive to healthy outcomes.

Genetics Alliance South Africa was aware that there would be financial implications on the State and that the pot was limited. The existing funds available to the State were not well accounted for. There was still ‘copious amounts’ of corruption in the system and service delivery issues – the Personal Protective Equipment (PPE) during COVID-19 was a prime example. How would those elements be resolved? There would be a huge positive difference to service delivery if corruption was dealt with. Genetics Alliance South Africa did not see solutions to the issue of corruption in the Framework. Access was not guaranteed in either system. In the private system, if one had good legal representation and an understanding of the law, one was able to advocate better. In the State system one found that there was simply no funding available. Genetics Alliance South Africa did not think that the Medical Schemes Act amendments were suitable nor did what it set out to do.

Dr Malherbe responded to the question about the scale of the health burden. There was a huge data deficit in all low to middle income countries. Genetics Alliance South Africa had looked at best practices globally and looked at modelling as an interim tool that could generate estimates of the impact of those conditions. There was some work that had been published the year before at a provincial level for a number of congenital disorders and rare diseases. There were additional papers that were peer reviewed. The burden of disease had been quantified, the services now needed to be costed, which served those populations. This was being worked on at present.

There was a need for increased, improved capacity as well as the implementation of quality standards. There was ongoing health professional development to maintain registration with the HPCSA. One needed to ensure that capacity building was not just a tick the box exercise to get a certain number of points to maintain registration. There needed to be some innovative ways of getting the appropriate training. She emphasised the need for capacity building.

Many people were being trained in South Africa, but there was nowhere for them to go. One of Genetics Alliance South Africa’s roles was to advocate for those positions. There had been a huge reduction in services and the quality of services. Services were being further neglected. With the impending burden of other infectious diseases, such as HIV and Aids as well as Tuberculosis (TB), a lot of the funding was frozen and diverted. Together with the Department of Health a revised Genetics Guidelines Document had been produced. Those services needed to be put in place but the funding was needed to implement it.

She responded to the question about infrastructure and the need to upgrade facilities. The year before, when the riots took place in KwaZulu-Natal (KZN), a number of patients lost all of their prescriptions and records, which were destroyed when doctors’ offices and blood banks were destroyed. Those patients could not access care due to not having access to their records or scripts. It highlighted the issue that patients needed access to their healthcare records – there needed to be some form of continuity through an electronic healthcare system. Early diagnosis and access to care was essential for persons living with these conditions. Early screening at birth as well as treatment avoided many of the long-term health effects or symptoms. Screening was not available for certain diseases within the public sector, and there was only limited capacity in the private sector. Those upgrades needed to start immediately, there was no reason to wait around till NHI was fully implemented. 

Presentation by the South African Clothing and Textile Workers Union (SACTWU)
Mr Andre Kriel, General Secretary, SACTWU, made brief introductory remarks to the presentation.

Mr Simon Eppel, Researcher, SACTWU, presented SACTWU’s submission on the NHI Bill to the Committee. SACTWU indicated their support of the Bill, as it offered a significant step toward safeguarding the lives and health of the vulnerable working class through the provision of free, decent, affordable and timeous healthcare

It was highlighted that the Bill should recognise bargaining council clinics as accredited healthcare service providers under the NHI. Indirect healthcare assistance included the collective bargaining forums in the clothing sector (e.g. bargaining council) which had run clinics since 1942. The clinics provided primary medical, dental and optical health care, as well as the provision of chronic medication and support of industry workers. Direct healthcare assistance included providing direct support to workers for about two decades, this included HIV/AIDS and TB awareness, training, testing and treatment services.

There were approximately 10 primary healthcare clinics across the Western Cape, KZN and Gauteng. Approximately 100 panel doctors provided on-demand services. It was highlighted that about 200 000 direct consultations were provided to workers free in 2019.

Currently, the Bill did not - but should - recognise bargaining council clinics as accredited NHI healthcare providers. Inclusion of bargaining councils in the NHI may require a suitable amendment to the Labour Relations Act. Section 28(1)(g) limited operations of healthcare funds of bargaining councils to council Parties and their members. There was a need to widen the scope so clinics could cater to the broader public under NHI. The Bill should include vigorous mechanisms to prevent fraud and corruption within the NHI Fund as well as procurement.

(See SACTWU presentation)

Discussion
Mr Munyai asked if SACTWU supported NHI and the Memorandum on the Objects of the Bill. Did SACTWU want the dual-system to remain? Most of the funding was not going to healthcare services, but to administration etc. He noted the request that civil society be included in the NHI structure. Did clause 27 not address this concern? He highlighted that clause 27 stated that the ‘Minister must, after consultation with the Board, and by notice in the gazette appoint a Stakeholder Advisory Committee comprised of representative from the statutory health professions councils, health public entities, organised labour, civil society organisations…’

Dr Havard asked if SACTWU would be alright with its clinics being used by surrounding communities to access healthcare services, if so was there a specific model that SACTWU would share with the Committee?

Ms Ismail noted that the tax base in South Africa was relatively small, would the pool of taxes be sufficient to carry the Bill in facilitating healthcare service provision to the country? With the current shortage of healthcare workers, the issues around the placements of doctors and workers and the dilapidated state of the infrastructure in healthcare facilities, would the NHI work? Should issues of staffing capacity and infrastructure upgrades not be addressed before the implementation of NHI? Considering that the OHSC struggled to monitor 20 percent of the current healthcare facilities, and there was a need for facilities to meet certain compliance requirements, did SACTWU think this would adversely affect the availability of clinics and public healthcare facilities? 80-90 Percent of healthcare facilities would not be eligible to function under NHI. How did SACTWU perceive this issue? Access to quality healthcare for all was crucial, to what extent did SACTWU think the Bill allowed for equal access to quality healthcare? Was this an all-inclusive Bill? Would the NHI in its current form be providing a health-based value model? Was the Bill sustainable in its current form?

The issue of corruption was well known, particularly with the COVID-19 Digital Vibes scandal, which involved the former Minister of Health. Did SACTWU think that entities of healthcare professionals should be sitting on the Board? When considering oversight, what would SACTWU recommend be included in the Bill to strengthen the oversight mechanism. Would the Bill stifle innovation in the healthcare sector?

The Chairperson stated that the strengthening of community-based care was welcomed. He suggested that clause 7(2)(d) of the Bill might address SACTWU’s concern. The clause stated that the user must first access healthcare services at the primary care level as an entry into the healthcare system and adhere to the referral pathways prescribed for healthcare service providers and health establishments. What was SACTWU’s view on this? Proposals were made for bargaining council credits to be retained under the NHI, so that SACTWU’s members could be represented by the organisation while using the current approach in offering healthcare services. Were SACTWU facilities intending to participate as accredited healthcare service providers under NHI, and if so, why would such a position be adopted? He asked to understand why SACTWU’s understanding was that workers would not be sufficiently provided for under NHI for their healthcare needs. He noted that SACTWU had proposed that there should be amendments to the Labour Relations Act, the assumption was that this would enable funds to be redirected to the NHI Fund. He asked for more clarity on that. He asked that the reimbursement method that was used to reimburse healthcare professionals for the services rendered be clarified, particularly if this was based on salaries or capitation etc. How did SACTWU manage to ensure sustainability of the funding that was received?

Mr Kriel stated that SACTWU was very clear about where it stood on the issues of NHI. SACTWU’s submission and presentation should not be seen as if it wanted ‘protectionism’ or ‘exclusivism,’ for the system that currently operated. SACTWU fully supported the NHI and its objectives. It was long overdue. SACTWU did not want the status quo to continue. The healthcare clinics that SACTWU operated were not medical aids, the clinics were self-funded by the industry, and not registered under the Medical Aids Act. The clinics were registered under the Labour Relations Act. At a national level, the fact that the largest proportion of the population was excluded from healthcare was a ‘sin.’ The implementation of NHI would help resolve that issue.

SACTWU would look more closely at the civil society reference in the Bill. SACTWU had wanted to emphasise the relationship between industrial self-funded healthcare and the NHI. He responded to the question about the specific model SACTWU would suggest for clinics in communities – currently SACTWU’s healthcare clinics serviced the industry. That was not SACTWU’s vision, it was not a vision that was generally shared by employers, because these were co-managed. SACTWU would prefer that there was broader access afforded to communities, to access healthcare clinics. It was not an exclusive domain that SACTWU wanted to maintain going forward. The health infrastructure development, including human capital such as medical staff, could not be seen as something that needed to be developed sequentially. When these systems were developed side by side it became more effective. Actual implementation versus theoretical posturing worked better. To debate endlessly and to do nothing was a problem for SACTWU. As one implemented new healthcare systems, the system would be fixed. If one waited, nothing would ever get done. If one did, one might stumble, but the issues could be fixed along the way. The same happened with the COVID-19 pandemic and the initial challenges with vaccine availability. There had been issues but the issues were resolved. Everyone waited for perfection, in the meantime people died from poor healthcare provision or an inability to access healthcare. The vaccine roll-out provision should be located as something that was part of the concrete development of the NHI.

SACTWU felt that NHI would be sustainable. He noted that Simon Eppel had dealt with the issue of corruption in the presentation. The scourge of corruption in society needed to be condemned in the strongest terms, it was robbing the poor from services they deserved. There needed to be strong mechanisms to combat that, SACTWU had some proposals on this, that would be put forward in a different forum.

He responded to the questions asked by the Chairperson. SACTWU’s healthcare clinics were never geared for the provision, dispensing and administration of the COVID-19 vaccine, but that infrastructure was built, and very quickly at that. The clinics were now accredited and linked to the national database, which was globally recognised. He noted that later that week, National Government, WHO and the Belgium Embassy would visit one of SACTWU’s sites of administration. SACTWU’s infrastructure was not perfect, but it delivered the outcomes - being high levels of vaccinations. The same could be done with any other infrastructure provision needs. The clinics were self-funded, there was a contribution from employers and from workers, being a direct deduction from their wages. This was managed through an independent facility. The Union did not control that money. The funding of the healthcare clinics came from deferred wages by workers. When SACTWU did collective bargaining and reached a settlement, whatever percentage, that settlement was carved up. Some of it went to ‘take home’ wages, some went to the provision of industry benefits, such as in this instance, healthcare benefits. It required an eye for detail – as one did not want to ‘tax’ workers indirectly. Workers did not see it like that. When the Green Paper on Comprehensive Social Security and Retirement Reform was published there was a huge outcry. SACTWU did not experience that kind of outcry about the funding of the clinics. This was because the contributions that the workers made and that the employers made, was not seen as a tax, as there was value-added services linked to it. It would be preferable for the healthcare clinics to be opened up to communities; these clinics were located in communities and it could grow from there. One wanted to prevent the destruction of a system that was built over many years. It would be a disaster if it was destroyed due to the introduction of NHI.

Mr Eppel responded to the question about who should be represented on the Boards. SACTWU’s experience and observations suggested that one could not populate a governance structure ‘with one’s friends.’ There needed to be sufficient representation from different parts of society. Members who conducted oversight needed to be sufficiently skilled. ‘Sufficiently skilled’ did not mean that everyone had a PhD or a Master’s degree or any formal degree. There were people who had gained skills or experience through experiential learning or from situations of ‘deep responsibility.’ He was not suggesting there be a requirement for formal education but there needed to be people who were sufficiently skilled to call out the challenges that might exist in the system.

He responded to the question if NHI would kill innovation. He suggested that the question was asked based on the assumption that innovation sat primarily in the private sector and that the public sector was not innovative. This was not necessarily true. There was an emerging strong body of research coming out about the role of the State in innovation. A fee model was used to reimburse doctors, he asked that Mr Andre Kriel provide more information about that.

Mr Kriel stated that when one saw people in the poorest part of the country and then saw that the privileged could ‘whip out’ medical aid cards and get medical service coverage – that inequality ‘broke the heart.’ It was not right and was not the kind of society that should be built. The NHI would play a role toward breaking that inequality. He acknowledged that it would not be perfect.

He stated that the proposals around the funding model would be left to Mr Mathew Parks, when he presented before the Committee. No cash changed hands between the panel doctors and patients, it was on an invoicing basis to the Bargaining Council based on a preferentially negotiated rate. there was an invoicing, disbursing and payment system which was handled separately to the Union. There was a lot of goodwill amongst many medical practitioners toward workers, many of them had roots in the communities that they serviced. Many doctors received bursaries from SACTWU, and thus wanted to give back to the Union. The dispensing of vaccines was open to the communities via SACTWU’s clinics, it was not ring-fenced. NHI was needed for the Country, and it should not kill existing services that were providing to the poor. He noted that there were many healthcare providers located within workplaces.

The Chairperson expressed that it was eye-opening having SACTWU present to the Committee and to be able to ask questions about how their model worked. His father had been part of the Leather Workers’ Union, and he had been able to go to certain doctors to get assistance. He was aware of the support that Unions provided to students, being the children of employees. It was commendable. It was important to hear the role of those clinics in communities and SACTWU’s vision for the clinics under NHI. He anticipated more discussions would follow and that the Federation would present before the Committee.

Presentation by the People’s Health Movement South Africa (PHMSA)
Dr Sinesipho Jojo, Deputy Director of the People’s Health Movement South Africa (PHMSA), presented PHMSA’s submission on the NHI Bill. It was noted that many of PHMSA’s partners had made submission on the Bill, and PHMSA had held education workshops about NHI. It was emphasised that PHMSA’s values aligned with those intended in the Bill.

The health crisis in the South African context was outlined with concern. South Africa was host to a large disease burden due to unequal access to goods and services for good health. There was fragmented, inequitable health services, between the public and private sectors and rural and urban areas. It was highlighted that there was poor governance and accountability across State sectors and those most in need had limited access to healthcare.

Accreditation and standards of care
Without a well-functioning public health care system the NHI could not succeed.

The most recent report of the Office of Health Standards Compliance (OHSC) found that that only a small fraction of public health facilities surveyed met the norms and standards required for NHI certification. It was therefore imperative to fix and upgrade the broken public sector to the level required for NHI accreditation. The Bill gave no detail of how to do this. There was a possibility of exacerbating the inequality, private facilities were not only more likely to get accreditation but are also overwhelmingly urban-based, thus increasing both urban-rural and private-public inequality. Furthermore, registration for the benefits of the NHI must be done at an accredited health facility, which issued the user with a registration number and physical evidence of membership, maintaining a register of all users and their dependents. This posed yet another risk that those already marginalised from access to care (rural populations, disabled, elderly) would be further disadvantaged. Facilities that already lacked staff, medicines and equipment would not find it easy to register users as smoothly as those facilities already functioning at a much higher level of efficiency. Many public sector facilities lacked easy internet access.

Primary care versus primary healthcare
Primary Care was about the provision of excellent and appropriate health care services to everyone. Equitable access to quality health care was essential but insufficient for promoting people’s health. The NHI Bill sought to provide these services through Universal Health Coverage (UHC). However, even the best health services could not address the root causes of ill health.

Primary healthcare was a broad, developmental approach to health that went beyond the health system. Primary healthcare emphasised comprehensive services by the health sector, but also addressed the factors that caused poor health. It relied on collaborative action across State sectors to deal with the root causes of ill health and reduce the burden of disease. The health system and NHI could not do this on its own. Primary healthcare emphasised meaningful community participation in issues relating to health (including in the planning, provision and evaluation of health services).Primary healthcare recognised that ‘Health for All’ was unachievable within the unfair current global economic order that entrenches inequality within and between countries.

(See People’s Health Movement South Africa’s presentation)

Discussion
Ms Gela asked for clarity about the statement that provisions of the NHI Bill did and would continue to marginalize members of civil society. How did the NHI Bill marginalise? Given that the role of clinic committees, hospital boards and district health councils were prescribed in the National Health Act, should chapter 5 of the National Health Act be amended? She stated that PHMSA’s concern around primary healthcare was unclear – did PHMSA align itself with the provisions of the NHI White Paper, specifically the service delivery model in an NHI context? 

Mr Sokatsha stated that it seemed that PHMSA was of the view that the public sector was ‘broken’ and the private sector was ‘perfect.’ PHMSA seemed to hold the view that only private facilities would be accredited under NHI. On what basis was this ‘very interesting blanket view’ made? Did PHMSA have a proposal of how the Stakeholders Advisory Committee could be constituted to be considered inclusive and participatory?

Dr Havard asked if PHMSA believed that there was no need to introduce universal healthcare coverage policies in South Africa. What was PHMSA’s view on the single payer, single purchaser, funding model?

Ms Ismail asked to what extent the Bill allowed equal access to healthcare. Was it an all-inclusive Bill? Would the NHI Bill provide a health-barrier based model? Was the NHI Bill sustainable? She noted that the tax base in South Africa was relatively small. She asked if the pool of taxes would be sufficient to carry the intent of the Bill to provide for effective healthcare services to South Africa. The presentation stated that infrastructure needed to be fixed. With the current shortage of healthcare worker placements and the infrastructure challenges, would NHI work? Would there be access to quality healthcare if the number of healthcare workers was not increased and improved healthcare infrastructure was not provided before the NHI was implemented? Would a single purchaser model not create a monopoly and increase prices of medicines? Considering that the OHSC currently could not manage to monitor 20 percent of the healthcare facilities in the country, and that healthcare facilities needed to reach certain compliance standards under NHI, how would it impact healthcare service provision under NHI? Under the Bill’s current governance and organisational structure, what oversight measures did PHMSA suggest be included to ensure accountability of the Board so as to mitigate the threat of corruption? Would the Bill stifle innovation in the healthcare sector? How should the public be offered the opportunity to get involved about the Bill? What recommendations could PHMSA propose on this? Did PHMSA anticipate that under NHI, most of the healthcare workers would leave the Country? She noted that PHMSA had highlighted the needs of ‘special needs’ patients. Did PHMSA think the referral pathways were too labour intensive, negatively impacting timelines and the health of patients?

Mr Munyai asked where PHMSA’s headquarters were. Had PHMSA contributed toward policy reform in other countries, such as the National Health Service (NHS) in the United Kingdom (UK)? Did PHMSA participate in the United States of America’s (USA) Obamacare? He asked that examples be provided of PHMSA’s involvement in policy reform in other countries. If PHMSA was not involved in other countries policy reform, why was it involved in the policy reform of South Africa. The Bill focused on covering personal healthcare services, what was PHMSA’s proposal on how funding for programmes, aimed at addressing the social determinants, be coordinated? PHMSA seemed to assert that universal health coverage might facilitate profiteering from the NHI Fund – what provision in the Bill created that possibility? What was PHMSA’s proposal to ensure that this did not happen? PHMSA seemed to support universal health coverage without NHI. He asked for clarity on this.

Ms Clarke raised an issue about the NHI grants that were received, which were meant to upgrade universal healthcare in the country. In 2020, Treasury shifted R1.4 billion out of NHI Indirect grants received, which funded the majority of NHI projects at the time. Treasury said the cut was due to slow-spending on contracting with general practitioners, mental health services and oncology services. Similar cuts were imposed in 2019, when Treasury moved R2.8 billion in unspent NHI funds to the provinces to fill critical posts. The Medium-Term Budget Policy Statement (MTBPS) saw Treasury cutting R300.8 million from NHI Indirect grant, trimming the allocations for the 2021/22 financial year. The February budget allocation of R7.5 billion to the NHI Indirect grant in the Medium-Term Expenditure Framework, included R906.8 million to fund contracting of healthcare services. R2 billion went to strengthen the health system, in preparation for NHI and R4.4 billion was allocated to infrastructure projects. Year on year the NHI grants, which have been given to the Department of Health in order to strengthen the health system, had not been realised.

R3.8 billion was spent on pilot projects and the outcomes of those pilot projects had not been factored into the Bill to realise positive outcomes. Access to quality healthcare was a right. It was a human right to choose who one wanted to use as a healthcare provider, and it should be one’s choice to go for a second opinion. She expressed concern about the referral timelines and how lengthy that process would be. She asked if PHMSA had any recommendations on that. Could the ‘current universal healthcare’ be fixed and how did PHMSA propose this should be done? Did PHMSA believe that the Bill could realise its desired outcomes, given the current state of hospitals? Only five out 686 hospitals were compliant in terms of the 80 percent requirement set by the Department. What would PHMSA suggest to improve the current healthcare system? If one considered global healthcare, given the current environment hospitals functioned within in the global sphere, did South Africa compete in that same structure? If Parliament played a ‘far more progressive role’ in establishing the Boards and Committees, would that make the process more transparent?

The Chairperson noted the concerns that the provisions of the Bill did not meet the healthcare challenges in the current healthcare system. He asked that PHMSA propose the wording it felt should be reflected in the Bill. In the presentation, it was highlighted that there was a lack of detail about the upgrading of the public health sector. Did PHMSA delineate between the jurisdiction of the Memorandum of Objects of the National Health Act against the Memorandum of Objects of the National Health Insurance Bill? How did PHMSA respond to the proposal made by the private sector for the incremental implementation of NHI? He asked that PHMSA provide examples of countries where issues were addressed before financing legislation. Was it not essential that through NHI, the financing of the health system be improved?

Ms Hlengwa asked for clarity about the ‘unequal decision-making powers.’ PHMSA spoke about primary healthcare and primary care – she requested clarity about the difference. She asked what was meant by ‘meaningful community participation on issues of health. When the Committee conducted hearings, the Committee had heard from the clinic committees. She asked that PHMSA clarify what was said on this matter and what was meant by ‘rubber stamping’ – who was ‘rubber stamping?’

Dr Jojo asked if a written response could be submitted, in addition to their oral responses, due to the number of questions asked.

The Chairperson stated that he would expect PHMSA to respond to as many questions as possible. This was the platform that the Committee liked to receive responses. PHMSA was welcome to send further written responses to anything unanswered.

Dr Jojo stated that PHMSA would do its best to respond to the questions in the given time, however she did not think justice could be given to the questions asked within the timeframe provided.

Dr Lauren Paremoer, Member, PHMSA, noted that a Member of the Committee had suggested that PHMSA viewed the public sector as ‘broken’ and the private sector as ‘perfect.’ PHMSA’s view was that the public sector did well with the limited resources it had. The COVID-19 pandemic had highlighted this, the public sector had done well in responding to the crisis. The point made in the presentation was that, compared to the private sector sites, public sector sites were often under-resourced both in its staffing and infrastructure provision. PHMSA was advocating for the strengthening of public sector facilities and the increase in human resources under NHI. A key part of strengthening public sector sites was to bring in community health workers as paid employees that had regular contracts and good working conditions. Community health workers were advocating to be employed as public sector workers, not to be appointed on short-term precarious contracts. The PHMSA were strong believers in a public healthcare system led by the government for the public interest to ensure that public sector provision played a dominant role.

She responded to the question about the single purchaser system. From research conducted by the Competition Commission on the South African economy in general – the economy was highly concentrated and the trend had deepened over previous years. In the health sector the for-profit sector was very concentrated. The Health Market Inquiry had reported on this at the end of 2019. One of the benefits of a single purchaser system was that there would be a purchaser that was big enough to drive-down prices and ensure fair pricing of medical services in both the public and private sector. Research found that the single purchaser model had better outcomes.

She clarified the distinction between ‘primary care’ and ‘primary healthcare.’ Primary care referred to care at the point of care closest to the patient – where there was a certain basic package of services. There was another concept, being ‘primary healthcare,’ which proposed that one needed to look at the bigger social and economic structures that drove poor healthcare outcomes and prevented people from accessing healthcare. A primary healthcare approach would not only emphasise good quality care close to patients but the complete rearrangement of the social, economic and commercial structure to ensure that it could happen. 

Ms Nowhi Mdayi, PHMSA and Gugulethu Health Committee, responded to the questions about community participation and the state of healthcare on the ground. The health committees represented communities. When it was asked if PHMSA was implementing health systems, this was the responsibility of government. She asked how the Committee interacted with officials who were supposed to provide report backs on the health system and the determinants of health, as well as the pro-right to health that took place in all clinics? She suggested that the questions asked by Committee Members, needed to be answered by them not PHMSA. Which health committees had the Committee met with when policies were developed? There were problems being faced in communities, government was not seen to be addressing these problems. Gugulethu and Klipfontein sub-district had many problems, the health committees wanted to sit down with the Committee to resolve them. The health committees were not given induction workshops…

The Chairperson attempted to interrupt Ms Nowhi Mdayi.

She reiterated that the questions asked by the Members, were questions that should be answered by themselves. Communities were waiting on the Committee. The Western Cape Government needed to implement NHI…

Mr Munyai stated that he did not understand what was happening. Seemingly PHMSA was asking questions of the Committee and making mention of the Western Cape Government. He asked that the Chairperson clarify the aims and objectives of the platform.

The Chairperson stated that Ms Nowhi Mdayi was addressing her concerns on the wrong platform. This was not the Western Cape Government; this was not the forum where street committees were appointed.

Dr Jojo asked if she could clarify the situation. Ms Mdayi was expressing herself on the number of questions asked and the time given to respond. PHMSA wanted to engage fully with the questions and respond to all of them, however the time did not allow for that. She requested that PHMSA be given the opportunity to respond in writing to all the questions to clearly voice its views.

PHMSA had submitted its responses to the White Paper and Green Paper in 2016, only to be invited five years later to a participation on work done years earlier. Some of the people who had previously worked on the project, were no longer members or had moved to different platforms. In response to the question about ‘rubber stamping,’ she stated that there were three levels of participation. There was ‘non-participation,’ where one got informed or got told what to do for example. Often participation, such as in the case of NHI, involved the public simply being informed. When the NHI Bill was formulated, there was no community participation; PHMSA was handed the Bill after it was produced. Who from civil society was included in the deliberations around the content of the Bill?

The Chairperson stated that it was the wrong platform to state this. There had been a Green Paper and White Paper before the Bill. It was not true to state that it had been five years earlier. In 2019, submissions were called for, it was only then that it came to the Portfolio Committee. He suggested that, given the limited amount of time, PHMSA respond in writing to the questions. He hoped that PHMSA had been able to record all the questions asked. This was a platform where inputs were called for from civil society on the NHI Bill specifically, which was what was done in the presentation.

Mr Sokatsha said he was worried, as there was a misunderstanding about the role of the Portfolio Committee. The Committee was not government. The Committee was an oversight body. The Committee went out to communities to hold public hearings on the Bill. He reiterated the role of the Committee. Many previous presenters had responded in writing, there was nothing wrong with that.

The Chairperson stated that he would give the PHMSA five minutes further to respond, the remaining unanswered questions could be responded to in writing via the Committee Secretary.

Dr Jojo asked if PHMSA would be able to access a recording of the meeting, to confirm all the questions asked, so as to answer the questions in writing.

The Chairperson responded that the meeting was in the public domain. PHMSA could write to the Committee Secretary who could consult with him and see to it that PHMSA got those questions, if there were ‘too many questions asked.’

Dr Jojo stated that there were not ‘too many questions asked’. PHMSA wanted to respond to the questions at the same level at which the questions were asked. PHMSA was under the impression that the Committee represented an oversight body that would communicate the needs or concerns of civil society to the government, in terms of the NHI process. That was PHMSA’s understanding coming forward. If PHMSA understood incorrectly, she apologised. This was the first time PHMSA had an opportunity to really express its concerns about the NHI Bill, private sector involvement, the lack of community participation and the process.

Mr Elroy Paulus, Deputy Chairperson, PHMSA, stated that he was also the Treasurer of the Parliamentary Monitoring Group (PMG). He offered to ask the staff of PMG to expedite the minutes of the meeting. PHMSA was very passionate about these issues; he was reluctant to only answer some of the questions raised. He noted that many questions were asked; a detailed written response would be provided. He asked if PHMSA could engage with the Committee in a manner that helped explain the passion of PHMSA’s members, who were committed to making human rights a reality in South Africa.

The Chairperson made brief remarks, reiterating that responses could be provided by PHMSA in writing via the Committee Secretary. 

Presentation by the Professional Provident Society
Ms Ayanda Seboni, Executive: Communications, Brand and Marketing at PPS, and Ms Simmi Bhima, of PPS, presented their submission to the Committee. The presentation covered the inequality of access to services, sustainability of the current system, recommendations of the Health Market Inquiry and the need for clarity on a number of issues in the Bill.

The presentation highlighted a number of developments since PPS previously presented, in July 2021. The COVID-19 pandemic had come full circle, everyone had seen the need for coordination and cooperation between the private and public sector. Firsthand shortcomings of the system and elements to build on had been identified. The control environment was a glaring area where tighter controls were needed – procurement was a
challenge in their response to COVID-19. On the technology front, the Department of Health had been successful in implementing a centralised vaccine registration and certificate system. This was a good first step on the technology side.

(See PPS presentation).

For the discussion on the PPS presentation, see PMG Report on the meeting held on 27 July 2021.

Interruption
Mr Munyai pointed out there was a similar presentation from PPS from the 27 July 2021, why would the same organisation present twice? He asked for clarity on this.

Mr P van Staden (FF Plus) asked if it was possible that Mr Munyai received the presentation from the email site, when the process started.

Mr Munyai stated that he was not confused. He suggested that the Chairperson ask PPS.

The Chairperson asked to be given the opportunity to clarify the matter with the Secretary. He had not seen the presentation, however he noted that he had been absent occasionally and may have missed it. He stated that he would call the Committee Secretary and ask the presenters’ if they had presented previously.

Ms Seboni confirmed that Mr Munyai was correct. PPS had been invited to present previously. The reason PPS was before the Committee a second time was because PPS had received another invitation to present.

The Chairperson confirmed that PPS had previously presented. He thanked PPS for being frank about this as well as Mr Munyai for alerting the Committee. The Committee Secretary indicated that two submissions were made from PPS, a written submission and email submission, that was the reason for the confusion. He apologised for the inconvenience. He asked that PPS not continue with their presentation.

Closing Remarks
The Chairperson stated that the Committee would be hearing further submissions the following day.

The meeting was adjourned.