National Health Insurance (NHI) Bill: Public Hearings Day 26; with Deputy Minister

Meeting report

The Chairperson welcomed everyone and said the Deputy Minister of Health, Dr Sibongiseni Dhlomo, would join the meeting later. The meeting was a continuation of the National Health Insurance (NHI) Bill public hearings. The Committee would receive presentations from Government Employees Medical Scheme (GEMS), the South African Medical Research Council (SAMRC); Alcohol, Tobacco, and Other Drug Research Unit (ATODRU), the National Planning Commission (NPC), and Scalabrini. The Committee of Medical Deans presentation would be postponed to the following Wednesday.

The Committee expressed condolences to the families of those who fell victim to the Tembisa Hospital shooting which occurred on 9 February 2022. This was a great tragedy.

Introductory remarks

The Chairperson said each organisation would be given 45 minutes to present.

Mr T Munyai (ANC) said what happened yesterday, should not happen. The Administration should not be allowed to invite organisations who had already made representations to the Committee, and there was no apology from the Administration regarding this. He asked why, as a matter of principle, the same organisation should be allowed to present twice. This would put the Committee into serious disrepute. The Chairperson should ensure organisations only present once, and not twice. Having one organisation make representations twice might lead to legal action being taken against the Committee. This would put the parliamentary process of the NHI Bill in a very precarious position. The Committee cannot work like police trying to scrutinise everything.

The Chairperson thanked Mr Munyai for the input and said he had made a follow-up and had given a reason the previous day. A decision was taken to allow a different unit from the same organisation to make a representation. The SAMRC was a very large organisation, and its Alcohol, Tobacco, and Drug Research Unit would make a separate presentation. Even though it is mentioned under the umbrella of the SAMRC, it was different from the previous day’s meeting.

Submission by Government Employees Medical Scheme (GEMS)

The presentation was led by Dr Sebayitseng Millicent Hlatshwayo, Chairperson, GEMS, who would give a broad overview, followed by Dr Stanley Moloabi, CEO, GEMS, who would work from the presentation slides. The submission would outline the key areas on the NHI Bill, GEMS’ view and evidence of support, and GEMS’ overall recommendation. GEMS had made a written submission that had more detail in it than what would be presented to the Committee.

Dr Hlatshwayo said the NHI Bill constituted a momentous piece of legislation that GEMS unequivocally supported in principle. South Africa is referred to as one of the countries with the most widespread inequality in the world. The source of this inequality is multifaceted. The public health sector had challenges of limited access because of shortages of healthcare workers, infrastructure, and medicines, as documented in the NHI White Paper. The right to life was enshrined in Section 11 of the Constitution and intertwined with the right of access to health care. It was imperative to implement the NHI Bill with a good government structure, with measures in place to prevent corruption, fraud, and wastage. The right to access to healthcare should be enjoyed by all citizens. Affordability is a key factor in creating access to healthcare. GEMS had extended coverage to over two million beneficiaries and had the widest definition of a “beneficiary”, which allowed cover for up to five generations in a family. Aligning the GEMS operating model with the NHI principles had resulted in reduced healthcare expenditure and improved member-provider satisfaction levels. Risk-pooling was the key to success. Effective risk-pooling required high-income earners to cross-subsidise low-income earners; the healthy to cross-subsidise the sick; and the youth the old. GEMS had tested this model. Members paid according to income bands. Risk-pooling was possible and sustainable in South Africa for all citizens. The NHI Bill could be implemented more efficiently and effectively by leveraging the existing structures and expertise within GEM and the medical schemes industry. GEMS noted its unequivocal support to eliminating economic injustices; healing the divisions of the past; and establishing a society based on democratic values, social justice, and the realisation of human rights as enshrined in the Constitution. South Africa must take concrete steps to ensure all South Africans receive the health services citizens need, without suffering financial hardships.

Dr Moloabi stated the GEMS mandate (see presentation slide).

Ms E Wilson (DA) asked the presenters to get to the crux of what GEMS wanted, to save time. She wanted to know what GEMS recommendations and proposals were. The Committee knew what the NHI Bill was, as it had been dealing with it for several years.  

The Chairperson said it was up to the discretion of the presenter on how the 45 minutes were used. It would not be fair for Members to dictate to the presenters what should be said or not within those 45 minutes.

Dr Moloabi noted the suggestion made by Ms Wilson.

In conclusion, GEMS supported the National Health Insurance Fund (NHIF) addressing the barriers to access, resulting from the current two-tier healthcare system. It proposed universal health coverage for the entire population could be achieved through a health system founded on social solidarity.

Submission by Alcohol, Tobacco, and Other Drug Research Unit (ATODRU)

Mr T Munyai (ANC) wanted to establish if the SAMRC had returned twice to request a presentation. As far as he knew there was only one request to present from the SAMRC, there were not two requests. He asked why the Chairperson was allowing two presentations from one organisation.

The Chairperson said there were two requests. There was an agreement to the two requests because these were different units within the same entity. The SAMRC was a very big unit and a big organisation. It was allowed because it would speak specifically about issues that were not spoken about before, and this would not be the same presentation SAMRC had made before. It was something the Chairperson had interrogated and he had applied his mind to it and he would allow ATODRU to present because it was a different presentation, and it was a different Unit within the SAMRC. The presentation would be allowed.

The presentation primarily focused on the neglected areas of noncommunicable diseases (NCDs) where there were known preventable risk factors, and where there were evidence-based public health interventions to combat these risk factors.

ATODRU said the NHI legislation could either plan for care or more and more ill people over the next few years. The numbers needing care increased beyond population growth and fails to provide the resources needed. Alternatively, it can put significant focus and resources into the promotion of health and the prevention of illness, thereby making NHI sustainable in the longer term. Its proposal to the NHI legislation was to establish a health promotion foundation as part of its structures, as was recommended in its presentation, and it must legislate at least two percent of the NHI fund must be delegated to health promotion and prevention activities. This would give the NHI a real fighting chance of survival.

NHI will to a very large extent flourish or flounder based on if the numbers of people who will need health care can be kept to numbers where it is possible to provide good quality care to all who need it. It was possible to prevent illness through evidence-based and cost-effective interventions. This would require investment in health promotion as a vital element of NHI. Prevention is needed to reduce the number of people who develop communicable diseases such as human immunodeficiency virus (HIV), tuberculosis (TB), and Covid-19, but also (NCDs such as cancer, diabetes, heart disease, lung disease, and mental disorders. From an in-depth analysis of health and risk factor trends in South Africa conducted within the SAMRC and elsewhere, there was an alarming rise in the incidence and prevalence particularly of NCDs and their risk factors. It was important to focus on NCD factors because the exact extent to which modifiable risk factors could prevent NCDs in South Africa had not been calculated, however, the World Health Organisation (WHO) in the region of the Americas (PAHO) estimated 80% of all heart disease, stroke, type 2 diabetes, and over 40% of cancer is preventable through multi-sectoral action. The NHI Bill, as well as the Memorandum of Objectives and the Department of Health pamphlet explaining NHI, all mentioned the importance of prevention and promotion. This was however not translated into concrete proposals of what would be done within the NHI context to achieve this.

National Planning Commission (NPC) Submission on NHI Bill

The presentation would be led by Prof Tinyiko Maluleke, Deputy Chairperson, NPC, followed by Dr Ntuthuko Melusi Bhengu, health sector expert and NPC Commissioner.

Dr Bhengu said the presentation would look at a brief introduction of what the NPC was about. It would also look at how the Commission had taken time to understand universal healthcare coverage and the World Health Organisation in respect of its views. The NPC supported the principles of universal healthcare coverage. There were areas of concern that revolved around governance regarding the powers of the Minister, and the appointment of the structures important for governing the NHI.

The role of medical schemes would be discussed and financial matters would be touched on too. After focusing on the main areas the responses to some of the issues would be dealt with.

The NPC supported South Africa’s commitment to undertake reforms to achieve progress related to Universal Health Coverage (UHC) in pursuit of the right to access to quality personal health care services. It accepted the elements of UHC as defined by the World Health Organisation (WHO) and it supports the objectives of the preamble to the Bill. It recognised UHC is embedded in one of the 17 Sustainable Development Goals (target 3.8 on health matters).

It was anticipated South Africa could possibly be a hung parliament in 2024. Democracy was based on political parties all fighting to lead government. Parliamentary representatives should think about the worst possible person and assume what it would be like giving such a person the powers which the Bill sought to give the Minister. There must be a return to the principles of governance in drafting the paper.

Submission by Scalabrini Centre of Cape Town

The presentation was led by Mr James Chapman, Head of Advocacy & Legal Advisor, Scalibrini Centre of Cape Town, who was joined by Fr. Peter-John Pearson, Director, Catholic Parliamentary Liaison Offices (CPLO). The CPLO was the sister organisation to Scalibrini and had endorsed and supported its submissions. Fr. Pearson was also a Scalibrini Board member. Mr Tatenda Kaponda, Children's Rights Project Assistant, was also present.

Mr Chapman introduced the team and commenced the presentation. The NHI removed ways of accessing healthcare services, which included those provided to non-citizens in violation of Section 27 of the Constitution. Progressive realisation was required, understood, and appreciated, but what was seen from the Bill was retrogression in violation of the principle of non-retrogression. The Constitution and a series of legislation were infringed and undermined, including the right to equality and the right to dignity afforded to asylum seekers, which was compromised.

The Constitution was the supreme law of the country and Section 9 protected everyone within the Republic. Everyone was equal before the law and may not be discriminated against. Persons also had the right to dignity. Foreigners had the same rights under the Constitution as citizens. Refugees, asylum seekers, and other categories of vulnerable migrants were protected by the rights within the Bill of Rights, and this included the right of access to healthcare. The NHI Bill took away access to healthcare services of asylum seekers

The Bill was not in line with the Constitution or other legislation. The Bill should be amended to make express and clear provision for asylum seekers and special permit holders in the revision of Section 4. The Bill took access to healthcare services away from asylum-seekers, immigration detainees, certain categories of children, dependants, citizens of the Southern African Development Community (SADC), and other undocumented migrants. This was unlawful, unconstitutional, inhumane, not in the interests of public health, and in conflict with the Bill’s own objectives.

Discussion

Government Employees Medical Scheme (GEMS)

The Chairperson thanked GEMS for its presentation and opened the floor for questions.

Dr S Thembekwayo (EFF) thanked GEMS for its presentation. Listening to the presentation it seemed as though GEMS had been promised administration of NHI. Dr Hlatshwayo stressed good governance.

Dr Moloabi said GEMS usually used good governance as its exit point. As GEMS positioned itself to administer the NHI, there were allegations of tender rigging, fraud, maladministration, and corruption totalling up to more than three hundred million rand. This was reported in ten explosive forensic reports which showed over a period of five years, GEMS had appointed and paid more than three hundred million rand to companies, in which some of its executives had a direct financial interest. Dr Moloabi asked GEMS if it can come clean on this matter. If GEMS were appointed by government to administer the NHI, it would lead the NHI to crash under the weight of corruption, like many other state owne- entities.

Ms H Ismail (DA) said GEMS had repeatedly said the funding for the NHI would be very good and it agreed with a Universal Health Care system. She asked if the NHI would provide good and effective healthcare service to the country once it is implemented; and if in its own opinion, GEMS views this Bill as one which would allow equal access to quality healthcare. It was important to consider if it were not for the private sector, citizens would receive or have access to healthcare services, to begin with. The country faces a shortage of healthcare workers, budget shortfalls, shortfalls in the placement of doctors and nurses, and infrastructure was also a problem. She asked if GEMS presumes the NHI in its current form provides a health value-based model; and if the Bill would be sustainable in its current form. She noted NHI would be sourcing funds from taxes, and the taxpayer group represents a small number due to unemployment. In light of this, she asked if the pool of taxes would be sufficient to carry the Bill. Presently the private sector was at the forefront of assisting with providing health services to the country. She asked if the Department of Health should concentrate on upgrading infrastructure, and on the placement of healthcare workers so necessities are in place when the time comes. She wondered how the NHI would actually be implemented if citizens do not have basic rights and if citizens do not have a foundation.

GEMS said the NHI Bill was constitutionally aligned. She asked if freedom of choice was not being infringed. People usually have a choice on what medical scheme the person wants to join. The NHI would take away this right of choice.

Some medical aid schemes provide better services, and citizens were entitled to choose whichever one the citizen sees fit. The NHI would create a limit to everything. She asked if the Bill was actually infringing on the right of choice, considering the Office of Health Standards Compliance presently cannot manage to monitor even 20% of healthcare facilities and considering health facilities need to reach certain compliance requirements. Under the NHI there were certain requirements necessary for a health facility to operate. She asked if many healthcare facilities, both clinics and hospitals, would have to shut down under the NHI; and if this would not have a negative impact on service delivery to the masses and those who needed it the most.

GEMS had emphasised the governance structure however, one must look at the corruption with the Digital Vibes scandal and the Special Investigating Unit (SIU) investigations in all the Departments, but specifically relative to the health sector. She asked if the private sector should be included on the Board under the Bill’s current governance and organisational structure to improve accountability and the legitimacy of the Board. She also asked if GEMS would recommend parliamentary oversight to mitigate the threat of corruption; and if the Bill would stifle innovation in the healthcare sector. She wanted to know if access to the top-up cover would assist in covering the additional assistance required by chronic patients; if the referral parties are labor-intensive; and could these parties have a negative impact; if referral cases were urgent if this would mean timelines were adversely impacting the health of patients where utilities were needed; and if this problem would not be exacerbated under the NHI, considering there were around R104 billion in medical negligence claims.

Ms A Gela (ANC) said she appreciated and welcomed the presentation by GEMS. As a councillor, she had observed how GEMS implemented and handled its members. It handled its members very well. GEMS had better options and it was affordable. Currently, not everyone received the same treatment or the same services in the health sector. Government wanted to ensure the health sector offered equal services to all. The NHI is aimed at pushing and implementing equality. She supported this. GEMS had covered everything in its presentation, but she had one question. She wanted to know if, as a government medical scheme which reports to the Minister of Public Service and Administration, Ms Ayanda Dlodlo, there were lessons GEMS would like to share on the various accountability lines to the Board and the Minister and Parliament; if there had been an experience where the Minister had placed undue pressure on GEMS; and she said she was happy with GEMS and all the services it provided to its members.

Ms M Clarke (DA) said she had mostly been covered by Ms Ismail on the questions she had wanted to ask. She had a few questions left to ask. She wanted to know if GEMS agreed, at present, South Africa had universal health coverage. The issue with the healthcare however was quality. She asked if GEMS agreed the health system was not in compliance with 80% of the national standard set by the National Health Department; asked how the NHI realised these outcomes and prevented the billions of medical claims currently faced in the country; asked how the number of medical claims would be minimised; wanted to know what role the NHI would play considering the massive budget which would not be included in the health budget; asked which recommendations there were to improve accountability and legitimacy of the Board; asked if the NHI gives the Minister too much power. She noted the recent fraud and corruption which had taken place, particularly the involvement of the previous Minister of Health, and asked if Parliament should play a greater role in terms of appointing the Board and Committees of the NHI. South Africa had legislation aimed at preventing irregularities in procurement such as the Public Finance Management Act (PFMA), as well as National Treasury regulations. The problem however was implementation and accountability. South Africa had experienced state capture, COVID-19, corruption scandals, and civil unrest, yet no one had been held accountable. What recommendations could GEMS give the Committee aimed at preventing this ongoing culture was in place? She asked how this would be by the NHI Bill; and how corruption, maladministration, theft, and irregular tenders within the NHI Fund would be prevented adequately. She asked for recommendations around this.

Ms E Wilson (DA) said she would keep her questions brief and asked about the future of GEMS if medical aids would only be used for complementary services not covered by the NHI. This would have a huge impact on the medical aid society because it eliminates the need for medical aid. She asked how GEMS would be affected. In the presentation it was said, if an establishment was unable to provide a registered service, then people should be transferred to another service provider or establishment. People at present cannot access medical health care services because of issues such as distance. One facility is not going to transfer another person to another facility, and secondly, there are few facilities available. She asked for a broader picture of exactly how GEMS thinks this should be done. People in rural areas face massive challenges concerning access to clinics and hospitals.

She referenced page 36 of the presentation titled “Overview of GEMS’ position on the 59 sections of the NHI Bill”. The Committee wanted to interrogate the suggestions to alternatives, particularly those sections of the NHI which GEMS had issues with. She asked what some of these sections/blocks were, and what those suggestions were. This was what the Committee was there to interrogate.

Mr M Sokatsha (ANC) welcomed the presentation from GEMS and asked if its members were beneficiaries of tax credits. He said Section 49 of the Bill says tax credits will be channelled into the NHI Fund. He asked how it was planning for this transition, should it apply to its members.

Mr T Munyai (ANC) said he wanted to grasp GEMS outsourcing of its administration if it did such outsourcing. The Committee must consider GEMS outsourcing and administration. He asked what the current level of administrative costs at GEMS was; how the Scheme planned to reduce those costs; and which lessons there were which should be taken into account when the Bill is debated and passed.

Mr P Van Staden (FF+) asked which measures GEMS would put in place to combat corruption and prevent looting within the NHI Fund if it became the administrators. This was important because Dr Thembekwayo had mentioned earlier, GEMS was involved in a corruption scandal of over R300 million. He asked which measures GEMS would put in place to assure South Africans the NHI Fund would not be looted. The Committee received very nice promises from previous persons. Digital Vibes would be an example of this. The issue of having measures in place to combat corruption and looting was of great concern to South Africans.

Ms N Chirwa (EFF) said the Committee heard many presentations, including Members who claimed South Africa had universal healthcare coverage, or the NHI would bring about universal healthcare coverage. Included in the attributes of universal healthcare coverage was that people should have access to healthcare services needed. Members knew this was not the reality in South Africa, and even when the NHI comes into fulfilment, universal healthcare coverage would still not be a reality. The Committee had rejected the National Health Amendment Bill stood testament to the fact that the concept of universal healthcare coverage was something that Members did not grasp.

She asked if GEMS anticipated the NHI would bring about universal healthcare coverage, taking into account the issues raised in respect of people living in township areas, rural areas, and informal settlements, who do not have access to healthcare services or facilities. The NHI would not bring about this particular reality of universal healthcare coverage. GEMS positioned itself as a vehicle that would administer the NHI Fund, so its allegiance needed to be checked. She asked where GEMS allegiance lies; where GEMS allegiance was regarding wanting the NHI to materialise, knowing very well the small details of what universal healthcare coverage is will not be covered through the NHI.

Incidentally, people had to go to or wait for clinics to open before having access to healthcare services. This was a testament to the fact there was no universal healthcare coverage in South Africa. She asked what GEMS position on the issue of universal healthcare coverage and the NHI was.

The Chairperson thanked everyone for the questions.  

Mr Sokatsha said his ears are so sensitive, when somebody mentions something incorrect he becomes irritated. He said Ms Chirwa was incorrect when she said the NHI Bill was rejected by the Committee.

Ms Chirwa corrected Mr Sokatsha and said she had said the National Health Amendment Bill was rejected and asked Mr Sokatsha to open his ears and listen.

A disagreement ensued.

The Chairperson intervened and called everyone to order. If a Member wanted to speak the Member should raise his or her hand.

Mr Sokatsha asked the Chairperson if he was cutting him because he was still on the floor and was disturbed by two rude Members.

Members responded by saying, “don’t call us rude members”, and he replied, “what should I call you?”

Another disagreement ensued.

The Chairperson asked Members to behave themselves.

Dr Thembekwayo said the meeting was a platform which afforded Members the opportunity to ask questions concerning the presentations received. It was not a time for Members to exchange words. Ms Chirwa, as a Member of the Committee, had the right to express herself and to ask questions without being interrupted. Mr Sokatsha was asked to withdraw the word “rude”.

Ms Chirwa asked the Chairperson to protect her. She did not appreciate being interrupted while posing questions to the presenters. The Committee had rejected the National Health Amendment Bill because it did not want clinics to operate 24 hours a day and seven days a week. Many reasons were given for rejecting said Bill even when the Bill was about universal healthcare coverage. At present certain Members wanted to present the NHI as a Bill that would bring about universal healthcare. The Chairperson was asked to assist in providing Members with context and briefing Members about the facts so Members were not abused. Ms Chirwa said she does not like being abused and she can also be abusive. When she spoke she should be listened to because she was a Member of the Committee. She would not be silenced by wrong facts. There was no universal healthcare in South Africa. The NHI would not create universal healthcare because people will still go to clinics that do not open for 24 hours, this is a fact.

The Chairperson said Ms Chirwa was protected.

Mr Sokatsha said he had never interrupted anybody. Ms Chirwa had finished speaking, so he had never interrupted her. This was a public platform and the Committee dealt with the NHI Bill. Ms Chirwa did not specify which Bill she was referencing.

Ms Chirwa raised her hand on a point of order.

The Chairperson said he had heard Ms Chirwa very clearly the first time she spoke.

Ms Chirwa said the Chairperson should not allow Members to lie and asked why people have to lie.

The Chairperson said he had heard Ms Chirwa say the National Health Amendment Bill. He asked Ms Chirwa to give him a moment to manage the meeting. He needed to bring this to the attention of Mr Sokatsha. He addressed Mr Sokatsha and said Ms Chirwa had indeed said what she claimed to have said. Mr Sokatsha was urged to continue with what he had to say.

Mr Sokatsha accepted the Chairpersons' ruling, as a disciplined Member. He still wanted to emphasise the word “rudeness”, which referred to someone who spoke over others or interjected while others were speaking. He was quiet when Ms Chirwa spoke because he was a disciplined Member. If he heard Ms Chirwa incorrectly she apologised, however rudeness means when somebody speaks you keep on speaking, this is rudeness”.  

Ms Chirwa told Mr Sokatsha to take his “L” and to open his ears next time.

Mr Munyai said the Committee was concerned with what had been presented by GEMS and was here to discuss the NHI Bill, not any other Bill. He asked the Chairperson to allow the Committee to focus on this, please.

The Chairperson wanted to raise a few points he had wanted to raise with the presenters and would allow extra time. He noticed the next presenters were on the platform and apologised for the delay. He would be strict about time management. Members should get straight to concerns when asking questions.  He had a few questions for GEMS - membership of GEMS was composed of government employees. It was established according to Public Service Co-ordinating Bargaining Council (PSCBC). GEMS had been established and negotiated at the PSCBC platform. He asked how GEMS envisioned the transition of its Members from GEMS to the NHI, and if there was a process it would undertake with Members and beneficiaries, on what should be expected when the NHI was implemented.

He asked what GEMS experience was on outsourcing its administration. The Committee needed to consider this as stated in the session on the purpose of the Act.NHI would be established as a single purchaser and a single-payer so comments on these questions were welcomed. The response from GEMS was limited to eighteen minutes and anything it could not answer, it was encouraged to submit to the Committee in writing.

Response from GEMS

Dr Moloabi thanked the Chairperson and Members for the questions. He would submit any unanswered questions to the Committee in writing. Dr Thembekwayo said it seemed as though GEMS had been promised to run the NHI, this was not the case and was not true.

Governance issues alleged to have rocked GEMS including fraud and tender manipulation. This allegation resulted from a publication circulated by News24. GEMS had dealt with those allegations. It addressed the Committee last year and explained what had happened concerning those allegations, which were said to amount to R300 billion. This amount was wrong. The Board had dealt with the issue. Officers who were involved in corruption activities were no longer part of the Scheme. Those officers either left the Scheme through resignation or were dismissed through a proper process within the Scheme. Due to those findings of fraud and tender rigging, the Board would be pursuing both criminal and civil litigation to recover what was recoverable. There were not ten forensic reports, there was an inspection in GEMS, and as a result of those allegations, the Board launched an investigation.

Most of the questions asked by Ms Ismail were leading in nature. Regarding if the NHI Bill provided for universal health care, Dr Moloabi said the Bill was a step towards attaining healthcare coverage which the country was committed to.

Regarding the question of whether the pool of taxes would be sufficient to carry the Bill, given the small taxpayer space, Dr Moloabi said the management of resources, particularly financial resources were managed by the fiscus which usually came from National Treasury.

When asked if National Treasury would be responsible for infrastructure, Dr Moloabi said the duties of government would depend on if the stipulated structures in the government were national, provincial, or on local level. Various tiers of government had their own responsibilities. Government would identify priorities and make budgets according to the needs of society at large, this was the approach.

Regarding if freedom of choice was being infringed by the NHI Bill, Dr Moloabi said the Bill sought to create access to healthcare, which is appropriate. This was the intention of the Bill. There was no intention to infringe on freedom of choice. There were factors that could hinder access to healthcare, but these issues would be dealt with in the premium. Hundreds of medical schemes did not exist in South Africa. There were actually under sixty medical schemes which were registered with the Council for Medical Schemes. The importance of compliance could not be understated. Healthcare providers were fully aware of the need for accreditation and were doing their best to attend training courses that would enable it to become accredited. All healthcare providers knew it had to adhere to the laws and regulations.

Speaking on if GEMS recommended the private sector to be involved with the Board of the NHI, Dr Moloabi said categories would not be appointed to the Board. It would be individuals who were deemed fit and proper and had the necessary skills to advance the objectives of the NHI Fund.

Regarding the 104 billion medical negligence claims, this was being dealt with and was not necessary within the responsibilities of the NHI. The Healthcare Professional Council of South Africa (HPCSA) was the institution that had oversight on how healthcare providers discharged the practice of its healthcare services. The 104 billion medical negligence claims fell within the ambit of the HPCSA.

Ms Gela was thanked for her encouraging comments. Her question concerned the need to delineate the accountability lines between the Minister, the Board, and other offices of the Scheme. This delineation was provided according to governance structures. The lessons GEMS had learned in its reporting responsibilities were, there had not been pressures exerted on GEMS.

In response to Ms Clarke’s question, Dr Moloabi said whenever faced with something to implement, one needed to improve as one went along. Those establishments that did not meet the minimum standards would take action, so when the next round of assessments happened it would have improved. The establishment of the South African National Standards (SANS) was very important to help assist healthcare establishments perform checks and balances on themselves.

On the question about if Parliament should be involved in the appointment of the Board, the answer given was the democratic legislative process provided for recommendations to be submitted from all angles of society. These recommendations would ultimately influence how the Bill would operate. The solution would be within parliamentary oversight committees to make inputs if this was not prohibited, which could be discussed at this particular level.

Regarding what recommendations GEMS had for the Committee on governance, the answer was, the structure was there. The King principles said, when determining the size or structure of a governing body, one must always take into consideration the size and complexity of the organisation and the role played as a governance oversight body. The Committee and GEMS should follow those principles. In the proposal of the NHI Bill, what the size should be was made clear.

Ms Wilson asked what the impact of NHI on GEMS would be, considering its complementary role.

There would always be a role. The implementation of the NHI was not an event; it was a process that could take any number of years. There was a desire to reach the endpoint as soon as possible, but things would be done incrementally. Former President Nelson Mandela alluded to the move towards universal healthcare coverage when he said women and children would have free access to healthcare. The transition would therefore happen incrementally. The COVID-19 pandemic may have affected the rate at which the NHI would be implemented, but these were the realities. As services shifted to NHI, those services would no longer be available in a medical schemes environment, per benefits stipulated from a regulatory point of view.

On the question about the availability or access of citizens in the rural areas, the answer was, in Haiti after the devastating earthquake the country had to deal with issues of access to healthcare, particularly for the treatment of patients with tuberculosis (TB), who lived in the rural areas. The clinics were very far and people could not access clinics. The government introduced a “buddy-taxi” system where if you own a donkey cart you collect the person who needed to get treatment. This system had a huge impact on the success of Haiti in dealing with TB. South Africa needed to be innovative in ensuring there was access to healthcare. Any person who used any healthcare services in the country would be a beneficiary of the tax credits. Tax credits were very complex. There would be a contribution for taxpayers. Tax credits would be given according to the citizens’ tax returns.

There may be beneficiaries of GEMS who are beneficiaries of the tax credits. On the question of what the levels of administration in GEMS were, the answer was, costs were 4.5% of contribution income at the end of 2021. The industry average was from the 2020 Council for Medical Schemes report and was 8.6%, so GEMS was fairly below what was allowed. The 10% of contribution income could be used towards non-healthcare costs. Non-healthcare costs were both service providers and corporate services, which included personnel and infrastructure. GEMS generally spent around 4.5% and had been low since inception. It had always been at about 7% and below, whereas at the beginning when GEMS started, the non-healthcare costs were around 18%. GEMS had always been around half of what the industry standard was. The scheme looked at the structure of how it would operate in the future, including how services would be sourced, whether internally sourced or outsourced, all of this was receiving attention.

Addressing the question of if GEMS would protect the NHI fund from corruption, the answer was, regarding governance the GEMS Board had made it a point to equip itself with all the necessary skills. This included belonging to societies like the Institute of Directors South Africa (IoDSA) and putting checks and balances in place to ensure corruption would not occur. There were independent committees like the Audit Committee, and the Risks, Social, and Ethics committees which were established by the Board. The Audit Committee was a minimum requirement by law and the other committees like the Risks, Social, and Ethics committees were not a minimum requirement of the Medical Schemes Act. These committees were put in place by the Board to ensure issues of corruption would be dealt with.

Ms Chirwa said universal healthcare coverage would not be reached as a result of the NHI. The approach of GEMS had always been it would monitor the policy evolution in respect of healthcare funding. GEMS promoted access to healthcare as best it could, by entering into arrangements with healthcare providers. It had won an award for creating access to healthcare. GEMS did whatever it could and what was practically possible to align itself and products with universal healthcare coverage. Having universal healthcare coverage was the medical healthcare utopia sought. The government needed to work towards it and at least achieve some measure of universal healthcare.

On the question of how GEMS envisions transitioning from being an employee public-sector medical scheme to a scheme where all other persons may be admitted, the answer was GEMS was established by a decision taken by Cabinet and employees. GEMS however functions according to the Medical Schemes Act. There were many strategic plans that the Scheme had conducted, and potential scenarios it had looked at. GEMS was modelled to be the blueprint from which policy changes would come. No single entity could manage the NHI on its own. The current number of service providers, experts, and advisors within the healthcare industry was not enough to administer the NHI. The industry was managed by a workforce of approximately nine to ten million, whereas the country had 60 million people to cater to. More people were needed to ensure skills currently available and needed were used.

GEMS had been built on outsourcing which was monitored very well. The Scheme had become wiser in monitoring outsourced contracts. The future of GEMS would be a mixture of both internal sourcing, and outsourcing where necessary, but internally sourced services would largely be used.

The Chairperson thanked Dr Moloabi for answering the questions. There was one question which he had not touched on but the Chairperson would give him an opportunity to answer it. The question was if South Africa was currently experiencing universal healthcare coverage.  

Dr Moloabi said there were elements of universal healthcare coverage in South Africa. When Nelson Mandela became president the first thing he did was introduce free healthcare services for women and children. There was an element of universal healthcare, it started there. There were elements of universal healthcare in the system at the moment.

The Chairperson said the definition of universal healthcare coverage as explained by Ms Chirwa was, healthcare services should be available when and where it was needed, without financial hardship. South Africa did not have universal healthcare coverage. The NHI Bill aspired to initiate universal healthcare coverage.

Closing remarks from GEMS

Dr Hlatshwayo thanked the Committee and the Chairperson for allowing GEMS to give its presentation. A contentious issue was being dealt with. Citizens deserved the best so the status quo would not remain the way it was. GEMS needed to assist in ensuring the aims of the NHI came to fulfilment.  

Alcohol, Tobacco, and Other Drug Research Unit (ATODRU)

Ms Wilson thanked the SAMRC for a thought provoking- presentation. The problem South Africa currently faced was, accessing facilities was a huge problem for the majority of the population. When persons arrived at those facilities there would be a lack of resources and appropriate care. With regards to non-communicable diseases, this was already a huge challenge for a vast amount of people in the country, considering the number of people who had HIV/Aids and TB. Without access, she asked what the government needs to do. She asked if more emphasis should be put on having appropriate resources, access, and personnel to enable an appropriate rollout.

Regarding addiction, there were beds in South Africa for only less than one percent of people who suffered from addictions. This created a huge problem because until such time these people could be treated, the country would battle and pay for these addicts' ill health. Most of these individuals were unable to gain access to drug rehabilitation centres without medical aid. She asked if this problem should not be addressed as part of the issue as well.

In the newest report from the Department of Health in Limpopo, there were 1 575 medical claims which amounted to R14 million. Of the 1 575 medical claims, 518 were cerebral palsy, as a result of problems at birth, such as bad deliveries, no resources, not being able to do caesarean sections when needed, and a lack of oxygen, 499 were obstetrics and gynaecology, 168 orthopaedic, 169 surgical, and 221 were registered as “other”. These medical claims had a huge impact on the budget. These kinds of incidents should be prevented. Those 1575 people could potentially need medical healthcare for the rest of their lives. The government should be promoting good health. One of the things that needed to be prevented was the lack of resources, specialist and availability of proper resources to prevent these types of medical claims.

She asked what SAMRC’s comment was on the NHI’s proposal to become a single purchaser of all medicines and medical resources, and asked if this did not pose a problem for SAMRC and if the NHI became a single purchaser would not halt innovation.

If a single purchaser decided who gets what and why, then why would this not prohibit innovation and discourage the discovery of better solutions and alternatives in the medical industry.

The South African population of approximately 57 million was constantly referenced in discussions of the NHI Bill, but another issue was the 15 million foreign nationals present in South Africa. The state was obligated to give foreign nationals in South Africa healthcare services. If government cannot give these people those services then government will not beat this battle. She asked if the NHI is sustainable in its current form, taking into account the current levels of poverty and unemployment, and considering the fact poverty levels are connected to unemployment. There was no way people could get access to nutrition. There would be an increase in diabetes, malnutrition, and stunting of children. This would get worse if it did not get better. She asked how SAMRC would respond to this.  

Dr Thembekwayo said, in addressing mortality issues, the Speaker spoke about the approach of health in all policies, and asked how government and the South African society would be incorporated into health in all policies approach. The Dr asked for concrete examples of those specific approaches which could be applied within South Africa; asked if these approaches fit into the current proposed NHI Bill; and if not where or in which section could it be applied. There was mention of bringing numbers down. The Dr asked when SAMRC conducted its research if it looked into the challenges faced by government in connection with the poor infrastructure, human resources, and poor governance of health establishments and national health services at large.

Ms Gela said she only had one question to ask. Section 40 which covered the information platform of the Fund, and other sections of the Bill, such as Chapter 3, Section 10, and Section 11, had articulated the role to be played by research.

She asked which additions should be made in the NHI Bill to adequately elevate the research related to the concerns which were raised by the Medical Research Council.  

Mr Sokatsha had a question in respect of health promotion. He asked if the objectives of the Bill were not adequate in covering health promotion concerns as raised by the presenter. The SAMRC had suggested the NHI Bill should provide for the establishment of the National Health Commission. He asked if it was convinced this should not be established by the amendments of the National Health Act.

The overriding theme in the SAMRC presentation was health promotion was a prerequisite to the successful implementation of the NHI. He asked if it was not more plausible the two could be implemented in parallel, rather than merely saying without the one the NHI should not be implemented.

Some of the specific proposals made on the Bill were commendable, such as providing two percent of earmarked funding for health promotion. However, he asked if this was this type of detail suitable for inclusion in a Bill dedicated to the founding of the Fund; and asked if this could be incorporated into the regulations supporting the operations of the Fund.

Mr Munyai said the Committee received a list of all the organisations which would come forward and present. On the list, there was no SAMRC 1 or SAMRC 2 present. This was an issue that the Committee had to, as a whole, follow through on. The Committee should not have new surprises.

He asked if the SAMRC, as an entity of the NDoH, engaged with the National Department of Health and the National Health Commission on the matters it raised regarding the promotion and prevention. The presentation used Thailand as a good example for South Africa to learn from on matters of health promotion. The presentation however also said the Thai-Health, which was equivalent to the NDoH, established health promotion, not the National Health Security Office of Thailand, which was equivalent to the NHI Bill in South Africa. He asked what the reason was for expecting a different dispensation for South Africa; and asked if it was not best to have separate provisions for the structures the National Health Commission or the Health Promotion Foundation catered to, rather than having it included in the NHI legislation.

He asked if SAMRC believed South Africa was one of the most unequal societies, taking into consideration the statistics and research. There were people who did not own shoes and were walking barefoot because of inequality in the Republic.

He asked if SAMRC wanted the two-tier system’s status quo to remain. Private medical aids received almost eight percent of the Gross Domestic Product (GDP) and accounted for over R400 billion while providing coverage to only 16% of the population. Private medical aids should contribute a percentage of the R400 billion towards health promotion, not only to its members but to non-members too. This could be addressed through NHI legislation.   

Dr X Havard (ANC) asked if there were any other proposals on how the current Bill could incorporate the promotion of health without advocating for new institutions, which were not part of the NHI Fund.

The Chairperson welcomed the Deputy Minister of Health, Dr Sibongiseni Dhlomo. The Chairperson had a couple of things he wanted to raise with the SAMRC unit, regarding the proposed two percent of the total NHI budget, which the presenters had suggested should be allocated to the National Health Commission or the Health Promotion Foundation. He wondered if SAMRC would preferably support the idea of having sin taxes and sugar taxes earmarked for this specific purpose, and channelled through the National Department of Health to pursue the same objective. He wondered about the proposal for the National Health Commission factor in the social determinants of health. The social behaviour model dictates healthcare is actually a complexity of elements, including health and social determinants of health. This model was recognised by the Medical Research Council. He asked why it seemed the aforementioned elements were expected to be incorporated into the NHI Bill; and asked if it was not better for there to be a more coordinated approach to health, which included other sectors such as education, water and sanitation, as well as social services.

In slide 18 SAMRC argued for the NHI Bill, as well as the Memorandum of Objectives. The Department of Health mentioned the importance of prevention and promotion, yet this was not translated into concrete proposals on what would be done with the NHI to achieve this. He asked if SAMRC was aware of the proposal concerning the Benefits Advisory Committee, which would be responsible for setting the services to be covered by the Fund. He asked why SAMRC seemed assured the services to be covered would not address the concerns raised.

Response from SAMRC (ATODRU)

Prof M Freeman said some of the questions asked related more to the other presentation which had been given by the Medical Research Council rather than this specific Unit. The Alcohol, Tobacco, and Other Drug Research Unit (ATODRU) is specifically related to health promotion issues. Hopefully, some of the questions had been answered when the previous presentation was done. The Medical Research Council did say it was in favour of NHI, subject to certain conditions being met. This had been previously covered. Focus would be placed on the issues related to the health promotion questions, particularly the idea of a National Health Commission or Health Promotion Foundation being part of the NHI or not. This was a very critical issue.

Ms Wilson was worried about the access to facilities and low personnel/staffing. This was a problem that needed to be addressed. Hopefully, the NHI would help to address this problem by encouraging a more equal distribution between the rich and the poor. The main issue was if it would allow those statistics to increase and therefore cause a healthcare decrease because more persons were allowed to get sick. This was illogical. The number of people who needed care must be reduced. This would make more money available for those who get sick and needed care. In this way, the quality of care would be increased.

Prevention is better than cure. If there were quality healthcare services, there would be fewer medical claims. Regarding “health in all policies” type of examples asked for, he said, if one took education as an example, the question which could be asked is, what the education Department could do to enhance the health of persons. It had already provided nutrition programmes, this would form part of the “health in all policies”, and “health in all education” approach.

Regarding the housing department “health in all policies” would ensure where settlements were built, these were well ventilated to prevent the spread of TB and would include recreational facilities such as parks with areas to exercise. These were examples where health would work together with other departments so the policies of other departments would promote health. In agriculture, one could look at the products grown to encourage the population to remain healthy. Health would get involved in the objectives of many different departments. The challenges of poor infrastructure had to be dealt with. ATODRU did not say these challenges should not be dealt with. Perhaps, the amount of infrastructure might be less if there were fewer people who needed healthcare services.

Prof Charles Parry, Director, ATODRU, would cover the questions around research in the Bill.

Regarding if the objectives of the NHI were inadequate, he said, the objectives did say ill health should be prevented, but the NHI Bill did not follow up on this. This was where the real concern stemmed from. Money, resources, and commitment needed to be put where the objectives were. The objectives should not be fulfilled inappropriately, for example, expecting the commissioning agencies would commission adequate promotion and prevention work, when in fact most of those decisions needed to be made at a national level. If these were not comprehensively thought about, then the wrong kinds of prevention and promotion work would result. If there is a limited amount of money available and there is a huge demand for services, committees would be put under enormous pressure to look at the short-term objectives, as opposed to the long-term objectives. A National Health Commission would have a long-term view and could start looking at how to prevent deaths within the next ten to thirty years. The NHI needed to last for the next twenty to thirty years. If two percent should be put into the NHI Bill itself or a regulation was a consideration.  

A Commission needed to be established with a percentage to be determined by regulation into the NHI Bill. It might start with two percent but gradually increase. This would be much easier to change in regulations than the Bill itself. A proportion needed to be put into the Commission or foundation, this needed to be written into the Bill, but the amount should go into the regulation. If the issues around the National Health Commission had been discussed with the National Department of Health was another question. Yes, there had been a discussion, but this was beforehand. Thai-Health was the health promotion foundation. It had worked with the NHI to reduce health care costs. ATODRU was aware of the poverty within the rural areas, townships, and informal settlements.

He asked how one promotes the health of people in poverty; and how does SAMRC work with other departments to ensure policies were put into place. It was important to help get people out of poverty but it was also important to help people get good health. The organisation would not want policies that were achieving economic growth but had a negative impact on the population’s health. It needed to work together and look at the objectives together. If the National Health Commission/Foundation should be part of the NHI Fund or the National Health Amendment Bill was another question. It should be part of NHI because it is so much part of NHI. It could be set up sustainably because of an NHI Fund which would exist. It could then ensure money is put into the foundation. Without money, the foundation would not work. If the foundation is made partly of the National Health Amendment Bill, it is possible it would be set up with no money to operate. By placing it as part of the NHI, sustainability would be ensured.

Ms Jane Simmonds, Research and Programme Manager, SAMRC, said she completely agreed with Mr Munyai. Very few South Africans had an understanding of the concept of poverty, which so many in the country lived in. Over 12 million people applied for the R350 basic income grant and it was allocated to six million people. This showed the extent of poverty because six million people were living on R350 a month. This fed into what Professor Freeman had said about “health in all policies” and the social determinants of health. She asked how one works in a society where there was such devastating poverty and where choices are limited by poverty; and where behaviour was so compromised by the search for food and survival. After spending time working on the COVID-vaccine outreach programmes with rural and vulnerable communities, a lot was learned about how these groups of people accessed healthcare services. The Social Behaviour Communication Model could be used as a way to define the difference between health information and health promotion. There was confusion regarding what health information was, and what health promotion was. Health information for example would be where you inform someone with hypertension of the illness and what the person needed to do to manage the symptoms. This was where the model of health promotion was needed. She asked how one moves from an individual message of health information to a family message. Studies had shown in China, children were coming from school with information on parents who should be eating healthy foods. This needs to be looked at, and also what was happening in the community, what was being grown and sold, water access, vegetable garden access, and so on. The environment also needed to be looked at on a political level. She asked what was happening at a socio-economical level; how would government or health promotion organisations work within NHI to bring all those permutations and factors together, so the individual within the middle of these circles could have choices. People would be able to choose behaviours, create those behaviours, and sustain the behaviours. With any of these levels missing, the behaviour or positive health outcome could not happen. There needed to be a vision of health promotion being bigger than a mere information pamphlet. Health promotion involved changing structures and determinants and putting in place the health in all policies approach.

Prof Parry said the message was not healthcare services were inessential, but rather space needed to be specifically and cognitively made for health promotion. This was important so health promotion would not be crowded out, and to prevent the depletion of resources by burdens of health service needs. There needed to be a specific focus. The Professor asked if government needs a new structure; a new structure was needed. There would be benefits to setting up a health promotions foundation; it would pay back in spades. There needed to be a specific focus placed on health promotion. Parliamentarians should emphasise health promotion and recognise the importance of what was said in the presentation. Space needed to be made for prevention services. If we look at the World Health Organisation’s programme of addressing addiction, alcohol abuse had five prongs to it called the “Safer Initiative”. Only one of the prongs looked at treatment, the other four dealt with the availability of alcohol, the marketing of alcohol, drunk driving, and the pricing of alcohol. The upstream factors needed to be dealt with, one should not rely on treatment. One cannot go into the river rescuing people who are drowning and bringing them to the shore. One has to go up the stream, up the river and find out why these people are falling into the river. One must ask why these people do not learn how to swim. The Professor asked which factors were causing people to get into the river and how this can be prevented. If certain factors are ignored, NHI could be put at risk.

In respect of the research questions asked by Ms Gela, this was fairly comprehensive but what ATODRU was saying, in addition to what was said in Section 40 and the additional sections and paragraphs, was specific space needed to be made for health promotion research. This research would help determine how one could prevent ill health by making cleaner water and air available. The objective was how to ensure people were healthy, even if people lived in an environment where people could not afford shoes. Health promotion was more than education it was about providing structural changes to enable people to make healthy choices and address those unhealthy drivers which brought about ill-health.  

National Planning Commission

Mr Munyai said the NPC recognised in one of its publications, in South Africa poor households were spending a large part of its income on health services and medicine as “out of pocket” payments. This observation was similar to the results presented on financing and benefit incident studies on the NHI white paper. The question was how the NPC would propose to address challenges faced by the indigent while also strengthening financial risk protection and social solidarity for all. The presentation conflated the role of government vis-a-vis the role of Parliament. It was the NPC’s assertion Parliament should run government programmes. In respect of the separation of powers doctrine, the aforementioned was not only impractical but unconstitutional too.

In the NPC’s publication titled ‘National Development Plan 2030 'Our Future-Make It Work’ a passage read that: The implementation of the NHI is underpinned by a vision 2030 of the National Development Plan which envisages by 2030 everyone must have access to an equal standard of care regardless of income. This common Fund should enable equitable access to healthcare regardless of what people can afford and how frequently they need to use the service.

He asked if the NPC agreed with this statement or if the NPC want the status quo of the two-tier system. The private medical aid sector received eight percent of the GDP, which was equivalent to over R400 billion while providing coverage to only 16% of the population.

He asked if the NPC thinks the status quo should continue and if the NPC agreed or disagreed with President Cyril Ramaphosa when he said the NHI is fundamentally about social justice and will ensure all our people, black or white, rich or poor, will be able to access a comprehensive range of healthcare services.

Ms Wilson thanked Dr Bhengu for a superb presentation. The title of the NPC said a lot about the Commission and what it was responsible for, it was the “National Planning Commission”.  She appreciated seeing the presentation referencing the need for a comprehensive health system, not only financing reform. The NHI was however a funding model. There was no indication anywhere that told the Committee how much NHI would cost or where funding would be sourced. There were talks about using taxes and taking money from private medical aids. She asked how one could plan for an NHI when one had absolutely no idea what the budget was. This was already a huge hurdle to cover. It was important to recognise the concern raised about the Bill being drafted on the assumption of a perfectly efficient, ethical, and capable state. In the current situation, none of these were applicable. There was no efficiency. There was a lack of infrastructure, resources, lack of personnel, and accessibility to healthcare systems. Ethics were questionable after the Zondo Commission as well as the capability of the State considering the current fiscal cliff. The drafting by way of assuming an efficient, effective, and capable state therefore tended to ignore the reality of the inadequate healthcare the country currently faced. He asked if South Africa would not be better off using the money to rectify those issues and create accessibility, build clinics, upgrade infrastructure, and make sure facilities were properly resourced. In Limpopo alone, medical negligence claims amounting to R14 million existed. These claims culminated from inefficiencies in health facilities. He asked if these issues should not be addressed first; and if focus should not be placed on prevention rather than trying to solve the problem after the horse has bolted.

Regarding the Zondo Commission and the SIU report, the powers of the Minister were a huge concern. It was opening oneself to a can of worms by giving a single person such monstrous powers.

He asked if the separation of powers should be maintained. This would allow proper oversight to be performed and accountability. The Competition Commission was there for a reason. He wanted to know if the NHI Bill’s single purchaser system was not particularly requiring the involvement of the Competition Commission. People appointed by the Minister would be given the sole mandate to purchase on behalf of the health system. Constitutionality and the threat to the freedom of choice was also an issue. Most people had been going to the general practitioner (GP) for years, and would likely not feel comfortable going to a new one. There were fears the referral system would take away freedom of choice.

The NHI Bill affected many other Acts. He asked if it was putting the horse before the cart or the cart before the horse, meaning, if it was the reverse of the proper order or the procedure. There needed to be an intense investigation into what effect/impact the NHI Bill would have on all the other legislation before proceeding with the process. Not performing this comprehensive investigation could lead to issues of constitutionality, loopholes, and potential irregularities.    

In respect of the WHO, standards and regulations of foreign nationals needed to be looked after. People could not be left sick and dying on the streets. A constitutional issue existed in that the NHI specifically specified things such as emergency care, which in respect of WHO standards were irregular.

Ms Ismail thanked the NPC for a very thorough, informative and well-presented presentation. She asked if the NHI in its current form was sustainable; and if the NHI Bill in its current form provided a health-value-based model. South Africa needed a health-value-based model. She noted the NHI would be sourcing funds from taxes, and the tax space in South Africa was relatively small, she wanted to know if the pool of taxes would be sufficient to carry the Bill. The private sector currently ran parallel to the public sector and the private sector took the load off of the public sector. The private sector made it possible for citizens and non-citizens to have access to quality health care. She asked if the government should place more emphasis on increasing employment opportunities instead of taking more from taxpayers. There was a major shortage of healthcare workers because doctors and nurses were not receiving placement as a result of budget constraints. She asked if the health system must be fixed first, before implementing the NHI. The Office of Health Standards Compliance (OHSC) could not manage to monitor 20% of healthcare facilities, and under the NHI, more work would be created for the OHSC. She asked if there would be health facilities that were compliant and providing healthcare services under the NHI, or if targets would not be reached. The NPC said it did not foresee the NHI materialising in the projected timelines, and she asked if there was a restraint in healthcare services in communities because most public healthcare facilities would not be running sufficiently under the NHI. Under the NHI Bill’s, “Current governance and organisation structure”, she noted the corruption with the Digital Vibes scandal and the SIU investigations in all the departments, but specifically relative to the health sector. She asked if the private sector should be included in the Board under the Bill’s, “Current governance and organisational structure”, to improve accountability and the legitimacy of the Board. She asked if the NPC would recommend parliamentary oversight to mitigate the threat of corruption.

Mr Sokatsha said there was a comment in one of the NPC’s publications on the benefits of economies of scale, in relation to buying power to negotiate prices with manufacturers, wholesalers, retailers, and dispenser clinicians in the context of the NHI implementation. The NPC was in support of the NHI in this context. He asked if the view of NPC changed; and if the Commission’s view had changed if it had conducted further detailed research to refute this initial stance on the benefits of economies of scale and the buying power.

It seemed as if the NPC presentation was based on the implicit assumption public healthcare services were all bad or inadequate, whereas the private sector was illustrated as all good. He asked on what basis this conclusion was made.

He asked if the NPC saw health as a tradeable commodity, or if it supported the notion of health being regarded as a public good, independent from the winds of market forces or market fundamentalism.

The NPC asserted the private healthcare sector contributed significantly towards tax and employment, and he asked if this meant sectoral reforms had to be implemented and asked if it was its submission the private sector was sacrosanct and hence should continue unchecked despite the social and health consequences on the greater population.

Ms Clarke appreciated the presentation being put forward and the real recommendations. The presentation made mention of 3500 ideal clinics roll-out. She asked how it would ensure those clinics conformed to the ideal clinic model. In every oversight she had conducted, none of the clinics conformed to the ideal clinic roll-out model. The powers of the Minister and the implications thereof were spoken about. There was mention of Clause 31, and the constitutional challenges presented by this clause; what the major risks of the current role of the Minister were, as stipulated in the NHI Bill; if parliament should play a role in the establishment of the Board and Committees of the NHI; and if this would mean more transparency and ensure accountability of the administration, the Board, and Committees to ensure fraud and corruption does not happen if the NHI Bill had to be passed. In respect of feasibility and costing, data available on the social and economic impact of the NHI and the outcome thereof was noted. The presentation made mention of nine million taxpayers, this was not correct. There were approximately five million taxpayers because of mass capital flight which needed to be taken into account. The question posed was, where would the money come from, the Fund the NHI Bill. There had to be avenues. An example of such avenues might be raising taxes. If VAT was increased from 15% to 20%, this would result in dire consequences on the poorest of the poor. Six million people received the R350 grant. The question was if the R350 would be taken away to fund the NHI. There had to be some feasibility costing so there was awareness around the costs and implications of those costs on the country and its citizens. Another question was if it was not more cost-effective to make use of the universal healthcare structures already in place, in creating an environment where quality healthcare was administered to citizens? A further question was if the Department of Basic Education’s budget would be cut to fund the NHI.

Ms Gela asked why the NPC was uncomfortable with the NHI Fund managing a budget estimated at R450 billion, but being happy with National Treasury managing the entire budget of government; asked if the NPC could elaborate more on this; asked if the NPC could explain its understanding of Section 10(c); and if it was not a misinterpretation to assume the entire health expenditure of R450 billion would be used for NHI; if this did not contradict Section 33 of the Bill, which spoke about medical aids paying for services not covered by NHI.

The NPC seemed really opposed to the Minister having executive authority to appoint the Board and other structures of the Fund. The Minister was constitutionally empowered to be responsible for health and the Fund. She asked why this was such a huge area of concern for NPC; asked if the Committee could be assured the advice crafted by the NPC was free of prejudice; asked if the NPC could assure the Committee it was looking at matters of health reform by wearing a public interest lens and not a pro-capital and business interest lens.

She also asked if the NPC was aware of the challenges in the public health sector due to the movement of specialists to the private sector; and asked if this was as a direct result of taking the best to serve the few in the private sector, leaving many waiting in long lines; and asked if the NPC was aware of this fact.

Section 15 of the Bill where the functions and powers of the Board were set out explained a comprehensive healthcare system was required under NHI. In the NPC slide titled, “Quality Healthcare”, the presenter appeared to find those provisions inadequate. She asked which additional provisions should be catered for in the Bill, for NPC’s concerns to be addressed.

Dr Thembekwayo said she had one question based on the visits to the ideal clinics, specifically the four clinics in two provinces where Dr Bhengu made mention of the fact of being pleased with the findings. The Dr asked about those attributes which certified the pleasing aspect of the findings; said nothing was pleasing in the clinics as long as the clinics were not open for 24 hours and seven days a week. The Dr asked what NPC’s recommendation was on the issue of having clinics open 24 hours and seven days a week. The Dr asked if the same enquiry should be extended to all clinics in all provinces, with the specification rural clinics could have a result of the same findings arrived at, to certify the validity and reliability of the findings.

Ms Havard asked if the NPC could explain how it viewed the inadequate human capital in the public sector; asked if people paid for services and did not use the services; if health professionals were taken away, with the majority left with no care, as has happened now.

The Chairperson thanked the Members for the questions and said he had a number of points to raise. The NPC was the custodian of the National Development Plan, 2030. A number of contradictions were noted and inconsistencies in what the NPC had presented, and what was in the Commission’s previous research and publications on related matters, based on the recommendations for a Multiple Fund Universal healthcare system. The NDP proposed that universal healthcare needed to be complemented by a reduction in the relative costs of private medical care while improving quality healthcare for all. The Chairperson asked if this meant the government should continue with the current health care system, which is highly fragmented in financing and provision; asked if the NPC considered, through empirical work, feasibility and costs of its recommendation, especially for the poor. The Chairperson asked if the NPC was happy about the current inequities and differences in financing and benefit incidents of healthcare in South Africa. These are pro-rich, with the wealthiest population receiving most of the total healthcare benefits available in the national health care system, despite having a relatively low health need compared to the poor.

The Chairperson asked how NPC proposed the Committee addressed social solidarity and financial risk protection for all, not only medical schemes; asked how the recommendation of the NPC aligned with the NDP, 2030 goals for quality of healthcare for all in South Africa, when the bulk of healthcare and financial resources are serving a small number of the population; asked if the NPC was aware the same medical scheme beneficiaries also sometimes used the State health facilities when these persons ran out of benefits, or when these persons could not afford medical schemes cover at all.

The Chairperson also asked how medical schemes were good for the economy; if the NPC considered the financial catastrophe members in the Scheme might face according to health entitlements; asked about the current two tiers of the health system, which the NPC defined differently, which had and continued to cause a myriad of health and social inequities for the population.

It seemed that the NPC was opposed to the Fund being empowered to make reasonable investment decisions. Medical schemes currently invested the monies of members. There was no opposition to this prior to the statement of NPC. It seemed as if the recommendation was meant to stifle the Fund’s flexibility in meeting its mandate, rather than any other reason. The Chairperson asked for an explanation of the rationale behind this.

The Chairperson asked why there was no objection to the Fund investigating fraud being committed according to Clause 22(e). The Clause did not say the NHI had to be a law enforcement agency, it said it must investigate fraud. The NPC had been charged with the responsibility to plan for the nation. The Chairperson asked if this organisation failed to assist the poor, where the Bill had been poked with trying to assist people’s accessibility to equal health care. This needed clarification.

NPC response

In respect to the question which asked about the NPC agreeing with the President, Dr Bhengu said, without a shadow of a doubt the organisation agreed with the President. The point was made in the presentation.  

In respect of the two tier system, he said the NPC was not pushing to keep the two-tier system. It was stated everybody must contribute towards NHI. There was a huge risk involved if one failed to gradually merge into the NHI. The concern is the NHI might instantly crash without a second’s opportunity, if not done right. South Africa had health professionals who were in demand all over the world; this needed to be borne in mind. The NPC was fully on board with all principles of universal health coverage, not only on contribution in terms of revenues, the pooling of funds, and strategy purchasing. NPC wanted to build from where it was. South Africa had a functioning healthcare financing system. The medical scheme industry received around R200 billion per annum, not R400 billion as stipulated by Mr Munyai. The total spend of the country on healthcare was 8.5% of the GDP.

The issue of financial risk protection was in alignment with what NPC proposed. The NPC was not conflating the role of government and parliament. The NPC was not infringing the doctrine of the separation of powers. The NPC wanted to ensure accountability. What the NPC recommended was nothing new, it was exactly how the South African Broadcasting Corporation (SABC) Board was selected. Notes need to be compared with the Presidential Commission, which advised how governing bodies were appointed. This was relevant because it spoke to accountability at every level. There was no suggestion the Minister would not be allowed to make any decisions, but it was really about separating the appointment at the highest body.

In respect of the question about the equal standard of care, what the NPC proposed was exactly what had happened during COVID-19 when people were allowed to use private hospitals because this was based on need. Subsidisation of the sick by the healthy and the rich by the poor was recommended.

In response Ms Wilson’s question about there being no indication of how much NHI would cost, he said this was not a question that should be directed towards the NPC. It was difficult for the NPC to say if funding would be sufficient or not. Comments would be reserved until the information was available. No government could demand the healthcare all its citizens demanded. Services needed to be rationed. In the case of Soobramoney v Minister of Health, KwaZulu-Natal the Constitutional court itself said under certain circumstances the State may not be wrong in denying healthcare, the right to emergency medical health care had a limited meaning. The assumption should not be for the NHI to be considered only once South Africa had all the money. Universal health coverage was a direction and not a destination. Dr Bhengu did not support the argument saying the government must first fix the infrastructure before it looks at the funding, because the health sector needed to start moving in the right direction. The path needed to be established to bring in the right reforms, and this could not be left to wait until all the monies were in place.

The issue of infrastructure was important and relevant. This was why the NPC made visits to those ideal clinics and documented those in the performance indicators of NPC. Although infrastructure was important there was no need to wait for all funding to be in place before starting. In respect of the NHI affecting other legislation or Acts, this was not surprising and was within the nature of governance. This was why different departments and arms of government needed to be involved with the NHI.

The NHI was everyone’s challenge. The COVID-19 pandemic had shown healthcare was equal to the economy. Employment was affected, people had lost incomes, education had been affected, and there was not a single component of society that was not affected. To come back and say only the Health Ministry should deal with this, would mean health issues were not recognised in the aforementioned context. When the NPC said Parliament and National Treasury must be involved in this, it was in recognition of health as a cross-cutting issue. A lot of the health problems held their genesis in socioeconomic determinants of health. This was about sanitation not being provided, early childhood development and other non-health issues which determine the wellness of the nation.

In respect of foreign nationals, the NPC did not comment on this because it was fully in agreement about all persons within South Africa having access to healthcare. The classifications were there. The NPC did not support a situation where foreign nationals are denied healthcare.

The question posed was if the NHI was sustainable in its current form. The NHI was not in place yet. One had to consider if the NHI was sustainable in its current form as it was proposed in the Bill. The first question about sustainability was the financial impact, and the Bill did not have this. This was a difficult question because sustainability had a lot to do with the funding model being used. The NPC was there to point out the gaps within the Bill which should be closed.

Another question was if the NHI provided value-based healthcare. Certain elements of the Bill lent themselves to value-based care, such as strategic purchasing. There were elements present in the Bill shifting the paradigm to a value-based healthcare system. This would be subject to implementation. The issue of acquiring funds from the tax pool was an issue present not only in the health sector. Those who, after paying for NHI still wanted to pay out of pocket for healthcare services should be allowed to do this. Services these people paid for, but failed to consume would mean there would be more for those who were dependent. This would be after-tax spending. This was to manage the risk which would arise if everyone on day one depended on the NHI for services.

Asking if there would be compliant facilities, it was said the OHSC was tasked with making sure facilities were evaluated and capable of providing quality care. It was still early days for the OHSC to deliver on its responsibilities. It needed to be independent and not compelled to give pass marks to facilities that were failing.

On the issue of corruption, one could not deny corruption existed; it also existed in the private sector. There was no intention to suggest corruption and fraud were only in the public sector. The private sector by large perpetuates bribing. This was a problem that needed to be dealt with. The issue of the private sector existing alongside the public sector was nothing new. It was fair to expect, even practitioners who were in private practice but provided services to patients referred by the public sector via the NHI Fund. These practitioners would have to provide those services at a lower rate for the NHI Fund. There was no change, only a misunderstanding of the context in which this question was raised.

He apologised if the presentation came across as the private sector being all good and the public sector all bad. This was not the intention. It was easy for individuals to think the private sector was better because of how private healthcare facilities branded themselves. It could not be said the public sector was all bad because it in fact trained the doctors who leave to practice, in the private sector. Working conditions between the public and private sectors were different. There was often co-operation between the public and private sectors. There were medical schemes that paid for care provided in the public sector. The Department responsible for regulation was to blame because it still had not moved on some of the recommendations which had to deal with the problems there. An issue would be pricing because it generally was difficult to determine how much a particular consultation would cost you. There was a solution proposed, which would be to give a reference price list, distributed to people would have a better idea of the costs involved in certain medical consultations. There was homework for regulators to do their part to ensure where the private sector was wrong, it is corrected.

The question could be asked if the NPC saw health as a tradeable commodity or if it supported the notion of health being regarded as a public good, independent from the winds of market forces or market fundamentalism. It could not be subject to absolute fundamentalism. This was why the NPC supported all principles of universal health coverage because it said healthcare should not result in the bankruptcy of people. All who needed healthcare should have access to it.

The issue of strategic purchasing had to do with the fact it could not be profit or loss. It was about using the power to negotiate and regulate prices. This was how the pharmaceutical industry worked, it was highly regulated. Healthcare should therefore not be subject to market fundamentalism.

Another question was how the NPC would ensure clinics conformed to the ideal clinic model. This was a management issue. It was about the OHSC also getting involved. When the NPC visited the four clinics it was not done to rate the entire system.

The question about feasibility and costing should not be directed to the NPC. The NPC was just as eager to learn how the NHI would be funded.

In 2017, the General Household Survey indicated a quarter of households said it would go to private doctors, clinics, or hospitals. In fact, 97% of households who attended private sector healthcare facilities were satisfied with the services received. Further, 5.3 households, as opposed to 0.6 who attended public healthcare facilities, were very dissatisfied. These were proxies that seemed to suggest a preference for the private sector.

Ms Gela compared the NHI Fund with SARS and National Treasury. SARS and National Treasury were staffed with professionals who were primarily trained to manage funds. This would not be the case with the NHI. One would have persons who were primarily fund majors to manage the funds. This question applied to Dr Jacobs question regarding the investment of unused funds. The investment of unused funds must remain within the NHI Fund. This was not a precedent. It was not okay to create a fund as big as the NHI, only to say everybody hands-off. There were issues that needed to be recognised and these issues were cross-cutting. The proposal was for the Minister to manage the NHI Fund, there was no opposition to the Minster’s powers. The NPC proposed t checks and balances, risk management principles being put in place to make sure there was protection.

The advice the NPC put forward was influenced to the extent of the many engagements the Commission had with people from all sectors of society. Members in the NPC, aside from the Minister, were all appointed as individuals and did not represent any organisation. Part of the NPC included people who were in the private sector. This would be disclosed. Dr Bengu came from the private sector and he did not own or run a medical aid. He worked and consulted with medical aids, but there was no reason he would prefer it over what was good for the country.

With commissioners who are active in the private sector, the expectation should be only public sector commissioners should be had within the NPC. It was impossible to influence any decision and to be

driven by financial interests. The NPC had checks and balances in place.

In respect of quality of healthcare and other provisions which could be suggested, the first step was to establish quality measures. One could not manage what one could not measure. In the NHI Bill quality had been considered through the health technology assessment and through assessing the intention of companies who were contracting, by having the companies prove it would provide quality services.

The issue of clinics being open 24 hours a day and seven days a week was something desired. It was unknown if this would be practical. The ideal clinics the NPC visited, some of the bigger ones, had one central clinic which was bigger and better staffed and would continue to operate after hours throughout the night. Within a certain radius, there should be a certain clinic one could run to for 24 hours and seven days a week. The clinic visit was about seeing what an ideal clinic looked like and how fast the organisation is rowing the boat.

In respect of the question posed by Ms Harvard, the issue of health professionals was a concerning one. This was one of the reasons why the NHI Bill made sense by saying healthcare would be acquired from both the public and private sectors. Human capital tended to flow in the direction of the private sector. This was up to the regulators to manage the process. The presence of Occupation Specific Dispensation intended to manage the migration from public to the private sector. One worrying scenario was where the country found itself in 2031, and the NHI system was down because healthcare providers had not been paid, the next month scores of healthcare providers would leave the country. This was a problem South Africa already faced. The issue of the management of human capital was indeed an important one. Hopefully, the NHI in securing services from the private sector did so on reasonable terms.

Dr Bhengu respectfully disagreed with the referenced contradictions and inconsistencies pointed out by Dr Jacobs. The solution of the NPC did not seek to perpetuate inequity. The mandatory contribution towards the NHI was fully supported by the NPC. There was no question the medical aid scheme industry should continue. Debates were heated between commissioners. There was not a single commissioner who felt medical schemes should be done. Implementation of the NHI Bill was not a five-year issue, it was at least a decade. The question was if there should be a horizon that could be argued.

Social solidarity and financial risk protection were the basics of universal health coverage, which the NPC supported. Healthcare for all aligned with the NDP. It was true medical schemes used the same benefits within the public sector. The Department was not without blame. It was not unknown for private patient to public hospital referrals, in some instances driven by the knowledge government hospitals would not be able to generate a bill. There was certainly a lot wrong in the private sector, but in most instances the only player sufficiently influential to correct it was government.

On asking if medical schemes were good for the economy, he said medical schemes had played a role. The more relevant question was about transitioning to the future. This question could be answered in full once some of the gaps were filled in the NHI Bill.

One had to ask which complementary services were being talked about. It would help the debate if one knew which ones those were. The investment of unused funds must remain within the NHI Fund and be managed by National Treasury, who was placed to do such. There was a reason why one needed scores of investment professionals to deal with matters of investment. The NPC was not convinced those would be found within 11 people, who would make up the Board of the NHI Fund.

One could ask if NPC was saying the Bill must not assist the poor. The NPC was very mindful there could be a perception it was perpetuating the two-tier system. This perception would only arise if one does not look at the nuances.

The Chairperson thanked Dr Bhengu for answering all of the questions. It had been a long walk from 2011 to the current year. All of the work started in 2011. The people of South Africa deserved universal healthcare coverage. The intention was to provide universal healthcare coverage to the people through the NHI. The input of the NPC was heard. The Committee would look at what had been presented by all the presenters.

Dr Bhengu thanked the Members for listening to the presentation. There was an entire team of dedicated South Africans who had prepared the presentation presented before the Committee. The NPC appreciated the Committee for accommodating it when it asked for a postponement. It was important to appraise the new members of the NPC. Professor Maluleke was thanked for the support as well.

The Chairperson opened the floor for questions.

Scalibrini discussion

Ms Gela welcomed the presentation. She asked how, in the face of physical constraint, the Centre proposed government should mobilise funding for healthcare for both documented and undocumented migrants; asked how this would be done without compromising funding for citizens; and asked what message Scalibrini wanted to be conveyed to the Department of Home Affairs, and other relevant departments? The health sector bore the brunt of the lack of enforcement in maintaining the integrity of the population database of South Africa.

Ms Clarke said considering Scalibrini’s view on the NHI Bill having some clauses which are unconstitutional, she wanted to know if Scalibrini foresees the Bill being successfully implemented in its current form.

Mr Sokatsha asked if Scalibrini supported the enforcement of the closure of South Africa to political, and asylum seekers through interventions of the security cluster, and asked if Scalibrini supported the current situation where the borders were porous.

The Chairperson said Mr Chapman made a strong case advocating for vulnerable groups. The presentation emphasised these specific vulnerable groups needed to have access to healthcare in South Africa under the NHI. Scalibrini’s view was non-South Africans who were in the country would not have access to healthcare services under the NHI. The Chairperson asked where this was reflected in the NHI Bill. This needed clarification.

Reference was made to Chapter Two of Section 4 of the NHI Bill, which provided for the provision of health care services to refugees, asylum seekers, and foreign nationals. The Chairperson asked for clarity regarding the statement made in slide three.

The Constitution said access to healthcare was available to all who were living in South Africa and did not specify citizens. The only right unique to citizens was the right to vote. The Chairperson asked what Scalabrini’s interpretation of this constitutional prescript juxtaposed to the Refugees Act was; and asked if there are any international best practices that could be emulated by South Africa to mobilise additional financial resources.

Some of the complaints from provinces in the north were about people crossing the borders purely to access healthcare services in South Africa. The Chairperson asked what the constraint would be on the country fiscus in this regard; and asked if Scalibrini supported the idea in which South Africa levied the countries from which the migrants came from. This could be done through SADC, African Union (AU), or the United Nations (UN) mechanism. 

The Chairperson asked if South Africa should be expected to go through the multilateral platform to source funding like other recipient countries.

Section 6.4.2 in Clause 4 of the Bill provided asylum seekers or illegal foreigners to be entitled to emergency medical services and service for notifiable candidates of public health concern. The Chairperson asked if offering the NHI free comprehensive services for non-legal residents and asylum seekers, without encouraging health, motivated migration.

Ms Ismail said there was mention of a study in Europe that showed giving healthcare access to migrants resulted in savings of direct and indirect medical costs. She asked if Scalibrini agreed with this study; and asked if Scalibrini viewed the Bill as potentially xenophobic as it stood, in its exclusion and inclusion of asylum seekers/or refugees.

Response (Scalibrini)

Mr Chapman thanked all Members for the questions. In respect of the constraints faced and the need the mobilise funds, he said data suggests the migrant populace might be as much as four percent of the population in the country. If one regularised, treated and proactively addressed things, costs would be saved. A good example would be the vaccine roll-out which was extended to undocumented “street people” in South Africa, undocumented migrants, and migrants with documents. To address the public health concern effectively, an inclusive approach that included all categories was required, otherwise, the pandemic would not be effectively combated. To effectively address health issues inclusivity was needed, particularly of vulnerable groups. In respect of the enforcement of the law to maintain the integrity of the South African society, if this spoke to removing migrant flows, this would be a very problematic position.

Scalibrini saw migration as an opportunity. There was research in Europe and Canada that supported the statement that a populace where health was adequately and properly provided for would be less burdensome on the economy and the fiscus. Scalibrini would continue to work with the Department of Home Affairs and in some instances, strategic litigation was unfortunately sought to ensure people were regularised and documented. This was important because a documented migrant was in a much better position to contribute to society and the fiscus, and ultimately the NHI Fund.

Regarding the question if the NHI Bill in its current form was unconstitutional, he said yes, it was.

The next question was if this meant it would necessarily be passed, and he said there were instances where unconstitutional legislation is passed. This could be seen in accordance with certain aspects of the Refugee Amendment Act which related to the Refugees Act 130 of 1998, which came into effect 1 January 2020. There were provisions that fell foul of constitutional and international legal obligations. Certain categories did not meet constitutional muster.

Regarding the Chairperson’s observation about asylum seekers, foreign nationals, and migrants being included in the Bill, the problem was the limitation of those provisions when one looked at Section 4(2), which spoke to only giving assistance when in the public health interest, or when dealing with emergency medical conditions. People with minor conditions and even women who were pregnant, including these women’s South African born infants would be excluded.

Regarding the question if Scalibrini would support the enforcement of the closure of South Africa to political and asylum seekers through interventions of the security cluster instead of pushing for closure or the enhancement of fencing, he said this approach of closure was not feasible.

It was better to look at the protections in place. Regularisation should be explored to avoid the risk of human trafficking, abuse, and exploitation. Documented individuals stood a better chance at being protected from trafficking, abuse, and exploitation.

The Constitution provided for everyone and spoke to everyone. There were only limited circumstances where not everyone was provided for in the Constitution. In accordance with the Constitution, the NHI Bill should make allowance and provision for everyone, as was provided for in our Constitution. The Bill fell short of this in its current form, particularly in respect of Section 4(2), which deals with galvanising financial resources and mitigating medical migration.

Resources could much more effectively be used if there was regularisation and provision of medical assistance from the first instance when migrants enter the borders. If migrants are included earlier, there are preventative information sharing campaigns, and provisions to avoid communicable and non-communicable diseases. South Africa would be in a much better position if there was early intervention, regularisation, and inclusion by acting in the interest of health by including all people. Refugees were recognised in the Bill, but it should go further. A healthy migrant population was a potential working population that would add to the economy and job creation. This could only be garnered if the health and well-being of the migrant population were protected and taken care of.

Answering the question regarding if the Bill was potentially xenophobic through its exclusions, he said yes, this was an argument that could be made. It was problematic where there was any unfair discrimination that took place.

Afrophobia was a reality in South Africa. This was something that needed to be addressed, and it should not be endorsed and promulgated in legislation.

Fr. Pearson said from the church's perspective there were particular concerns with the special permit cases regarding generating financial flows, speaking specifically about people who had been in South Africa for 15 years and longer, who in most instances pay tax contributing through sales tax and VAT. This needed to be taken into account when making too broad an assertion regarding such persons seen as not contributing any more than South Africans were. People working in areas of faith have recently pushed for examining the regularisation of migration and ensuring the pathologies which go with dangerous migration and unregularised migration should be minimised and abolished. This was one of the best ways of border control. Language within Bills may not be inflammatory, taken against the current emergence of a narrative promoting xenophobia. Further discussions should be had around the issues raised in the presentation.

The Chairperson thanked Mr Chapman and Fr PJ Pearson for their contributions in answering the questions of the Members. Mr Chapman thanked the Committee for being invited to make the presentation. The Chairperson thanked everyone.

The meeting was adjourned.