National Health Insurance (NHI) Bill: public hearings day 28, with Deputy Minister

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16 February 2022
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary


NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee held public hearings on the National Health Insurance Bill. Two organisations made oral submissions: South African Committee of Medical Deans (SACoMD) and the
National Education, Health and Allied Workers Union (NEHAWU). Both organisations supported the move toward universal health coverage and proposed a number of improvements to the Bill.

The South African Committee of Medical Deans was supportive of a single healthcare system and the undoing of the inequitable two-tier health system. SACoMD was concerned about the disconnect between the White Paper and the NHI Bill. SACoMD stated that the pilot projects did not produce the results that everyone expected – these were not written up in an evidence-based way. The pilot projects predominantly focused on district healthcare systems and to a small extent the contracting of private providers, but only in terms of individual practitioners. Perhaps the piloting could be extended into hospital-based spaces and other areas that had not been covered in the previous pilot projects. SACoMD wanted to see the purchaser and funding mechanisms separated, to ensure good governance. There were benefits in purchasing that could be negotiated at a global scale – but there was concern about it being tied up in a single purchaser model.

Committee Members asked if parliamentary oversight would address the organisation’s concerns about the Minister being a political appointee. A Member asked if more pilot projects should be carried out and if the infrastructure and capacity issues should be addressed prior to the implementation of National Health Insurance. The issue of medical negligence claims was raised; it was asked if there was concern about it worsening under National Health Insurance. Clarity was requested about the inclusion of universities and training within the Bill. A Member asked if the South African Committee of Medical Deans agreed with the National Development Plan and Vision 2030. Concerns around the lack of positions for qualified nurses, healthcare workers and doctors were highlighted.

NEHAWU supported the implementation of National Health Insurance, as it sought to ‘transform historical injustices and inequalities caused by the apartheid state.’ The presentation highlighted how government subsidies were used to benefit medical aid members. The unaffordable private healthcare system was outlined, with particular reference to the medical schemes. There was a shortage of healthcare workers in the Country, this had become evident during the COVID-19 pandemic. The Union supported the public administering of the Fund, the future role of provinces and tertiary institutions being provided with autonomous powers. It was suggested that political support was needed to overcome the challenges in the healthcare system, particularly in restructuring financing of healthcare and the roles of both sectors.

Committee Members asked that the Union look into the issue of graduates refusing to work in rural areas after qualifying. A Member asked if the healthcare issues in the country could have been addressed in the 28 years under the new dispensation. The lack of adherence to the Public Finance Management Act and Treasury's instruction was highlighted with concern, in light of the extent of corruption. It was asked what measures could be put in place to prevent such occurrences. Concerns were raised about the small tax base and sustainability of the Fund. A Member asked how the Union was dealing with the situation of healthcare workers losing their jobs, particularly in the Eastern Cape, due to a lack of permanent positions.


Meeting report

The Chairperson gave brief opening remarks and noted those in attendance.

South African Committee of Medical Deans (SACoMD) Presentation
Prof Lionel Green-Thompson, of the South African Committee of Medical Deans (SACoMD), presented SACoMD’s submission on the National Health Insurance Bill to the Committee. He highlighted a number of developments since SACoMD’s submission in 2019, particularly given the COVID-19 pandemic.

The presentation located NHI in the broader public healthcare delivery system as well as the two-tier system. Academia and the health professional training platform was located in the NHI context and issues around governance were highlighted.

The issue of the Minister responding to Parliament was highlighted, in terms of its being a political appointment. It was suggested that this might not be appropriate nor the best form of control. It was put forward that this needed to be explored in making global comparisons. Neither the Department nor the Board included an academic component. The need for this was emphasised.

The sustainability of producing sufficient healthcare professionals of good quality depended on the quality and stability of the healthcare system. This system needed to be addressed and ‘repaired.’ There was a need to discuss the funding and management of the academic system, particularly in health sciences education. There needed to be discussions about central hospitals versus academic hospitals, including the latter as potential service providers.

Public health entities needed to be strengthened and there was a need for clarity about the management and funding models. Clarity was requested about the interim measures in the implementation of NHI. It was suggested that universities needed control of the training platform.

(See SACoMD’s presentation).

Additional Remarks by SACoMD
Prof Ncoza Dlova, of the South African Committee of Medical Deans, introduced herself to the Committee. She was Head of Clinical Medicine at the University of KwaZulu-Natal (KZN).

Prof Risenga Chauke, of the South African Committee of Medical Deans, suggested that SACoMD’s proposed additions to the Bill would go a long way in strengthening it and the health system of the country. SACoMD believed in the Bill and the realisation of universal health coverage.

Dr Kerrin Begg, of the South African Committee of Medical Deans, was a public health specialist and Deputy Dean of Undergraduate Education at the University of Cape Town (UCT). Universal health coverage was something that universities had been pushing for over a long period of time. This was taught at both an undergraduate and postgraduate level so that when students entered the healthcare system, they had an understanding of what was needed to provide healthcare for all. SACoMD stood with the principles of universal health coverage. She highlighted the length of time it took to train health professionals and the need to acknowledge this in the broader context of the Bill and any changes to it.

Ms H Ismail (DA) asked if SACoMD would recommend that the governance of specialised hospitals remain with provinces. Did the Bill address the social determinants of health and preventative strategies? What were the implications if these items were not addressed? SACoMD highlighted that the Minister was a political appointee, and that independent oversight was important. Did SACoMD recommend parliamentary oversight to improve accountability and the legitimacy of the Board? To what extent did the Bill allow for equal access to quality healthcare? Was this an all-inclusive Bill? How sustainable was the Bill, in its current form? Would the NHI Bill be providing a health-barrier based model? Did SACoMD foresee a rise in emigration from South Africa, as soon as the NHI was implemented? Had the Department of Health adequately planned for NHI, taking into consideration that the pilot projects were not an effective tool for establishing if the NHI would work? Should more pilot projects take place to see if NHI would work before overhauling the whole system? With the current shortage of healthcare workers, and the infrastructure crisis, would NHI work or should these issues be addressed before the implementation of NHI?

She noted that SACoMD had mentioned the single purchaser, single buyer, model. Did SACoMD believe this model would cause a monopoly which would increase the prices of medicines? Presently with the Public Finance Management Act (PFMA) and Treasury requirements, tender processes were not adhered to. The Office of Health Standards Compliance (OHSC) presently could not manage to monitor 20 percent of the existing health facilities. The facilitates needed to reach certain compliance standards under NHI. Would this further hamper Health service delivery to the country? The Health Ombudsman could not manage to oversee and ensure compliance. She noted that SACoMD had suggested that the Office of the Health Ombudsman needed to be strengthened – but how would it manage to ensure compliance under the NHI, if it could not manage it right now?

There was at least R104 billion in medical negligence claims presently. Would this be worse under NHI? What was SACoMD’s view on the lack of timeous placement of nurses, medical doctors and healthcare workers? Many students went overseas to study medicine, simply because there was no opportunity to study in South Africa. She noted that the delay in the issuing of certificates, after examinations, was delaying placements in employment positions. She noted the Mandela and Fidel Castro programme, where students came into universities for a period of 18 months. There was a lot of money being spent on that programme. Would SACoMD recommend that funds be allocated within the Country rather than outside it?

Mr M Sokatsha (ANC) noted the argument that there was no mention of the National Health Laboratory Services (NHLS) in the Bill – did SACoMD miss clause 6(8) of the White Paper, which provided details about improving the efficiency of NHLS in preparation for the implementation of NHI? Clause 57(4)(g)(3) of the Bill also made specific reference to the NHLS. He noted the concerns about decentralised purchasing, which created financial and administrative risk. What was SACoMD’s proposal on this? Would SACoMD support centralised purchasing of personal healthcare services by the NHI Fund?

Ms A Gela (ANC) noted that SACoMD was worried that the Bill did not locate the NHI Fund in the broader public healthcare delivery system. Was SACoMD recommending that a greater level of detail be included in the Bill? SACoMD raised concerns about the need for the separation of purchasing from payers – as contained in clause 2(a) of the Bill. She asked for further clarity about this proposal in the context of the purchaser/provider split.  She asked for clarity about the proposal that a chapter be included about the role of universities, including training. She asked if there should be a chapter that dealt with the funding of universities and the training of health professionals.

Mr T Munyai (ANC) asked if SACoMD was concerned about the NHI Bill providing an adequate framework for infrastructure and capacity, which was needed to achieve the desired outcome of universal health coverage. He noted that SACoMD had recommended that the NHI Bill needed to locate itself within the context of the two-tier system. Should the contextual analysis found in the White and Green Papers be redone? Should the NHI Fund maintain the inequality that was seen under the two-tier health system? Was the purpose of the Bill not to end the apartheid generated inequality? He noted the statements about the ‘NHI Fund Bill.’ He asked if SACoMD had considered clause 2 of the Bill, which spoke to the purpose of the Act, being to establish and maintain the NHI Fund.

Would SACoMD agree that the NHI policy had outlined the critical health system issues that would ensure successful realisation of the mandate of the NHI Fund? Did SACoMD agree with the current status quo of the two-tier system that put profit before the needs of the people? The current private medical aids received 8 percent of Gross Domestic Product (GDP) accounting for R400 billion, that served only 16 percent of the population. 84 percent of the population was not served with that money – did SACoMD support this and the maintenance of the status quo?

He asked if Prof Chauke agreed with President Cyril Ramaphosa’s statement that ‘NHI was fundamentally about social justice, NHI would ensure that all the country’s people, whether Black or White, rich or poor, would be able to access a comprehensive range of healthcare services.’ Did SACoMD agree with the White Paper? The White Paper noted that NHI represented a substantial policy shift that would necessitate massive reorganisation of the current healthcare system to address structural challenges that existed in both the private and public healthcare sectors. It reflected the kind of society one wanted to live in, where there was fairness and social solidarity. The implementation of NHI was consistent with the global vision that healthcare should be a social investment not a private investment that could profit before the people. What was SACoMD’s view? Did SACoMD agree with the notion in the White Paper that the implementation of NHI was underpinned by Vision 2030? Did SACoMD agree with the National Development Plan (NDP)? Vision 2030 envisioned that by 2030, everyone needed to have access to an equal standard of care, regardless of their income as well as the establishment of a common fund. There should be equal access to healthcare, regardless of one’s ability to afford it and the frequency of use.

Dr S Thembekwayo (EFF) asked a question about medical interns. The Committee had engaged on matters of medical interns and specialists, and was aware of the concerns. Sometimes there were complaints from qualified doctors who were unemployed. The Committee engaged with the National Department of Health to address those matters and find employment opportunities. There were similarly complaints by some interns who were not paid by hospitals, specifically in Gauteng – the Committee was often able to resolve these. Those interns came from the ten universities that formed part of SACoMD, what was SACoMD’s intervention strategy after those graduates had qualified?

Where would academia be located in the NHI Bill, as it stood? She asked that the specific clause be indicated. There was a need to address the social and economic divide to promote health and disease prevention through inter-sectoral collaboration and strengthening of non-personal healthcare. Clarity was sought about the need to move to the White Paper, particularly given the Bill took into account public comments. She noted the comment made by SACoMD about the language – that it should be clear and more inclusive in the document. She asked for clarity on this as well as examples from the Bill – what clauses would make it an inclusive and clear document? What inclusive aspects were left out of the document?

Dr X Havard (ANC) noted that SACoMD made comments which suggested that it was against the accreditation of service providers under NHI. She asked for clarity on SACoMD’s inputs, particularly as it related to comments made about clauses of the Bill and healthcare services coverage.

The Chairperson asked questions on behalf of Mr E Siwela (ANC). A question was asked about the foreign students in South Africa; foreign students should not be expected to purchase private medical aid or insurance. Should foreign students be allowed free access to healthcare benefits covered under the NHI? He asked that SACoMD clarify what the international best practice was on this. 

The Chairperson asked his own questions about the presentation. The NHI Bill made reference to the National Health Normative Standards Framework, which was based on seven domains and six national core standards. Infrastructure was included in those domains. Was SACoMD familiar with the National Quality Improvement Plan? Did this plan not adequately address infrastructure requirements? The Memorandum of Objects outlined the quality improvement plan, did SACoMD perhaps overlook this? SACoMD appeared to advocate for South African residents to remain undocumented – was there a reason for this approach? How would health records of undocumented persons be tracked and traced? Based on the comments about the preamble of the Bill, SACoMD had made proposals for the Bill to be amended in line with the current segregations of the public and private sectors. Was this not promoting the maintenance of the status quo? He asked why the health needs of foreign nationals be elevated to particularly include ‘oral health coverage.’ Did SACoMD have recommendations to remedy the problems identified in the Bill? What amendments should be made to clause 11 of the Bill?

Prof Green-Thompson stated that a number of questions would benefit from a written reply, so that SACoMD could engage collectively in responding.

Prof Chauke stated that when the world met in Russia in 1978, and the Declaration of Alma-Ata was signed, the world said ‘by the year 2000 there must be health for all.’ 1978 Was a far cry from when National Health Service (NHS) was established in the United Kingdom (UK) in 1948, after the second world war. It was a great and noble undertaking, when the NHS was established. NHS was established when there were no models and nothing on which to base it. He stated this in response to the question about waiting for infrastructure to be established. There would never be a ‘right’ time to establish NHI. It needed to be done immediately. He agreed with the view that NHI was about social justice. There would never be a perfect system. SACoMD did not believe in a two-tier system of health in the country. A one tier-system should work without ‘compromising the other.’ It was important to strengthen the public health system. SACoMD believed that medical training institutions and tertiary training hospitals should be sitting under the National Department of Health, rather than the provinces.

Dr Begg stated that SACoMD was supportive of a single healthcare system and the undoing of the inequitable two-tier health system. SACoMD was concerned about the disconnect between the White Paper and the NHI Bill. To some extent, the NHI Bill would be better articulated as an ‘NHI Fund Bill.’ As this was what it represented; then there perhaps needed to be additional legislation that put effect to some of the gaps that existed between the Bill and the White Paper. SACoMD supported the principles of the White Paper, with some additions and modifications. The NHI Bill was a paring down of the White Paper, which was one of SACoMD’s concerns.

SACoMD strongly supported equitable access to resources and equitable treatment of all in South Africa. The pilot projects did not produce the results that everyone expected – these were not written up in an evidence-based way. SACoMD would have liked to seen that. The pilot projects predominantly focused on district healthcare systems and to a small extent the contracting of private providers, but only in terms of individual practitioners. Perhaps the piloting could be extended into hospital-based spaces and other areas that had not been covered in the previous pilot projects.

SACoMD wanted to see the purchaser and funding mechanisms separated, to ensure good governance. There were benefits in purchasing that could be negotiated at a global scale – but there was concern about it being tied up in a single purchaser model. This would not fit with the current governance model of ‘fiscal federalism’ in provincial entities. SACoMD was aware of what was contained in the National Health Act and the amendments of the OHSC in terms of quality. The coherence with the NHI Bill was not there. Hence, the suggestion that the Bill should be named an ‘NHI Fund Bill.’ Issues of service provision and quality control should be put in an additional piece of legislation. There were concerns about capacity. There was a quality assurance mechanism not an improvement-based mechanism. Many of SACoMD’s members had contributed to the High-quality health systems in the Sustainable Development Goals era.There were good policies and principles in South Africa, but not necessarily good delivery. Medical negligence was a particular challenge and would continue to be. As one improved quality of services, that should lessen.

She responded to the questions about the training of health professionals. It was concerning that graduates were not being placed, including nurses and healthcare workers. The delays seemed to be centred around the funding of those posts, particularly given the current economic context post-pandemic. Many of those posts were contract posts which were easy to curtail from a provincial expenditure perspective. There was no alignment between the national placement of those professionals and the funding of those posts at a provincial level. When there were austerity measures put in place, provinces cut posts and the number of interns in community service were not able to be placed. SACoMD believed that the country should be able to train all health professionals that the Country needed. There was a need for it to be ramped up. If one was not able to place those that were trained – it would be an expensive exercise.

There were challenges around people training overseas and wanting to return to the country. SACoMD would want to work together with government to train within the Country. With the Mandela Fidel Castro programme, people who were recruited form rural areas tended to return to those rural areas to work.

Prof Green-Thompson stated that one could not predict emigration of health workers. SACoMD remained committed to equitable access. He asked to respond to the remaining questions in writing. He responded to Dr Thembekwayo’s question: SACoMD had spoken about the insertion of an additional chapter relating to higher education institutions. The wording that would facilitate greater inclusivity was contained in SACoMD’s written submission. SACoMD supported national health and universal health coverage; NHI was an important contribution to this.

The Chairperson commended the universities for training more medical students. It had come a long way since 2011.

Prof Green-Thompson addressed the issue about graduates not being placed – SACoMD had tried to address this. He requested that perhaps the Committee and SACoMD could look at ways to anticipate this as there were some places where there were recurrent problems.

National Education, Health and Allied Workers Union (NEHAWU) Presentation
Mr Tengo Tengela, Parliamentary Officer, NEHAWU, made brief opening remarks about the presentation.

Mr Zola Saphetha, General Secretary, NEHAWU, and Ms Slindile Mbhele, Researcher, NEHAWU, presented NEHAWU’s submission on the NHI Bill.

Government subsidises medical aid schemes holders through tax benefits (tax rebates). High-income earners benefit the most from this arrangement since the more expensive the product, the greater the subsidy. As part of funding for the NHI, government should completely end tax rebate to medical scheme holders. Furthermore, government should redirect tax rebates towards the NHI fund.

As things stood, there was a shortage of healthcare workers; this was most evident amidst COVID-19. Austerity measures posed a threat to public healthcare, the shortage in human resources was one of the factors contributing to the public healthcare’s inability to provide health services effectively and efficiently, which is critical for an attainment of quality healthcare. The unequal social and economic stratification caused by the country’s finance policies can be located to the inequalities experienced by essential healthcare workers.

The workers in question are often if not always subjected to precarious conditions ranging from receiving low incomes, government undermining of collective bargaining agreements and working under poor conditions which were aggravated by the COVID-19 pandemic.
Moreover, temporal healthcare workers that were employed to assist with combating COVID-19 potentially face unemployment provided that their contracts are not renewed and/or converted to permanent. This equally becomes an impediment to the effective implementation of the NHI.

NEHAWU supported the structural reorganisation, as envisaged in the Bill pertaining to
The NHI fund being publicly administered, the future role of provinces, tertiary institutions being provided with autonomous powers and the creation of the Contracting Unit for Primary Health Care (CUP).

According to the Council for Medical Schemes medical scheme members paid R3.2 billion out of their own pockets more for private health care in 2015 than in 2014 (R27.2 billion in 2015 compared to R24 billion in 2014). This was a clear picture that private healthcare in South Africa was unaffordable and has turned healthcare services into a commodity enjoyed/accessed by only those who can afford it. The NHI would provide the Country with the health system that was for everyone as well as achieve the health goals embodied in the National Development Plan (NDP).

(See NEHAWU’s presentation).

Mr Munyai noted the need to ensure the appropriate distribution of health professionals across facilities. He asked that NEHAWU share their views of how this could be achieved under NHI? He suggested NEHAWU should look into the refusal of some graduates to work in rural areas. The majority of these facilities fell in the public sector. He asked what NEHAWU’s views were on the solutions for such issues under NHI. NEHAWU highlighted the level of unemployment and inequality in South Africa – he agreed with this.

NEHAWU raised issues of budget cuts in healthcare and other social services. What alternative could NEHAWU put forward to combat the detractors of NHI? He asked that NEHAWU reflect on who the detractors were and what the detractors were saying. Many of the ‘detractors’ suggested that infrastructure be fixed first – yet the inequality was well-known. He noted that private medical aid schemes received 8 percent of GDP, accounting for R400 billion which served only 16 percent of the population. What was NEHAWU’s view on this? Did NEHAWU agree with President Cyril Ramaphosa that NHI was fundamentally about social justice, that it would ensure that all South Africas, whether Black or White, rich or poor, would be able to access comprehensive range of healthcare services?

What was NEHAWU’s view on the NHI White Paper and its intentions? Did NEHAWU agree with the values of justice, fairness and social solidarity, as a way of implementing NHI? Some people said they wanted universal health coverage, but without NHI. What was NEHAWU’s view on this?

Ms Ismail stated that the country was 28 years into democracy, there had been a new dispensation in government for at least 27-28 years. Did NEHAWU think that the healthcare system could have been attended to or fixed during that space of time? The NHI Bill was a funding model. The healthcare system was in tatters. Everyone looked at the NHI as a means to provide quality healthcare to the Country – but it was essentially a funding model. On that basis, she asked a number of questions. NEHAWU agreed with the single purchaser, single buyer model. NEHAWU’s submission did not take into consideration the flaws in the implementation of procurement laws. According to the PFMA and National Treasury’s instruction to date, departments were meant to advertise tenders with details, such as price, company names, award date etc. In addition, the PFMA highlighted that price was the first indicator that should be considered when awarding tenders. As seen in the Special Investigating Unit’s (SIU) Report, tenders were awarded to companies that over-charged for products or services. Considering the flaws in implementing procurement laws and regulations, how did NEHAWU foresee the lowering of prices? How was the Fund protected from African National Congress (ANC) cadres seeking to fill their own pockets, as was seen in the Digital Vibes scandal? What suggestions could NEHAWU provide to protect the Fund from political interference?

The NHI would be sourcing funds from taxes and the tax base in South Africa was relatively small. It was known that there were many underprivileged and a major unemployment crisis in the Country – did NEHAWU feel that the pool of taxes would be sufficient to carry the Bill, since presently the private sector was at the fore-front of providing health services in the Country. Should the National Department of Health focus on upgrading infrastructure? There was a major shortage of healthcare workers at all levels – should this not be addressed before implementing NHI? The excuse from government was a budget shortage. The Country was already facing a budget crisis in the Country – with its small tax base how would the NHI Fund actually work? Was the freedom of choice not infringed by the Bill? Was the Bill constitutionally aligned? The OHSC was struggling to monitor 20 percent of facilities. Facilities would need to reach compliance standards under NHI. Would this not impact the delivery of health services to communities, where clinics might have to close due to not meeting compliance requirements?

Under the Bill’s current organisational and governance structure, did NEHAWU recommend that the private sector be included on the Board to improve the accountability and legitimacy of the Board? Should there be parliamentary oversight to mitigate corruption? Would the Bill stifle innovation in the healthcare sector? She highlighted the extent of medical negligence claims – would this not be worse under NHI?

Ms M Clarke (DA) asked if, within the South African context, infrastructure was equal to the benchmarking of other countries internationally where NHI had been implemented. What was NEHAWU‘s view on the contributions of the private healthcare system to the economy of South Africa? How would NEHAWU resolve the issue of job losses in the private healthcare system, if it no longer existed? There were issues currently of workers not getting paid over the past three months in the public healthcare sector, including security and cleaners. Would this be mitigated under NHI? If Value Added Tax (VAT) was increased to fund NHI – how would that impact the poorest in the Country, specifically considering the high cost of living in South Africa (for example food prices, interest rates, fuel prices, electricity). She suggested that if VAT went up it would have devastating consequences on the poor.

Dr Thembekwayo asked a question about the healthcare workers during the COVID-19 pandemic, with reference to the healthcare workers in the Eastern Cape who had lost their jobs. What was NEHAWU’s view on this and other similar issues in other provinces? What interventions could NEHAWU propose?

Mr Sokatsha stated that the presentation was progressive and spoke to the poor in the country. What was NEHAWU’s response to those that were opposed to the Bill? It was suggested that some stakeholders would go to court on the constitutionality of the Bill. How would NEHAWU respond to these threats? The ‘noble cause’ of providing healthcare to all was being threatened. NEHAWU had raised concerns about austerity measures imposed by National Treasury on the healthcare sector and the provision of public goods. What was NEHAWU’s proposal on protecting the funding that would be coming from general revenue into the NHI Fund? Would NEHAWU support the earmarking of the NHI budget?

Dr Havard asked what NEHAWU’s opinion on for-profit providers contracting services to be funded by the NHI Fund.

Ms Gela stated that the country was moving forward to correct all the health challenges the Department of Health was facing – NHI was a good move to equalise the standard of healthcare in South Africa. What was NEHAWU doing to prepare its membership for NHI? She asked that NEHAWU explain its experiences of how post-war countries were able to implement universal health coverage – what could South Africa learn from those experiences?

The Chairperson noted that many different opinions had been expressed on the Bill, one of them was that government needed to fix the public health system before NHI was implemented. What was NEHAWU’s view on the phased implementation of NHI? It had been said that innovation would be crowded out – what would the positive and negative effects of a monopsony be? What was NEHAWU’s view on medical schemes providing complementary cover?

Mr Sidney Kgara, Head of Policy Unit, NEHAWU, responded to a number of questions asked by the Committee. He noted the question about the challenges of deploying interns to rural areas. He acknowledged that this was a challenge – there had been discussions about incentives that could be introduced to encourage interns to work in those parts of the Country. It was an issue of the philosophy of the medical sector. In Cuba, it was inherent that healthcare worker graduates would address issues in remote under-privileged areas. The hospi-centric approach in the South African context took the focus from where it should be. Austerity undermined the progress that could be made, particularly under NHI. Out of COVID-19, the Country could have realised how important the healthcare system was – particularly the centrality of the healthcare workers and invest more in this. Spending on health contributed toward economic development through the multiplier effect, for example.

The Constitution called for government to ensure that everyone had access to care. There were people who rejected that. NEHAWU was not afraid to comment on that. He suggested that the money spent in the private sector was a waste of resources and inefficiencies. He advised that Members, specifically who supported the private health system, should read the report of the Competition Commission and what it said about the inefficiencies of the health system. NEHAWU wanted to see funding support of NHI. NEHAWU’s analysis of the medium-term strategic focus of the Department of Health indicated that more could be done to prepare for the implementation of NHI.

NHI presented a big shift. It emphasised primary healthcare as the foundation of the healthcare system. Preventative and promotive measures were important under NHI and made it sustainable. NEHAWU supported the single purchaser, single buyer, model - the logic of pooling healthcare funds so that it could be rationalised and not wasted. It could cross-subsidise the poor, who might not have the resources to access healthcare. The White Paper proposed a shift in the purchasing model and this was supported by NEHAWU. There were a number of countries who implemented universal health coverage – South Africa was an outlier, along with the USA.

Every country that had universal health coverage relied on tax. The high-income taxpayers subsidised the poor. He did not think this was a problem. The poor had subsidised the rich in the country under Apartheid. Under Apartheid people in the same occupations were paid different amounts and did not have any benefits, such as health or retirement etc. It was an old argument about fixing infrastructure – this could be done in-parallel. The situation in the public sector came as a result of a whole range of challenges that existed due to governance and budgetary allocation. The public sector was unable to progress while it was systematically undermined by the private sector (higher salaries in the private sector etc). One needed to address all these issues at the same time. Many people would welcome the improvement of the public sector.

The question asked about freedom of choice, was not about ‘freedom.’ It was very abstract. One could only have freedom of choice, if one had the means. The State needed to ensure that everyone had access, in line with the Constitution, and had the fullest experience of freedom. He did not agree that the private sector was accountable nor corruption free. The ‘State corruption was linked to the private sector.’ If one looked at the reports of the Competition Commission and the Health Market Inquiry, collusion took place in the private sector.

There needed to be accountability of the NHI Fund Board and it needed to be broadly representative of different sectors. There needed to be expertise of labour relations. There were many countries that made the progressive shift toward universal healthcare coverage, including Ghana. It was successful. The majority of countries favoured universal health coverage – this was reflected in the United Nations (UN) development goals.

NEHAWU did not anticipate there being job losses under NHI, there would likely be more employment in the public sector, because more resources would be diverted to the public sector. NEHAWU did not support the funding of NHI through VAT – it would not be sustainable. He noted the question about temporary workers in the Eastern Cape, NEHAWU had been actively engaging with the Department of Health on that. It was a pity that Treasury was of the view that there should be no permanent commitments outside the fiscal framework – which was why there was a problem. NEHAWU was able to raise funds and obtain a loan on the basis that it would help with the recovery of the health system and economy. These were some of the interventions that the money was being used for. South Africa was still under a state of disaster and there was a possibility of further waves of the pandemic.

NEHAWU had been working on the NHI campaign for some time. NEHAWU was not afraid to express its views against detractors. Treasury was vehemently opposed to earmarking allocations. The question was of commitment. Workshops had been held to inform NEHAWU members and members were involved in the parliamentary hearings in provinces. There were members of the public service that were skeptical about NHI. Overtime people would realise the benefits of NHI.

A lot of countries in Europe were able to, on the ‘ashes of the war,’ train healthcare workers and establish infrastructure for the health system to rebuild the economy. This could happen in South Africa. He did not think the monopsony fund would crowd out innovation. Those that rejected the NHI, needed to understand that the alternative needed to provide an answer on how to achieve universal health coverage.

Mr Saphetha responded to the question of attracting healthcare practitioners into rural areas. There was a model used by the Department of Education to attract teachers into such areas – he suggested that model be applied to the health sector. Those services were needed in rural areas. The curriculum lacked revolutionary moral aspects; the student who graduated needed to have a sense of social responsibility. This should be looked into.

The OHSC had the responsibility to ensure compliance. If one looked at matters of compliance in isolation, one would make a mistake. South Africa had a general challenge of compliance. Parliament was also a culprit of this. Departments were custodians of the laws, such as occupational health and safety under the Department of Employment and Labour. This was not being applied in workplaces where NEHAWU’s workers were. That report had been published in July 2020. There should be a review process of the OHSC – particularly of the role and powers of the Office. There should be a review of the relationships amongst departments. Everything would be done to defend NHI, noting the contending views.

Mr Sidney Kgara noted the question of the disparity in healthcare workers as well as the rural question. He was surprised that nobody had asked a question about the Competition Commission report on the private sector and tax expenditure subsidy. This had deprived the majority of people access to those subsidies.

Consideration & Adoption of Meeting Minutes

Minutes of Meeting held on 25 January 2022
The meeting on the 25 January 2022 covered public hearings on the NHI Bill as well as the consideration and adoption of past meeting minutes.

Mr Munyai moved to adopt the Minutes.

Ms Gela seconded the adoption of the Minutes.

The Minutes of 25 January 2022 were adopted.

Minutes of Meeting held on 26 January 2022
The meeting on the 26 January 2022 covered public hearings on the NHI Bill

Mr Sokatsha moved to adopt the Minutes

Ms Gela seconded the adoption of the Minutes

The Minutes of 26 January 2022 were adopted.

Minutes of Meeting held on 28 January 2022
The meeting on the 28 January 2022 covered public hearings on the NHI Bill.

Ms Gela moved to adopt the Minutes.

Mr Sokatsha seconded the adoption of the Minutes.

The Minutes of 28 January 2022 were adopted.

Minutes of Meeting held on 8 February 2022
The meeting on the 8 February 2022 covered public hearings on the NHI Bill.

Ms Gela moved to adopt the Minutes.

Mr Sokatsha seconded the adoption of the Minutes.

The Minutes of 8 February 2022 were adopted.

Minutes of Meeting held on 9 February 2022
The meeting on the 9 February 2022 covered public hearings on the NHI Bill.

Ms Gela moved to adopt the Minutes.

Mr Sokatsha seconded the adoption of the Minutes.

The Minutes of 9 February 2022 were adopted.

The meeting was adjourned.

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