National Health Insurance (NHI) Bill: clause 5 to 6 deliberations, with Deputy Minister

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08 June 2022
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary


NHI: Tracking the Bill through Parliament

In this hybrid meeting, the Committee continued with clause-by-clause deliberations on the Bill, with a specific focus on clauses 5 and 6. Members of the Committee expressed their party’s position on the various sub-clauses.

The African National Congress generally supported the two clauses covered, with the exception of clause 6(o) of the Bill, wherein minor amendments were proposed as follows ‘to purchase healthcare services that were not covered by the Fund through a complementary medical scheme, registered in terms of the Medical Schemes Act or out of pocket as the case may be.’ The party reiterated its support for the Bill, as it would increase access to healthcare services and respond to the needs of the people, as expressed during the public hearings.

The Democratic Alliance raised concerns about the need for birth certificates and other identification documents for registration with the Fund, specifically as there were current problems experienced on the ground in obtaining birth certificates from the Department of Home Affairs. Clarity was requested about how this would be addressed under the National Health Insurance. It was suggested that accredited establishments keep proper records of registered users and that it not be the responsibility of the user. Concern was raised about the need for users to register with accredited health care providers or establishments, when facilities were unlikely to meet the accreditation requirements. Concern was raised about the change to the referral system and the potential for fragmentation. Clarity was requested about what health services were covered under ‘emergency services. Concern was raised about the need to pay towards the Fund and private medical care, where the Fund might not cover all healthcare services - particularly given the strained economic context. Concern was raised about the sustainability of the Bill on the ground.

The Economic Freedom Fighters proposed that alternative ways needed to be made available for users that did not have documentation, particularly where proof of address was concerned etc. Concern was raised about the potential of the Fund to exclude people, on this basis, from accessing health services.

The Freedom Front Plus raised concerns about the use of the term ‘accreditation’ and how other laws would be impacted by these provisions. The Party did not support the Bill nor the clauses discussed. The current state of health infrastructure was highlighted as a particular concern.

The Chairperson informed Members that in the following week, they will get a response from the Department and the legal advisors on the deliberations concluded.

Meeting report

The Chairperson made brief opening remarks. He would read through a clause and the Committee would then discuss the clause in deliberation of the National Health Insurance (NHI) Bill clause-by-clause. 

Clause 5 of the Bill: Registration as users
Clause 5(1) of the Bill stated that ‘a person who was eligible to receive health care services in accordance with section 4 must register as a user with the Fund at an accredited health care provider or health establishment.’ Clause 5(2)(a) of the Bill stated that ‘a person as contemplated in subsection (1), must register his or her child as a user with the Fund at an accredited health care service provider or health establishment.’ Clause 5(2)(b) of the Bill stated that ‘A child born to a user must be regarded as having been registered automatically at birth.’ Clause 5(3) of the Bill stated that ‘a person between 12 and 18 years of age may apply for registration as a user if he or she was not registered as a user in terms of subsection (2).’ Clause 5(4)(a) stated that a supervising adult as contemplated in section 137(3) of the Children’s Act, 2005 (Act No. 38 of 2005), must register a child in the child-headed household concerned.’

Dr S Thembekwayo (EFF) noted that the Committee had received a different agenda to the way the meeting was being carried out. The Committee was due to start with the response from the Department of Health on policy issues which was to be followed by input by the Parliamentary Legal Advisor and State Law Advisor. After that, the Committee was due to deal with the clause-by-clause deliberations.

The Chairperson stated that the Committee would not be sticking to the proposed agenda. He proposed that the Committee consider the clauses this week and receive the briefings the following week.

Dr Thembekwayo stated that the Committee members had not agreed to this. She asked if Members were all in agreement about the way forward.

Mr T Munyai (ANC), Mr N Xaba (ANC) and Ms A Gela (ANC) supported that the meeting proceeds in the manner proposed by the Chairperson.

Ms E Wilson (DA) stated that the Committee had received an agenda and Members came prepared to work on the agenda, as it was communicated to them. Procedurally, one needed to consider Members’ input if the agenda changed.

Ms N Chirwa (EFF) highlighted that it would not set a good precedent if one could simply show up in the meeting and change the agenda completely. She asked that the Committee sticks to the original agenda, particularly as Members wanted to hear from the Department.

The Chairperson stated that Members were forwarded an agenda. The Committee had dealt with clauses 2 to 4 of the Bill in the previous meeting. Within the powers he held as the Chairperson, he had thought that the Committee should go straight to clause 5. By the following week, when the Committee returned, it would start with the other agenda items. 

Mr Xaba stated that the African National Congress (ANC) supported clause 5(1) of the Bill, on the basis that the National Health Insurance Fund be linked to the population register, as maintained by the Department of Home Affairs. The Fund needed to endeavour to ensure that the population registration process was automated and linked to the Department of Home Affairs database. Presenting to an accredited service provider should be the purpose of allocating a user to a provider who was accredited. This would enhance the planning process, including the determination of reimbursement strategy, such as capacitation to providers engaged at a primary healthcare level. 

Ms M Clarke (DA) stated that she had spent a lot of time preparing for the meeting. The notes she made related to the chapter as a whole and were not structured per clause. She would prepare differently for the next meeting. Clause 5(5) of the Bill stated that in order to register as a user of the Fund, a person was required to provide his/her biometric information and identity card, or original birth certificate or refugee identity card…

The Chairperson interrupted Ms Clarke and asked that she hold off until clause 5(5) of the Bill was discussed.

Ms Chirwa reiterated the point made. She had prepared her notes similarly to Ms Clarke, her notes related to clause 5 of the Bill as a whole. She suggested it would be better to look at the entire clause instead of each sub-clause.

Mr P van Staden (FF Plus) stated that in another Committee, where the Land Bill was being considered, Members were allowed to summarise their inputs at the end of each chapter. It was easier for many Members to do that than to go clause by clause. He suggested that this be the approach.

Dr Thembekwayo agreed to the above points made by Members. Members had prepared to discuss the whole clause. Otherwise, long debates would take place on each sub-clause and the Committee would never finish.

Mr Munyai suggested that the Committee continue to go clause by clause. 

Dr Thembekwayo clarified that Members were putting forward that the whole clause be presented and discussed not sub-clause by sub-clause, as was being done. 

Mr van Staden stated that he agreed with Mr Munyai but there had been no problem the week before when he had made comments on the whole chapter.

Mr Xaba stated that they should follow the Chairperson’s initial guidance to go ‘clause by clause.’

Ms Gela stated that she had prepared for the meeting and the Chairperson’s approach was good - to go clause by clause. She added that if other Members were not prepared, ‘they should just listen.’

Ms Chirwa interrupted and stated that Ms Gela ‘must focus’ – Members were not disagreeing about ‘going clause by clause,’ Members were disagreeing about going ‘sub-clause by sub-clause.’ Addressing Ms Gela, she added: ‘Wake-up, wake-up, you’re sleeping on the job.’

The Chairperson stated that he would not allow interjections in the meeting.

Ms Chirwa asked that a solution be found that worked for everybody. If the Committee went through a process that excluded some Members, the meeting could not be expected to go smoothly. A way needed to be found for all Members to contribute to the meeting. She asked that the Chairperson not pledge political allegiance, this was a very important discussion and Members had raised issues in an orderly manner in contributing to the meeting. She asked that the Committee go through the Bill clause by clause and not sub-clause by sub-clause.

Adv Ayesha Johaar, State Law Advisor, Office of the Chief State Law Advisor, stated that two different methodologies were being proposed which could be combined to accommodate all Members and their input. The Committee could decide that an entire clause be read, each Member then had the option to give their input as a whole, or to ‘zone in’ on specific sub-sections, and make proposals.

Ms Sukers supported what the State Law Advisor proposed. The Legal Team could then facilitate and guide the inputs.

The Chairperson thanked Members for their input. His ruling was that the Committee would discuss the entire clause. Members were free to do as they wanted as he did not stifle debate. Members who only wanted to speak on one sub-clause were welcome to do so.

Ms Clarke stated that clause 5(5) of the Bill determined that in order to register as a user of the Fund, a person was required to provide his/her biometric information, identity card, original birth certificate or refugee identity card issued in terms of the Refugee Act. However, it was common knowledge that not all persons, that would be eligible to use the Fund, would have birth certificates or identity documents. It was recommended that the Bill make provision for those unable to produce birth certificates or identity documents to be provisionally accepted as users of the Fund until they were able to produce such documents. She asked for clarity about how the State would ensure that the processes implemented could be accessed by all, particularly those in rural areas where there was limited existing access to healthcare resources. This would need to be looked at.

Clause 5(8) of the Bill determined that a user who sought healthcare services purchased for his/her benefit by the Fund from an accredited healthcare service provider or health establishment needed to present proof of registration to the healthcare service provider or health establishment when seeking those services. It may be argued that it was inappropriate for a user of the Fund, to provide the healthcare service provider with proof of registration. She suggested it should be the task of such establishments to keep a proper record of registered users.

In terms of ‘registering the particular funders’ – what process would be followed in order to ensure that those funders were registered in a transparent manner and the process followed through. If one was not registered with a healthcare service provider, and one was in need of medical care – what would happen? Would one be turned away or would there be a process to assist community members?

The Bill sought to change the current referral system by having tertiary hospitals under the management of the National Department, this would lead to a complete breakdown in the system, and ordinary South Africans would not be able to hold provincial departments responsible for poor outcomes. Due to the fragmentation – it would bring normal-functioning systems to a halt and take power away from the people ‘closest to them’ on the ground.

Ms H Ismail (DA) stated that the NHI Bill put forward that users of the NHI Fund must register with an accredited provider. If registration was limited to accredited providers, what were the implications for people who moved or became ill on holiday? Clause 5(1)(g) of the Bill did not explicitly state the levels of care that should be funded – such as rehabilitation – clarity was needed on this point. When one considered the requirement to provide proof of residence – it would exclude vulnerable persons and deny them access to health services. The recommendation was that clause 5 be expanded to allow for the registration of the user, in instances where someone might be on vacation in another area where that person had registered. A clause should be added to outline how this would be managed.

Ms Chirwa stated that accommodation should be made for persons who did not have the required documentation – as it allowed for the exclusion of people who did not have registered permanent addresses or identity documents. The issue of documentation in South Africa was not limited to immigrants and foreigners – there was an issue of undocumented South Africans in the country. There was a study conducted by the United Nations High Commissioner for Refugees (UNHCR) on the issue of undocumented South Africans. There should be a proper intervention on this issue. State organs failed people in not reaching them at their point of need.

Mr van Staden stated that in practice clause 5 was problematic as a person would not be able to see a specialist or doctor of his/her choice before a patient was registered with a primary healthcare facility, which had control of referrals. The Bill clearly contravened Section 27 of the Constitution, which expressly stated that everyone had the right to access healthcare, including reproductive healthcare and nobody may be refused emergency medical treatment. He noted that Minister Mkhize was unable to provide clear answers about the Bill in previous engagements – particularly how the registration process would work and how the database would function at State hospitals nor how long it would take for people to register at these institutions. The problem of maladministration was evident in State hospitals at present. Database problems at clinics had been noted on oversight visits. The Auditor-General had brought reports to the Committee, that similarly highlighted the database problems.

Mr E Siwela (ANC) made comments about clause 5(3) of the Bill. The ANC supported the clause. There were children and young adults who currently did not have identity documents with the Department of Home Affairs. This was sometimes due to children being orphaned or being born at home or in settings where one was unable to obtain identity documents. Many also lost their identity documents.

Ms Gela supported the inputs made by Mr Xaba and Mr Siwela. The ANC supported clause 5(2)(a) of the Bill. Children, including children of asylum seekers and illegal foreigners, would be registered automatically at birth, presenting to an accredited service provider.

Ms Wilson stated that she had specific issues about the clause, particularly around the word ‘accredited.’ Public hospitals to date had not been regulated by any independent agencies or structures. Public hospitals were directly administered by provincial governments. The Office of Health Standards Compliance (OHSC) was established to regulate. The private sector was regulated by regulation structures – yet this did not seem to apply to the public sector. Although the OHSC identified itself as independent and impartial, the entire leadership was in fact appointed by the National Minister of Health and reported to him. Meetings had already taken place with the OHSC and the statistics had been shown. She did not think a tenth of the hospitals or health facilities would meet the accreditation requirements.

This clause strictly stated that a person eligible for NHI must register as a user with the Fund at an accredited healthcare provider or establishment. She noted that there were few hospitals and clinics in rural areas and those that existed were located far apart from one another. There was concern about these few facilities meeting the accreditation requirements and how this would impact people on the ground in registering for health services. Where would people go? Would people then be denied care?

Clause 5(1)(b) of the Bill stated that ‘a child born to a user must be regarded as having been registered automatically at birth.’ This did not always happen – one was very lucky if one could find anyone from Home Affairs in public hospitals – she knew from experience. One could not assume or state bluntly that a child was ‘registered at birth.’ She suggested the Committee needed to look at how that could be re-worded.

A person between 12 and 18 years could apply for registration as a user if that person was ‘not registered in terms of the above clauses.’ If one went down to clause 5(5)(a) to (c) of the Bill, it stated that one needed various documentation to do so. One could not deny a 12-year-old access to medical care – if that person could not register because they did not have those documents. The wording of the clauses needed to be looked at, because it stated one thing and then contradicted itself later. The word ‘must’ was non-negotiable – in that, it left no room for alternatives. The use of ‘must’ in the Bill could create a situation that went against the Constitution, specifically the Bill of Rights. The Children’s Act was mentioned – if no adult had been designated in terms of section 137(2) of the Children’s Act – any employee of the accredited health service provider must assist the child to be registered. Would there need to be amendments to the Children’s Act to make provision for the NHI? The NHI Bill could not be implemented, until all the other health acts that this Bill affected, were amended. If the Bill affected the Children’s Act - Members needed to be advised on this.

She had a concern about where it stated that the Minister, in consultation with the Minister of Home Affairs, may prescribe any further requirements for registration of foreign nationals. This was problematic. She proposed the addition that the Minister may propose further requirements, with the agreement of Parliament, or at the very least the Portfolio Committee.

Mr Xaba stated that Members should be reminded that definitions would be attended to as the Committee went along. He noted that a number of Members had an issue with the word ‘accreditation.’ He suggested that there was a support team present who could assist in the discussion of that and the definition. He echoed the inputs made by Mr Siwela and Ms Gela. In clause 5(1), the basis for registration for the NHI Fund needed to be linked with the population register as maintained by the Department of Home Affairs.

In clause 5(4), the ANC supported the use of employees of accredited health establishments assisting children to register. This would ensure that there was no child left behind or disadvantaged and that children were accommodated. The ANC supported clause 5(8) – the user needed to be identifiable to the accredited healthcare provider through producing necessary means of identification, as outlined in the ‘preceding clauses.’ The users would access services from accredited and contracted service providers. This was necessary so that the system had proper control of registration.

Dr Thembekwayo made a comment about the term ‘eligibility,’ as it was expressed in the Bill, under ‘registration as users.’ There were cases where children were born to people who did not have a home or an identification document – these children would not have birth certificates. This was a problem in accommodating people. She referred to clause 5(6), which stated that the Minister, with consultation with the Minister of Home Affairs and suggested the powers did not only have to be given to the Minister. Powers could be given to the National Health Council, which included the Minister, in consultation with the National Home Affairs Council, which included the Minister of Home Affairs. This ensured that it did not rely only on the powers vested with the ministers.

Mr Munyai stated that he had made a concrete substantive recommendation about the definition. This was communicated to the Secretary. He stood by the submissions of Mr Xaba, Ms Gela and Mr Siwela. The ANC supported clause 5(6). It recognised the joint responsibility of the two ministers. The legislative responsibility placed on the Minister of Home Affairs was recognised – specifically on the population registration and the stewardship role of the methods to be used to identify foreign nationals. The Minister of Health had the legislative responsibility of providing a stewardship role of how healthcare services were to be accessed and provided.

Dr X Havard (ANC) stated that the ANC supported clause 5(4)(b) in that any employee of an accredited health care service provider or establishment could assist a child to register. This would ensure that no child was left behind or disadvantaged.

Mr van Staden agreed with Ms Wilson. He worried about the use of the word ‘accreditation.’ It was easy to insert a word or two into a law, but when it came to the execution of the law it was problematic. Accreditation was problematic. If one looked at the definition, it said ‘official recognition or something that met official standards or the external recognition set of standards to ensure an official status.’ One could not put a term like this into a law if it would not be executed properly at the end of the day. He agreed with Ms Wilson, that a lot of other laws needed to be changed simply to accommodate the word ‘accreditation.’ Public health facilities at this stage were not accredited according to such standards.

The Chairperson stated that clause 5(5) spoke about biometrics. It was important that the Committee agreed to support this as a form of verification of the users of healthcare in the future and to ensure that those entitled to benefits could access them and that Home Affairs knew who was registered. The world was moving toward relying upon biometrics in order to identify people – it might as well be included in the Bill from the outset. The ANC supported clause 5(5) in its totality.

Ms Sueanne Isaac, Parliamentary Legal Advisor, Constitutional and Legal Services Office, stated that in clause 5(1), where it stated that a person eligible to receive healthcare services must register with an accredited healthcare provider, the clause provided for children who were vulnerable – one also needed to consider other vulnerable groups, such as those who were mentally or physically ‘impaired’ or aged.

She highlighted clause 5(8) around proof of registration to access healthcare services. If there was a medical emergency and a person had not registered, that would create an issue, where there was no proof of registration and people were denied healthcare services.

Ms Clarke stated that it was necessary for the Committee to understand what constituted an accredited healthcare service provider. From her own experience of doing oversight in hospitals, hospitals needed to have a Home Affairs desk in order to assist with registration. That was not the case at the moment in many hospitals. It was a huge problem that children were not being documented.

Ms Wilson stated that there was a misunderstanding about ‘accreditation.’ During the public hearings, people came to support the NHI. When one listened to what they said, it always came with a ‘but.’ Private healthcare facilities could register for the NHI and offer certain services. The whole range of NHI benefits might not be offered, depending on availability and staffing etc – those facilities might opt to register. This was where accreditation became very important. There was a public perception that the moment the NHI Bill was passed, people could go to any hospital they liked, private, public, or otherwise. That was not the case. One needed to be wary of this. If a private facility did not register with NHI, one could not go there if one wanted NHI benefits, unless one was willing to pay for it. A private hospital might be accredited with NHI for maternal care or a specific service. Simply because there was accreditation, did not mean that anyone could walk in and expect to be serviced.

Mr Xaba stated that it was important to have accredited institutions. He asked that people familiarise themselves with the definitions. He reiterated his earlier points.

Dr Thembekwayo stated that the EFF did not support the NHI Bill in its entirety, the same applied to clause 5 of the Bill.

Ms M Hlengwa (IFP) recalled that in 2018, KwaZulu Natal (KZN) had started to prepare for the NHI registration process. She had seen the Deputy Minister there. She noted that there were Home Affairs desks in public hospitals in KZN. When it came to children and child-headed households, there was assistance given in registering the children, including those who gave birth at home. She fully supported the Bill.

Ms Gela supported the implementation of the NHI Bill in the country. People who were covered currently did not care about those who did not receive healthcare. The Committee had heard the opinions expressed during the public hearings – people wanted the Bill ‘implemented yesterday.’ She spoke about access to emergency services – in the preamble, the Bill outlined the provisions of Section 27 of the Constitution – about no one being refused access to emergency medical services.

The preamble ensured that the NHI would provide continuity and portability of financing and services throughout the Country.

Ms Ismail spoke to the matter of Home Affairs at hospitals and services on the ground. Two months before she assisted a mother to apply for a birth certificate for her three-month-old baby as the hospital could not register a child. The current system was not working. It was happening at various hospitals. Home Affairs was a problem – it was not providing the efficient service delivery required. This needed to be addressed and included in the Bill. The reality was that so many people would be sitting without medical healthcare due to the inconsistent service delivery on the ground. She had attended quite a few public hearings. In most of the public hearings, everyone was looking forward to NHI as they saw it as a universal healthcare system. The Democratic Alliance (DA) totally agreed with and supported universal healthcare for the country. However, every one of the public submissions stated that it had major issues with the current healthcare delivery on the ground.

The definition of ‘accredited’ needed to be included in the Bill – not simply in a dictionary. The Bill needed to clearly state the factors that the Benefits Advisory Committee and the Fund would consider when looking at which services would be included in the benefits package. If the medicine was not available under that package, one would need to seek additional funding support from another source. Medicines were not specified – this needed to be specified. When it came to referral pathways - if there were delays in that pathway it could implicate the health of the patient.

Mr Munyai stated that the ANC supported clause 5(4)(a) - many children came from child-headed households. Clause 39(2) of the Bill dealt with accreditation and the meaning thereof. The description was clear. The Committee would consider this matter when it got there.

Ms Sukers stated that in the Portfolio Committee on Social Development, the Children’s Amendment Bill was being concluded and the Committee had decided to deal with the foster care clauses in order to meet the court deadline. She asked if the matters in the Children’s Amendment Bill were being tagged with what the Committee was dealing with in this Bill, where it related to children. One needed to consider what the law would look like in practice. Currently, there were at least 500 000 children in South Africa without birth certificates. 80 Percent of them were South African citizens. The NHI Bill needed a provision to enable the children to register as users, while they waited on Home Affairs, which could take many years. In terms of undocumented children, there were social circumstances that made it difficult for children to be registered – especially vulnerable children. She asked that the legal advisor advises on such matters.

The Chairperson stated that clause 5(7) spoke about unaccredited health establishments. This was straightforward – if one wanted to attend a facility, whether it was private or public – one would go to a facility that was registered and able to provide services. Those medical personnel would also be registered with the relevant professional body. It stood to reason that those healthcare service providers would then be obliged to maintain a register in order for them to show good practice. The ANC supported clause 5(7) of the Bill.

Ms Isaac noted the query about medical emergencies. She had been referring to clause 5(8) which stated that a user needed to provide proof of registration if they wanted to access healthcare services. There may be instances where there was a medical emergency and a person could not, due to their health, provide proof of registration etc. This needed to be taken into consideration. 

Mr Theodore Hercules, Principal State Law Advisor, stated that accredited services were defined and clause 39 provided for the process of accreditation. That was a detailed process for healthcare service providers to comply with. There were statutory obligations, there were contractual obligations and there was provision made for renewal and refusal of such accreditation. These were detailed in the Bill and would be further detailed in regulations. The issues regarding refugees, asylum seekers, and foreigners were dealt with within the scope of clause 4 of the Bill. In terms of the Immigration Act – ‘foreigner’ was defined as someone who was not a citizen. There was a specific provision in clause 55(4), which provided that regulations must be tabled in the National Assembly and National Council of Provinces for a period of one month before being finalised. The Legislature would consider any draft legislation before it was finalised.

Ms Clarke asked what services were covered under emergency medical services. She asked if standard prescribed minimum benefits constituted emergency medical services.

The Chairperson stated that Ms Clarke would receive clarity on this the following week. 

Clause 6: Rights of users
The Chairperson said the Committee would receive inputs the following week from the Department on clauses 5 and 6.

Clause 6 dealt with the rights of users. Clause 6 of the Bill stated that ‘without derogating from any other right or entitlement granted under the Act or under any other law, a user of health care services purchased by the Fund was entitled within the State’s available and appropriated resources (a) to receive necessary quality health care services free at the point of care from an accredited health care provider or health establishment upon proof of registration with the Fund.’ Clause 6(b) of the Bill stated that a user was entitled ‘to information relating to the Fund and health care service benefits available to users.’ Clause 6(c) of the Bill stated that a user was entitled ‘to access any information or records relating to his or her health kept by the Fund, as provided for in the Promotion of Access to Information Act, in order to exercise or protect his or her rights.’

Ms Gela stated that in the meeting the following week it would be appropriate to deal clause-by-clause and sub-clause by sub-clause. When it came to the rights of users, the ANC supported clause 6(a). Users would be entitled to receive quality healthcare services using applicable standards and norms.

Ms Clarke asked what would constitute ‘unreasonable grounds’ as contained in clause 6(d) . In terms of the appeals committee that needed to be established, what criteria would be used to establish that committee?

She referred to clause 6(o) of the Bill. NHI would provide treatment for certain cases, where treatment could not be provided, there would need to be medical aid or a private insurance fund. In this current economic climate in South Africa, people were really strained financially. She realised that Dr Crisp had said that people would not be paying extra taxes, but in the next line, it said funds would be sourced from payroll tax. The income brackets had changed, there was no longer a large middle class, the upper class had moved down to what was the middle etc.

Ms Ismail stated that clause 6(o) outlined the rights of users to access healthcare services not covered by the Fund through alternative funding mechanisms. Due to the impact of COVID-19 and the state of the economy, this would put unnecessary strain on people as they could not afford two medical aids. That was what it would ‘boil down to.’ One would be hampering healthcare services by having these two specifications. There was a lack of transparency about what was available to prevent the State from withholding reasonable care. It was concerning given the State’s failure to procure and provide appropriate medication in a number of hospitals currently. There were concerns about implementation on the ground at present and then under NHI and how it would be workable.

Ms Siwela echoed what Ms Gela stated. The ANC supported clause 6(b). Under the promotion of access to information, users of healthcare services had a right to be given access to information regarding the Fund and its operations. This required transparency and accountability to users. The ANC supported clause 6(c), it was reasonable for an individual to receive information related to their health. The ANC supported clause 6(d), the meaning of ‘unreasonable grounds, as outlined in the proposed revised definitions, which Mr Munyai spoke to the week before, meant ‘beyond the limits of acceptability or fairness.’

Mr Munyai stated that the ANC supported clause 6(n) – the users should always have access to full accurate and transparent information about the healthcare services at all levels of care. Such information should be readily accessible in local languages, through the local media and other publicly accessible communication channels.

Mr Xaba supported the submissions made by other ANC Members. The ANC supported clause 6(g) concerning the professional standard of care. The standard of care should not be lowered – it should be progressively improved – which was in line with the principle of safe standards – where users needed to be told what level and quality of services were received. The ANC supported clause 6(j) to request written reasons on decisions of the Fund, as it required that the Fund needed to operate in an open and transparent manner. Users must be provided with sufficient details about the decisions of the Fund.

Dr Havard stated that the ANC supported clause 6 of the Bill. The ANC specifically supported clause 6(l) as it recognised the importance of non-users to seek judicial review if unhappy with the decisions reached by the appeal tribunal. Users needed to be provided with the full information about the decisions made.

Ms Sukers stated that she had a process question. she asked if inputs were being considered by all Members of the Committee or were Members there to simply ‘rubber stamp’ whatever was already contained in the Bill. She asked what provisions were made for undocumented children.

The Chairperson stated it was important that the Committee followed the correct process so that there were no challenges at a later stage in this regard.

Mr Munyai stated that the ANC supported clause 6(k) on the basis that it recognised the importance of allowing the users to seek redress when dissatisfied with a decision reached by the Fund. This needed to happen in an environment where users’ rights were respected as well as in a sympathetic manner. Users must be treated with courtesy and must not accept any form of insensitive treatment. He supported clause 6(f) of the Bill – with regards to the meaning of ‘reasonable time period,’ as outlined in the proposed revised definition, as defined by the Benefits Advisory Committee, through the clinical guidelines and protocols as well as the standards of operating procedures.

Mr van Staden asked what the State’s current and appropriated resources were – as outlined in clause 6 of the Bill. Could the State hospitals and clinics, with their current challenges and shortages of staff be seen as a favourable environment for the implementation of NHI?

Ms Chirwa raised an issue about the proof of registration being a requirement before having access to the Fund, as outlined in clause 6(a). It became an issue of access. The NHI presented itself as a solution to access healthcare – but clauses like this excluded people from accessing services. The fact that one was talking about documentation and referral systems went to show that the very same people it intended to serve were actually being sidelined. The timeframe for registration of the NHI was not known and it was not stipulated. There was no assurance of this process being done diligently. There needed to be a provision for healthcare to still be accessible. Clause 6(d) was in contradiction with other clauses.

Ms Wilson stated that clause 6 basically dealt with the rights of users – in line with the Constitution and Bill of Rights. The constitutional right to quality healthcare was encapsulated in clause 6. As the Committee worked through the Bill, it would go through clauses and discuss particular issues around the wording around quality, access, and accreditation. Clause 6 dealt with what people should get. Therefore, she basically supported what was said there.

Parliament had turned down bills in the past that were deemed to be unsustainable. People were entitled to necessary quality healthcare – but it was not being provided/received. In the 2017 OHSC Report, mortality rates were specifically dealt with and only seven establishments out of 696 public health facilities managed to meet the score necessary to be accredited as service providers. While clause 6 dealt with what one should get – it was unsustainable for the Department of Health, given the state of the current system. The Health Ombudsman had four members of staff, who would need to deal with millions of complaints when NHI was implemented. The same structure in Britain had 80 staff members.

Dr Thembekwayo noted that the Committee consisted of all the different political parties – she was concerned about how these inputs were taken into account. She supported what Ms Chirwa had highlighted, given the problem of undocumented persons.

The Chairperson noted that persons who were able to make decisions about their healthcare should be allowed to make those decisions, as outlined in clause 6(h). The ANC supported this clause. Clause 6(o), which dealt with the purchase of healthcare services, was similarly supported by the ANC.

Mr Xaba stated that the ANC supported clause 6 of the Bill. The issue of access had been spoken to. There was no way the Bill would undermine the Constitution, specifically given the preamble of the Bill. Clause 5(4)(b) had stated that there would be no children would be left behind. Undocumented children would be accommodated. The health registration system would register undocumented people already. The issue of access would deal with the issue of local languages as stated in clause 6(n) of the Bill.

Mr Siwela stated that the ANC supported clause 6(i), the clause recognised the importance of allowing users to redress when dissatisfied with the standard of service and empowered them to submit complaints that had to be addressed swiftly.

Ms Gela stated that the ANC supported clause 6(e). This clause was in line with the Constitution and Bill of Rights. The ANC supported clause 6(m), this was in the spirit of ensuring that the provisions in the Bill were consistent and prescribed in the Constitution and Protection of Personal Information Act. The information was necessary for the operation of the Fund so that it could serve the interests of users of healthcare services.

The Chairperson read the proposed amendment to clause 6(o) of the Bill, ‘to purchase healthcare services that were not covered by the Fund through a complementary medical scheme registered in terms of the Medical Schemes Act or out of pocket as the case may be.’

Mr Munyai wanted to reaffirm the proposed amendment as put forward by the Chairperson – to purchase healthcare services not covered by the Fund. This was in line with the provisions of the Medical Schemes Act.

Ms Clarke stated that there were clauses that made a lot of sense however, the problem was down to implementation. The DA’s view was that many of the clauses were not sustainable nor achievable. Therefore, the DA would not support the Bill at this stage.

Ms Sukers stated that the African Christian Democratic Party (ACDP) did not support the NHI Bill due to the current context and the issues of excess in society. She asked about the right to make ‘reasonable decisions about his/her healthcare.’ How would this relate to children, specifically children below the age of 18 years? In terms of the Children’s Act, many children could make decisions on issues of abortion for example. She asked for clarity on issues of parental rights and informed consent etc, as contained in the Bill.

Ms Chirwa stated that the Economic Freedom Fighters (EFF) rejected clause 6 of the Bill. She did not think the Bill would translate into access for people on the ground.

Ms Ismail asked if NHI would only be implemented once the infrastructure had been adequately upgraded to the necessary compliance requirements. The NHI Bill needed to clearly express that healthcare practitioners would not lose their accreditation if they chose to provide medication that was out of the formulary, where the cost of the medication would otherwise not have been covered by the Fund.

Ms Hlengwa stated that the Inkatha Freedom Party (IFP) went right down to the grassroots level, where South Africans were the poorest. The IFP fully supported the NHI.

Mr Munyai indicated the ANC’s support of the Bill and clause 6, with the slight amendment proposed to clause 6(o) of the Bill.

The meeting was adjourned.


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