Repeal / Amendment of Acts Affected by NHI Bill; with Deputy Minister

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


NHI: Tracking the Bill through Parliament

On a virtual platform, the National Department of Health (NDoH) presented the repeals and amendments that were made to 11 pieces of legislation affected by the National Health Insurance (NHI) Bill. These Acts included Medicines and Related Substances Act 101 of 1965, Occupational Diseases in Mines And Works Act 78 of 1973, Health Professions Act 56 Of 1974, Allied Health Professions Act 63 of 1982, Compensation for Occupational Injuries and Diseases Act, 1993, Road Accident Fund Act No. 56 of 1996, Competition Act No. 89 of 1998, Correctional Services Act No. 111 of 1998, Medical Schemes Act No. 131 of 1998, National Health Act, 2004 and Prevention of And Treatment for Substance Abuse Act.

Some Committee members requested that the Minister of Finance address how the NHI Bill would be funded. They were concerned about the potential non-payment of service providers given the limited funds and entities such as the Road Accident Fund being in financial disarray. They expressed concern that the NHI was being turned into a state-owned enterprise. They wanted amendments so that the legislation was clearer on issues such as the freedom to choose one’s own medical practitioner. Concerns were raised about the constitutionality of the legislation.

The Chairperson said that these concerns would be addressed and time would be set aside for the Department, Minister of Finance and the state law advisers to respond to all concerns raised.

Meeting report

The National Department of Health (NDOH) delegation included Deputy Minister of Health Dr Sibongiseni Dhlomo; Dr Sandile Buthelezi, Director-General; Dr Nicholas Crisp, Deputy Director-General: National Health Insurance; Dr Aquina Thulare, Technical Specialist on Health Economics for NHI; Ms Ntobeko Mpanza, Director of Operations.

Ms Ayesha Johaar, Deputy Chief State Law Adviser, and Mr Theo Hercules, Principal State Law Adviser, were present as was Ms Sueanne Isaac, Parliamentary Legal Adviser.

The Chairperson welcomed the Deputy Minister to the briefing on the Schedule of the National Health Insurance (NHI) Bill which dealt with the repeal and amendment of legislation as referenced in clause 58 of the NHI Bill.

Ms M Clarke (DA) raised a concern about the time the presentation was received. The presentation was sent the night before at 21:15. She asked if documents could be sent earlier as a lot of work and research is required to ensure members could discuss issues in the meetings. Ms Clarke asked for an explanation why the meeting was changed last minute from an in-person meeting to a virtual one.

Ms E Wilson (DA) noted the frustration of several amendments made to notices and the meeting procedure. It was unacceptable that the meeting was said to be in person and attendance was non-negotiable but this was then changed to a virtual meeting at the last minute. Members made travel arrangements to ensure they would be present. It was unacceptable that the presentation was sent late as this was an important Bill. The Bill required a lot of work and Members did not have the opportunity to do this work.

Mr T Munyai (ANC) said perhaps the circumstances were out of the Chairperson’s hands. It was important to be in solidarity with the Chairperson. An opportunity must be given to the Chairperson to explain.

The Chairperson said a notice that the meeting would be in person was sent. However, notification was given two days ago that in-person meetings could not take place as this meant the meeting could not be broadcast to the public. Meetings must be accessible to the public and this was the reason for the Parliament's YouTube and television channels. This also ruled out the possibility of a hybrid meeting and therefore the only option available was a virtual meeting.

The Chairperson said the presentation sent to Members late was not something that was within his control. He hoped Members had enough time to go through the presentation. The meeting was set for the Committee’s regular Wednesday morning meeting. The Chairperson said tomorrow at 17:00 a special meeting would be held to receive responses from the Minister, Deputy Minister and the NDOH on the Bill. This meeting was dealing with the Schedule.

The Chairperson hoped the Committee was satisfied with his response and handed over to NDoH.

Repeal and Amendment of Legislation Affected by NHI Bill
Dr Nicholas Crisp, Deputy Director General: National Health Insurance, said the presentation would go through 11 Acts and their minor and major amendments envisaged as part of the Bill. As discussed in a previous meeting with the Committee the amendments were intended to be concomitant with the implementation of the Act. Different clauses would be promulgated at different times which needed to be taken into account.

The legislation that would be of focus would be the National Health Act. He apologised that a slide on  the Compensation for Occupational Injuries and Diseases Act was left out plus three slides on section 27 of the National Health Act. However, they would be covered during the presentation.

Presentation of Slides 1-12:
Medicines And Related Substances Act 101 Of 1965

Proposed Repeals or Amendments made to:
Section 22G(1)
Section 22G(3)(a)
Occupational Diseases In Mines And Works Act 78 Of 1973
Proposed Repeals or Amendments made to:
Section 36(1)
Section 36A(1)
Section 36A(2)
Section 36A(3)

Health Professions Act 56 Of 1974
Proposed Repeals or Amendments made to:
Section 53(1)
Section 53(2)
Section 53(3)(a)

Allied Health Professions Act 63 Of 1982
Proposed Repeals or Amendments made to:
Section 38A(1)

Mr Munyai agreed with slides 1 and two of the presentation as read by Dr Crisp. On slide 3 he would send a written submission on the aspects he agreed with and those he disagreed with. Mr Munyai said he agreed with the amendment made to Section 22(G)(1) of the Medicines and Related Substances Act 101 of 1965 and the rationale used by the Department.

Ms Wilson said the proposed amendments to these 11 Acts hinged on the NHI Bill being passed. She asked if this meant the NHI Bill should be passed first before these amendments were dealt with. Ms Wilson said public participation was also needed. She raised concern about putting the cart before the horse. The Bill needed to be passed before addressing amendments. 

On the Medicines and Related Substance Act, the assumption was that everyone would be contracted under NHI. Ms Wilson said this would not happen and asked what would be done with those who were not contracted to the NHI as the NHI would be the sole provider under the provision. What would be done in a state of emergency? She pointed to what happened at Livingstone Hospital where people were forced to go.

On the Occupational Diseases in Mines and Works Act, there were a lot of mining clinics and some mines had health facilities which would not be part of the NHI. People went to these facilities without paying but not to pay anything they would now have to go to an NHI-accredited facility, of which there are none. She would not put her worst enemy in these facilities and these facilities did not even meet the NHI accreditation criteria. The Department said employers would have to pay for NHI. She asked how and through what mechanisms employers would pay for NHI. Would it be to an NHI Fund or through an increase of personal income tax and value added tax (VAT)? Ms Wilson said her concern was due to her engagement with a tax expert who made it clear that under the current economic circumstances and growth trajectory unless there was an increase in VAT, with the medico-legal claims, the country would end up with an R108 billion shortfall. This would make this exercise moot because a Bill that was not sustainable and could not be funded could not be passed.
Ms Clarke questioned the major amendments made and asked the state law advisers to comment as public participation needed to be ensured. She asked how the tax would work as NHI would be funded through tax. Employee tax was deducted from employee payslips but what would happen to independent contractors? How would funds be raised for them? Employees earned less than independent contractors however they would take the full brunt of the taxes being raised. Independent contractors who own their own company would be paid a lump sum without a payslip or an Employee Tax Certificate (IRP5) and declared their taxes using the company’s income. However, independent contractors did not contribute to employee tax which was what was being used to fund the NHI. Would an additional tax be added for independent contractors? How would independent contractors be taxed to fund the NHI?
Mr E Siwela (ANC) agreed with Mr Munyai about slides 1 to 3. Public participation had been conducted throughout the provinces and oral presentations were made by stakeholders. Mr Siwela said it would not be proper to have public participation at this stage. The amendments were in order as the NHI Bill included amendments to Acts because they went hand in hand with the Bill. These changes were based on the NHI White Paper that was consulted on for many years. He supported the proposed amendments to Occupational Diseases in Mines and Works Act and Section 22(G)(1) of the Medicines and Related Substances Act.
Ms A Gela (ANC) supported Mr Munyai and Mr Siwela submissions. She emphasised that there had been consultations with the public and saw no need for further public consultation. Ms Gela said perhaps her colleague did not understand. Mr Siwela indicated the Committee could make the amendments. Ms Gela supported the Department’s presentation thus far. She supported the proposed amendments to the Occupational Disease in Mines and Works Act and the Health Professions Act. 
Ms N Chirwa (EFF) said she was under the impression the Department would be responding to the concerns raised by the Committee in the previous deliberations about the affected legislation. 
The Committee had been told that the Department was attending Committee meetings and taking note of the concerns raised. However, the presentation did not cover most issues raised. 
Ms Chirwa wanted to know when the Department would respond to the issues the Committee raised about the legislation. The Department’s response that the Bill was constitutional was insufficiently detailed. A Department response was necessary to ensure that the previous deliberations were not useless, especially because the legal team was also involved in the raising of these issues. Her second concern was that the NHI referral system would subject people to the same hospitals they had been going to; however, these hospitals would now be without a budget as the budget would be moved to the private sector. This concern needed to be addressed as the hospitals in townships were not ideal and did not meet the NHI criteria. 
Ms Chirwa asked what the Department’s response was to the fact that most township and rural hospitals did not meet and would never meet the NHI criteria. The NHI would take funds from the public sector to the private sector because the private sector would not have time to debate the government on payment systems. Government would have to pay or people would drop out. 
She asked what would happen to private facilities that did not apply to be a part of the NHI. Who would cater to the development of infrastructure in the public sector if funds were centralised around paying the private sector for their services? The private sector would not be forgiving about non-payment because they do not or about integrity but profit. Ms Chirwa said the Department was avoiding very important conversations which strengthened the claim that this was an ANC money laundering scheme that they needed to be wary of. 
She said the EFF had written the Chairperson a letter when Mr Tito Mboweni was still the Minister of Finance requesting that the Finance Minister needed to address the Committee on all the funding concerns. Ms Chirwa asked to make this request again because there were gaps and the Department’s presentation did not adequately address funding concerns. 
Mr Munyai raised a point of order and said the NHI Bill was a Bill before Parliament and not an 'ANC money laundering scheme'.
Ms Chirwa responded Mr Munyai should have just kept quiet.
The Chairperson asked Ms Chirwa to continue. 

Ms Chirwa asked the Chairperson to respond favourably to what the EFF wrote. They wanted to know how the funding would work given the challenge faced by the Committee due to the NDOH being unable to tell the Committee how much everything would cost. The Committee had raised numerous financial concerns. 
During deliberations on the NHI funding and how the establishment of certain bodies would be undertaken given the current purse deficit, these concerns were not answered. A response from the Minister of Finance was needed. Although the EFF disagreed with the NHI, this concern needed to be addressed to ensure the health system was not overburdened – despite it having already been collapsed by the ANC. They could not let this happen without contesting and confronting those in charge of this.
Mr N Xaba (ANC) supported the submission by Ms Gela and the Department presentation. He clarified that this was government work, not ANC work. 
Ms Clarke agreed with Ms Chirwa and said she had written a letter asking for the Minister of Finance to present on the financial aspects of the Bill to the Committee. However, the letter was not responded to. She did not see how a Bill could be implemented when the Committee did not know how it would be funded. Asking for the Minister of Finance to present to the Committee was a fair demand. 
Ms Clarke said it seemed as though the ANC members had received the presentation before the other Committee members who therefore had less time to work on the presentation.
Mr Munyai raised a point of order and said Ms Clarke was alleging that the ANC members did not receive the presentation at the same time as other members. He asked her to retract the statement.
Ms Clarke said it was a question.
The Chairperson said if Ms Clarke meant it as a question she should have phrased it as one. 
Ms H Ismail (DA) highlighted that the Committee had raised many concerns for which they requested comment from the legal advisers. These were being discussed again. It would only be fair that before they proceeded to the next step of the discussion that the comments from the state law adviser were heard. 
She said the funding concerns had been raised many times and noted that the presentation was received late. They would have appreciated feedback on their queries before the deliberations in the current meeting took place. Ms Ismail asked the Chairperson if he could arrange this. 
Ms Ismail said that the impact on taxpayers was becoming more and more worrisome as the burden would be carried by the taxpayers. She asked how this would work considering the high unemployment rate in this country. 
The state of the country’s public healthcare facilities means the discussion of the NHI Bill did not make sense because most public hospitals did not meet the compliance criteria in the NHI Bill. The basics needed to be addressed first. The Department needed to tell the Committee how far along they were and how these issues would be fixed and the solutions implemented. They were currently looking at an NHI Bill that would drain and overburden the public healthcare system which was already strained. 
The Financial and Fiscal Commission (FFC) reported that fewer and fewer of the country’s clinics were reaching ideal clinic status.
Mr Xaba said the matter was a health not a finance concern. However, the issue was the Bill required major sources of funds which taxpayers were expected to pay despite the failing healthcare system. This matter was a financial concern because the NHI meant looking at the billions of rands that would impact taxpayers.
Ms Gela said it seemed as though her colleagues did not read the presentation and were not taking the work seriously. Even if the presentation was received late, Members were still required to read and prepare for the meeting.
Ms Chirwa spoke but it was in a different language (1:16:51)
The Chairperson noted Ms Wilson’s point of order and asked Ms Chirwa to raise a point of order if she wanted to speak. 
Ms Wilson said Ms Gela was out of line and the Committee was dealing with an important Bill. This meant critical work needed to be done. However, this work could not be done when the presentation was sent at 21:30. Some Members needed to catch early flights and did not have access to the necessary information. Ms Gela’s comment was unacceptable and unfair. 
The Chairperson agreed with Ms Wilson and asked Ms Gela to withdraw her comment.
Ms Gela withdrew her comment. 
Ms Gela said although the presentation was received late the Member knew there was a meeting today. It was indicated last week that the Committee would continue the work on the Bill and that there would be a debate in Parliament on the Bill. They should have continued with the work as agreed upon last week and focus on the Bill's schedules. 
Ms Chirwa said Ms Gela should realise that men would throw her under the bus despite her defending them always. They would forget that Ms Gela was a part of the same party and have her withdraw. Men were not good. 
The Chairperson said he was unsure why this became a sexism issue. Ms Chirwa could perhaps explain this one day although he thought she was incorrect. The Committee should not get sidetracked from what they were there discussing. The Chairperson had said in his closing remarks last week that the Department would brief them on the Bill schedule in the current meeting. This was the Committee's regular meeting time which had been the same for the last three years. There was an order to the way things were done. The request for responses from the Department would be dealt with in the meeting scheduled tomorrow evening at 17:00. The Minister, Deputy Minister and Department would be present at this meeting. On the request for responses from the state law advisors, there was a scheduled time for state law advisers and Parliament's Legal Services to address legal concerns. The order of events was the schedules today and the next was for responses from the Minister, Deputy Minster and the Department. This would be followed by the summarised matrix of public hearing and political party submissions. The Chairperson reminded the Committee to forward their submissions on the Bill to the secretary. Feedback would then be received from the legal advisors and after this, there would be a discussion on the A list and B version of the Bill. The A list and B Bill would be compiled by the Committee Secretariat, content adviser and researchers. 
After the completion of the A list, the Committee would be looking at the Memorandum on the Objects at the end of the NHI Bill. This was required by the rules of Parliament. The Chairperson hoped that Members understood where they were going and asked them to be a bit more patient with all of this. He noted that members of the public were not allowed to participate in the meeting it was for members of the Portfolio Committee only.
Dr Harvard agreed with the proposed amendments and rationale by the Department on the Occupational Diseases in Mines and Works Act and the Health Professions Act.
Presentation of Slides 13-20:
Compensation For Occupational Injuries And Diseases Act, 1993 (COIDA)

Proposed Repeals or Amendments made to:
Section 1
Section 16(a)
Section 42(2)
Section 42(4)
Road Accident Fund Act No. 56 Of 1996
Proposed Repeals or Amendments made to:
Section 17(4)(a); (5) & (6)
Section 17(4)(b) & (c)

Competition Act No. 89 Of 1998
Proposed Repeals or Amendments made to:
Section 3(1)(b)

Correctional Services Act No. 111 Of 1998
Proposed Repeals or Amendments made to:
Section 12(1)
Section 12(3)

Mr Munyai said he looked carefully at what Dr Crisp presented on slides 16, 17 and 18. He agreed with what was proposed in these slides. He would send the ANC submission on this.

Ms Wilson said there was a lot in the presentation that did not make sense to her and needed to be digested. The amendments to the Competition Act would not be accepted under any circumstances. Getting into those kinds of clauses would mean the NHI would be turned into a state owned enterprise (SOE) which would not be allowed. Ms Wilson said they also would not be accepting the use of “in the public interest” which was sometimes used under the Competition Act. They did not want another SOE as the country could not afford it. This Fund would be running out of money as it was unsustainable. On the correctional centre inmates, she would love to know what they were getting now and how this Bill would change things for them. They were looking at amendments that could not be made until the NHI was passed and this was still a long way away. She understood the procedure but this was putting the cart before the horse. She noted that it was frustrating because the Bill had not been passed and they did not know how it would be funded. The Road Accident Fund (RAF) was bankrupt and therefore amendments were being made to a Fund that barely existed. This was being done without stakeholder participation which they were going to insist on because this was going to end up in a court of law.

Mr A Shaik Emam (NFP) asked for clarity as it was obvious the Fund would be limited in terms of resources. What would be the case if funds were exhausted and services providers could not be paid – especially considering the 30-day payment rule and this could impact the services that the service providers provide. He asked what the position would be when service providers refused to provide services due to the lack of payment. What would happen to the people who needed these services? Mr Shaik Emam expressed concern with the implementation of this Bill. The RAF was bankrupt and would not be paying anything. What would this mean for patients who wanted the service. Would they still be covered?

Mr Xaba said the Department presented well and he supported it and Mr Munyai’s comments. Mr Munyai also outlined that the ANC would be making a written submission.

Ms Clarke said there were material amendments being made to legislation particularly the Road Accident Fund Act and the Compensation for Occupational Injuries and Disease Act (COIDA). Ms Clarke asked the state law advisers to provide an opinion if they thought these amendments required public comment as they were a big impact on current legislation. These amendments were not just aligning definitions for the NHI; they were material.

Ms Clarke said that the COIDA amendment concerned changing the definition of compensation. With top-up medical aid still being allowed under NHI would that have any bearing on the definition? What would happen if treatment was not provided in terms of the Fund?

Amendments to sections 16 and 42(4) allowed any medical practitioner of their choosing. What would happen if the chosen medical practitioner was not registered under NHI? This question was raised during the NHI Bill deliberations.

In terms of RAF what would happen where medical procedures were required that would be ordinarily covered under medical aid but were now not covered under the NHI? How would payment work now? Would the RAF not cover a previously covered injury? Ms Clarke asked for clarification.

The sentences on slide 17 made no sense with the removal of the word tariff. She asked for clarity on this. In Section 12 of the Correctional Services Act where the person may be allowed a medical practitioner of their choice. What would happen if this practitioner was not registered with the NHI Fund?

Ms Gela supported Mr Munyai's submission and Dr Crisp’s presentation. On the RAF Act, the ANC commended the amendments made to sections 17(4)(a); (5) and (6). The ANC noted and agreed with the removal of the 'tariff' in the RAF Act and there should only be one tariff in the entire Health System. The ANC was concerned that the RAF tariff was very high; it was higher than that of medical aid schemes. This high tariff was responsible for the financial challenges faced by RAF. The NHI tariff needed to be standardised to avoid the same financial challenges faced by the RAF. 

Mr Siwela supported the contributions made by Mr Munyai, Mr Xaba and Ms Gela. It had been said many times but he reiterated that the NHI was not an SOE but a Schedule 3A entity like the Council of Scientific and Industrial Research (CSIR). These public entities are structured with a governance model that leads mostly to unqualified audits by the Auditor-General. 

Ms Chirwa asked about being allowed to get a health practitioner of one's choice and a second opinion that would not require monetary payments as it would be covered by NHI. In the freedom to choose a medical practitioner, were the choices limited under NHI and if so the amendments needed to state this limitation because the legislation needs to reflect what is truly going on. She asked if medical practitioners who were not registered with the NHI could be chosen and compensated by the NHI. If this was not the case, the Bill should reflect this to avoid confusion or false illusions about unlimited choices. She asked what would happen to a complainant who was not registered with NHI in terms of these amended Acts. She requested if these particular amendments could be made to resolve these questions.

Mr Xaba clarified that the ANC supported the amendments to the Competition Act amendments to section 3(1)(b). The amendment exempted the operations of the NHI Fund from the Competition Act. This ensured the Fund as a Schedule 3A entity was not subject to market whims and its operations were seamless. The ANC supported slides 19, 20 and 21. He also supported the submissions made by Mr Siwela, Mr Munyai and Ms Gela. The NHI was for the people.

The Chairperson supported the deletion of Section 1(11) of COIDA where it was suggested that the second half of the definition of 'compensation' should be deleted. He supported the deletions made to sections 16(a) and 42(2) of COIDA. He supported the submissions made by Mr Xaba, Mr Siwela, Ms Gela and Mr Munyai.

Presentation of Slides 21 - 52:
Medical Schemes Act No. 131 Of 1998

Proposed Repeals or Amendments made to:
Section 1 Definitions (a); (b) ; (c) & (f)
Section 2(1)
Section 24(1)
Section 33(1)

National Health Act, 2004 (No. 61 Of 2003)
Proposed Repeals or Amendments made to:
Section 1 Definitions
Section 21 (a)&(b)
Section 21(d)
Section 21(2)(m)&(n)
Section 21 (2)(m)-(q)
Section 21 (2)(r)
Section 21(5)(e)
Section 25(2)(a)-(l)
Section 25(2)(n)-(s)
Section 25(3)
Section 31(2)(a)
Section 5(b) & (c)
Section 31(1)(2)&(3)(a-d)
Section 31(3)(f-m)
Section 31A(3)(n)
Section 31A(4)
Section 31(B)(1)
Section 31(B)(2)
Section 31(B)(3)
Section 31(B)(4)
Section 31(B)(5)
Section 31(B)(6)
Section 41(1)(a-b)
Section 41(1)(c-d)
Section 41(2-3)
Section 90(1) & Section 90(1)(b)(i)
Section 90(1)(d)
Section 90(1)(e)

Prevention Of And Treatment For Substance Abuse Act No. 7 Of 2008
Proposed Repeals or Amendments made to:
Section 7(1) (a) &(c)
Section 7(2)

Ms Gela supported the presentation. The ANC supported amendments made on slide 23 on the definition of relevant health services. Under the NHI, medical schemes would only provide complementary cover. She agreed on the reference in the Medical Schemes Act to private institutions as the only providers of complementary, nursing and midwifery services needed to be amended as there were providers in the public and NGO sectors who could provide these services.

The amendments to the role of the national and provincial government were consistent with the restructuring process under the NHI. The national and provincial governments had concurrent functions as reflected in the proposed amendments to the Medical Schemes Act. Ms Gela supported the amendments because they treated pregnancy services as part of the NHI package. This country had a free care policy for pregnant women and children under six years. The NHI would extend these services by making them available to all. These services would be provided by the NHI. The public and private sectors would both be part of the NHI and therefore not be listed separately which is why the deletion was being made. 

Ms Clarke said the changes made to the Medical Scheme Act relating to clause 33 of the NHI Bill needed to be addressed before amendments could be made to the legislation. In terms of slide 23, it was not necessary to ring-fence health services. The Committee needed to know what these health services are as to date no list of procedures allowed by the Fund had been made available. The Committee needed to know what treatments were available, especially those involving women’s bodily integrity.

On slide 23, subsection (f) and the removal of 'private', what would happen in cases where the Fund did not provide a particular service? She asked if this removal of 'private' would affect the receiving of procedures from service providers that were not registered with the NHI.

On slide 24, this Act should still not apply to government medical aid which provided a top-up as per the state’s explanation. Medical aids would offer complementary cover.

On slide 26, clause 33 raised serious constitutional concerns about access to healthcare and a medical aid's freedom of trade, occupation and profession as well as freedom of association. If this clause was unconstitutional this meant the amendment was void. She asked for clarity on this.

Mr Xaba supported the Department’s presentation and Ms Gela’s submission. On slides 21 to 26, the ANC supported the presentation and noted that the objective of the NHI Bill was to provide universal access to quality health as enshrined in the Constitution. The NHI Bill aimed to achieve the objective by ensuring no one would be deprived of their rights because of their socioeconomic status. The public health fund had adequate resources to effectively meet the health needs of the entire population, not just a select few. To avoid fragmentation there would be one funding pool for healthcare for both the public and private sectors. The South African healthcare system was currently the most expensive in the world. Through this Bill, this cost would be reduced. Visits to health facilities will be at no cost as the NHI Fund would cover the costs in the same way medical aids cover costs for their members. This Bill would narrow the gap between the rich and the poor in the standard of healthcare received. People will not need to be a part of a medical aid scheme to receive quality healthcare. Recognising the provision in clause 33, the Medical Schemes Act must become subordinate to the NHI as schemes will progressively only cover for complementary services whilst the NHI Fund would cover comprehensive healthcare. 

Mr Munyai agreed with the Department presentation up until slide 40. The ANC would be making a submission on what it agrees and disagrees on. Slide 21 dealt with the general functions of the Department in sections 21(2)(a) and (b) and the ANC supported the movement of the function to the National Department. This was because it assisted the Department with a disparate information system that currently bedevilled the healthcare system. The ANC supported the responsibility of healthcare system norms and standards being in the domain of the NDOH as this would ensure the Department was empowered to provide information on the norm and stands of the healthcare system where required. In section 24(1) on the registration of medical aid schemes, the ANC supported the amendment and proposed the addition of “the provision of the National Health Insurance Act 2019”. This was because once the NHI was operational they would not delay waiting for the changes made to the Medical Schemes Act before its implementation. South Africans had been waiting for the NHI for far too long and implementation did not need to be delayed further. The ANC agreed this insertion in this Schedule meant that integration of the public and private sectors could happen faster. 

Mr Siwela supported the contributions made by Mr Munyai and Ms Gela. The ANC supported the amendment on slide 29 which included health services rendered through the District Health Management Office (DMHO) as a structure to be coordinated at the national sphere in pursuit of the national health system.

Ms Wilson had many questions, particularly about medical aid schemes. By taking all these things out of medical aid schemes they were severely constraining resources and sending more people into a severely constrained public health sector. This was not sustainable and the medical amendments would deprive people of their constitutional rights to bodily autonomy. Discussions were being had on amendments but it must be noted that the moment these amendments were passed they would become immediately actionable. However, the NHI Bill had not been passed and the first stage had not begun which would take five years. The first stage would also involve the establishment of committees and bodies. No one even knew where the Minister would find time to do all of this. All of this needed to be concluded before the basics such as suppliers, services and the cost of these services were in place which would take seven, eight or nine years. This would mean the moment the amendments were passed before the NHI was in place a situation would be created where those who were affected by these changes would not be able to perform because of the sudden changes in the law. This would mean these people would be acting out of the bounds of law in other words illegally which simply did not make sense. 

The District Health Management Offices would be established as National Department components. This would strip provinces of their power to finance and plan for District Health Services and give these powers to the Minister. The amendments further stipulated that the DHMOs must establish contracting units that would receive funds determined by a formula from the NHI to contract primary care providers. This creation of government components could not be done without a feasibility study. No feasibility study had been presented. This was putting the cart before the horse. The Committee was being made to approve or disapprove amendments with nothing to work from expected pie-in-the-sky ideas put together by a team that said the NHI would solve all the challenges the country’s healthcare system faced. The NHI would not solve the issues the healthcare system faced but instead make them worse because the Department was working from nothing and provided no evidence as to why these legislative amendments needed to be made. There was no feasibility study and the NHI Bill was becoming laughable.

There was a back-and forth-between Ms Gela and Ms Wilson.

Ms Harvard fully agreed with the amendments presented on slides 25, 26 and 28. The ANC agreed that the Correctional Services Act should provide for the application of the NHI Act and no inmates should pay because this ensured equity. The amendment to definitions in sections 1(a), (b) & (c) of the Medical Schemes Act was to ensure there was no duplication between medical aid payments and NHI. NHI would cover all services provided by the public and private sectors so there would be no need to cover the same services. The ANC was in full support of the amendment and the rationale the Department used for the refined definition of the health agency in slide 27. Without the revision, it would be impossible to categorise the NHI Fund as a health agency. She supported the submissions made by Ms Gela, Mr Xaba, Mr Siwela and Mr Munyai.

Mr Xaba spoke to slides 30 to 32 concerned with the general functions of the National Department of Health. The ANC supported the inclusion of the functions of planning for the development of the public and private health establishment. This gap was identified during the Health Market Inquiry and the Department was implored to exercise its responsibility in this area. The Committee need to remember that the state currently contributed to medical aid programmes for public servants including Committee members and this Bill ensured that all South Africans gained access to good healthcare through the NHI. Medical aids needed to provide services that complemented but did not duplicate those of the NHI. If the system was kept the same it would mean the inequality between the healthcare received by those with resources and those without would remain. Mr Xaba supported the submission made by Ms Gela, Ms Harvard and Mr Siwela.

Mr Munyai said the ANC called on the Department to defend the equity of hospital infrastructure as opposed to when the budget sat with provinces. This change would assist the National Department in planning for health infrastructure.

Ms Gela apologised to Ms Wilson and said that her microphone was accidentally unmuted and what was said was not about Ms Wilson. Keeping the status quo was being defended which meant the exclusion of those who contributed to Members' healthcare benefits. She asked what was unconstitutional about making healthcare accessible to all. The ANC supported the amendment proposed on slide 30 that the responsibility of managing the costs and financing of health establishments and their infrastructure would be the National Department's. This would ensure the Department would have direct control over the management of infrastructure costs. They believed that this was one of the most important reforms that amendments to the National Health Act would bring to the healthcare system. 

Ms Gela supported the submissions made by Ms Harvard, Mr Munyai, Mr Siwela and Mr Xaba. As the ANC they were focused on supporting the Department and serving the interests of South Africans. During public consultations, the public made it clear that they wanted the implementation of the NHI as soon as possible.

Ms Ismail said that presently healthcare was provided to all. The unconstitutionality was the removal of the freedom of choice. This was because the healthcare system was a failing system with decaying infrastructure and a shortage of staff. The reality was that whilst saying the system needed to be improved using the NHI, there was no indication of how this would be funded. There was no feasibility study available. The provision of healthcare by provincial departments was stated in the Constitution. The amendment of these things without concrete facts that would show how this would be viable, means the NHI will not work. This discussion did not make sense because people currently had the right to choose where to go and if they wanted medical aid. They were aware of the unemployment rate and they needed to get these things right first. They needed to ensure that there was an environment for investment and employment opportunities. That was how equity could be reached through people being employed who could afford to pay for medical aid. Shoving the NHI Bill down their throats was not going to work. Everyone had the right to make contributions on what they agreed or disagreed about in the Bill. The fact remained that the healthcare system was fractured currently and looking at amendments before a financial feasibility study was looked at, put the cart before the horse.

The feasibility study was needed so that the Committee could know what services would be provided because at the moment everything was abstract. This was unconstitutional and did not make sense.

The Chairperson said the principles informing the amendments were reflected on slide 2. The amendments were there to enable and support the transitional arrangements as indicated in Section 57. This schedule was part of the Bill and therefore should be treated in the manner the Committee was treating it.

The Schedule amendments reiterated the provisions of clauses 8 and 31 of the NHI Bill. The amendments were based on the principles that underlie the establishment of the NHI Fund in clause 9. The amendments intended to ensure that the NHI Bill would be implemented properly over a period of time - and this applied to the Schedule too.

The ANC supported the addition of the function to develop a national policy framework for procurement and use of technology. It supported developing guidelines for the management of health districts and controlling the quality of healthcare facilities. These amendments would ensure all these functions were implemented in an integrated and unified manner. The amendments to COIDA ensured there would be no fragmentation in funding. 

Mr Xaba supported the Chairperson's submission and said the ANC supported the proposed amendments in slides 33 to 36. Clause 25(2) would ensure the functions that were moved were allocated appropriately so the health system was effective and achieved the objectives of the NHI. He supported Ms Harvard’s submission.

Chairperson’s closing remarks 
The Chairperson thanked Dr Crisp for the presentation and said that they would continue tomorrow evening at 17h00 to finish this section of the schedule. The Minister and Department would then be allowed to respond in tomorrow’s meeting. He asked the Committee to consider tomorrow’s meeting starting at 17:00 and ending at 21:00 to ensure there was enough time for the Minister to respond. an indication had been given to the Committee in terms of the direction of the Bill and the work the Committee still needed to do. The Chairperson said he hoped the Committee understood what work was left for them to do over the next few weeks to not spend time on questions about the processes that need to take place. 

The Chairperson thanked the Department, state law advisers, legal services from Parliament, members of the Committee and all those who were in attendance for their time.

The meeting was adjourned.


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