NHI Bill: Health Minister's response to comments

Meeting report

Chairperson’s opening remarks
The Chairperson said the National Department of Health (NDOH) would complete its briefing on the Schedule of the National Health Insurance (NHI) Bill. Thereafter, the Committee will get a response on the public hearings and the clause-by-clause deliberations, led by Minister Dr Joe Phaahla.

Schedule of the NHI Bill – repeal / amendment of Acts affected by NHI Bill
Dr Nicholas Crisp, NDOH Deputy Director-General: NHI, completed the presentation from yesterday (see document).

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)

Discussion
Mr T Munyai (ANC) said that he supported these 100%. He repeated the ANC comments from yesterday on the reasons it supported the amendments to section 21(a) and (b) of the National Health Act. 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.

The ANC is in agreement that Clause 31(B)(2) should be moved to Clause 37 of the NHI Act, to ensure that the Fund has the mechanism for contracting for the primary healthcare services, including prevention, promotion, curative, rehabilitative, ambulatory, home-based care and community care, and to ensure that the purchaser-provider split is adhered to.

Ms M Clarke (DA) said that there are constitutionality concerns with the national sphere taking over the provincial constitutional framework. There are still a number of queries on Clauses 20(2)e(ii); 32(2)(c); 36(1)(c); 38(3)(e & f); and Clause 55(1)(l), which need to be answered before considering these amendments. Clause 37 still has queries that need to be answered before this can be considered, as the provincial framework is replaced by control being given to the national level.

There are a number of concerns on the funding, particularly with how each contracting unit would comply with its responsibilities when funding of health care is not yet guaranteed or known. She had read through the Davis Tax Committee report, which stated that by 2025/26, R71.9 billion would be the NHI shortfall, assuming a GDP growth of 3.5%. So, it is really important that the funding model is addressed going forward.

Mr N Xaba (ANC) said that the ANC supported the amendments for section 25(2). It is important that the functions that have been moved from the province to national will ensure that these functions are allocated to the appropriate level of the health system, to ensure efficiency and effectiveness to achieve the objectives of the NHI.

The ANC strongly support the decentralisation of health care services through the District Health Management Offices (DHMOs).

Ms A Gela (ANC) said that the ANC supported the amendments in slide 30, where the NDOH is given the responsibility of the controlling and managing the cost and financing of health establishments, including all infrastructure. This will ensure that the NDOH has direct control over how cost of infrastructure is managed. The ANC believes that this is one of the most important reforms that the amendment to the National Health Act can bring to the country’s health system.

Ms E Wilson (DA) said that she obviously had concerns, some of these were raised yesterday, particularly on the DHMOs which will be established as national government components. Generally, one does not establish components without a feasibility study. Her second concern is that the amendments are clearly taking away the constitutional mandate of the provinces, which is very concerning.

She referred to slide 43 and 44 and questioned why the amendments were made to the National Health Act that already has such provisions. The health system should know what the demographics of districts are, it should know what the burden of disease are in certain areas, it should know what the shortfalls are, this should have been known a long time ago, but now all these things are added to the Act. Her biggest concern is that the amendments are placing a layer on top of a layer of structures, it is a board for this and a board for that, a unit for this and a unit for that. This will be hectically expensive and it is not sustainable. Creating more and more structures will make the management of health care 10 times harder. When there are too many structures, that is when disaster hits. And that is when people get away with things that they should not do.

She asked if these amendments to 11 Acts have been communicated to the relevant Portfolio Committees. For example, have there been discussions with the Portfolio Committee on Transport, on the amendments to the Road Accident Fund Act? There are many layers to the Road Accident Fund, which is going to be challenged by these amendments. If not, why the cart is being placed before the horse? This Committee would need the engagements and opinions of those Portfolio Committees. However, it seemed this Committee was going ahead as if it has carte blanche but it does not.

These amendments cannot be allowed to be dumped into an A-list and passed because these are serious amendments. She was concerned that the Committee was discussing amendments without having gone through the appropriate participation process and stakeholder engagements. She needed assurance that these processes will be followed appropriately.

These amendments cannot be considered until the NHI has been brought into operation because if the amendments are passed then it ties the hands of business, health and other sectors.

Ms Gela raised a point of order. She had heard Ms Wilson say that this meeting was not the proper Portfolio Committee to deal with this. She does not know if Ms Wilson was confused. The Chairperson must correct this as this was the proper Portfolio Committee to deal with the NHI.

The Chairperson replied that sometimes certain statements are not worth bothering about. Sometimes wrongful statements are made that might not necessarily be of concern. It does not necessarily mean that one responds to everything. Sometimes certain statements are made by people which do not require one to react, this was one of them.

[Ms Wilson and Ms Clarke raised points of order]

Ms Wilson said that she had said nothing of the sort. She respects this Portfolio Committee and what it does, she takes it very seriously. All she had said was that this Committee must be assured that the legal procedures would be followed. Never at any stage had she said anything about the Portfolio Committee or what it can do. Never at any stage had she said that this is not a proper meeting. She is participating like every other Member, because it is a proper Portfolio Committee, if she felt that it was an improper meeting then she would not be there.

The Chairperson said that Ms Wilson’s point was well taken.

Ms Clarke felt that Ms Gela should withdraw her statement. Ms Wilson had raised an issue that the legislation affected by the NHI Bill would need to be discussed by the relevant Portfolio Committees. At no stage did Ms Wilson say that this is not a proper Portfolio Committee meeting.

The Chairperson said that Ms Gela had now heard what Ms Wilson and Ms Clarke had clarified. He asked Ms Gela if she would be willing to withdraw her statement.

There was no response from Ms Gela.

The Chairperson said it appeared that Ms Gela had lost connectivity. He asked to continue.

Ms X Harvard (ANC) supported Dr Crisp’s presentation. The ANC supported the refined definition of “health agency”. Without the revision, it would be impossible to categorise the NHI Fund as a health agency. She supported the submissions made by Mr Munyai, Mr Xaba and Ms Gela.

Mr E Siwela (ANC) supported the contributions of Mr Munyai, Mr Xaba, Ms Gela and Ms Harvard. The ANC supported the creation of the DHMOs to support the activities of the Fund. The ANC supported the establishment of Contracting Units for Primary Health Care (CUPs) in Clause 37 of the NHI Bill. The ANC is in agreement that section 31(B)(4) should be migrated to Clause 37 of the NHI Bill.

The ANC agrees that health human resources should be the responsibility of both the national sphere and the DHMOs. The ANC believes that this amendment would ensure that the current challenges experienced in human resource planning, development and management, will be planned at both national and at the district level in a decentralised manner. This will allow proactive planning for HR needs in a decentralised fashion.

Mr Siwela noted that the Bill has been consulted publicly. Everyone who wanted to make comments was given plenty of time to make comments. This Committee received those comments and dealt with them. This Committee should not be misled that the NHI Bill was not consulted on.

Ms H Ismail (DA) raised the moving of the mandate of provinces to national. The functions of the provinces are the second most important mandate of provinces, and moving these functions from provinces is unconstitutional.

She referred to the National Development Plan (NDP) 2030, where the weakness of government has been noted with associated recommendations. It clearly states “The public service needs to be immersed in the development agenda but insulated from undue political interference”. She had quoted this because the NHI is clearly providing more and more powers to the Minister. The NHI allows way too much power to the Minister and thus allows more political interference, which needs to be done away with.

She agreed with Ms Wilson about the Acts amended by the NHI Bill that fall under the mandate of other Portfolio Committees. It is important that the inputs from these Portfolio Committees are heard. This Committee needs to do away with working in silos and consider those inputs.

Dr S Thembekwayo (EFF) referred to section 31(2)(a)(iv) of the National Health Act on the establishment of district health councils. It states that a district health council consists of not more than five other persons. The very same clause is followed by the phrase 'promoting community participation'. That number is very limited. She asked if community members were included in the district health councils, if not, then an amendment should be made to double this number, from five to ten, to accommodate community member participation.

She wished that Dr Crisp was with the Committee on its oversight visit to the Eastern Cape. Based on what the Committee had seen in Eastern Cape, district health management is not able to run as it is right now, it is just a collapse. To add amendments that give responsibility to the DHMOs would collapse the Department even more that it currently is. There is no way that the EFF would accept this discussion on the proposed amendments. The NDOH should first pause and rectify what needs to be rectified in the Department throughout South Africa, and then come back and consider these proposed amendments.

Mr Xaba agreed with Mr Siwela that the Committee had consulted on the NHI Bill. He supported the point Ms Gela had raised. The ANC is not available to comfort the EFF or the DA; the ANC is of service to the people.

Mr Munyai supported the amendments in slide 30 on the NDOH being given the responsibility of controlling and managing the cost and financing of health establishments, including infrastructure. This will ensure that the NDOH has the direct control over how the cost of the infrastructure is managed. The ANC believed that this is one of the most important reforms that the amendments of the National Health Act can bring about to the country’s health system. He supported all the inputs from the other ANC Members, and agreed that the NHI Bill had been consulted on.

The Chairperson said that it is generally understood that the NHI would be implemented incrementally. The ANC supported the additions which were made about the functions of developing the national policy framework on procurement, the use of health technology, development of guidelines for management of health districts, assisting the DHMOs in controlling quality in health facilities. It is vitally important that these functions be done correctly and that these additional functions are mentioned. The amendment would also ensure that these functions are implemented in an integrated and unified manner.

National Health Act, 2004 (No. 61 of 2003)
Proposed Repeals or Amendments made to:
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)

Discussion
Mr Munyai supported all the amendments that Dr Crisp had presented. The NHI is the way to restructure the healthcare system to make it efficient and HR equipped so people can receive quality care.

Mr Siwela agreed that the NHI is indeed the way to restructure the health system. The ANC supported the proposed amendment to section 41 of the National Health Act in adding the DHMOs to determine the range of healthcare services delivered at health establishments. This will ensure that a decentralised platform is directly engaged in the determination of the services.

Ms Wilson asked if the proposed amendments to the Prevention of and Treatment for Substance Abuse Act have been discussed with the Portfolio Committee on Social Development, and if they have made inputs.

Mr Xaba supported Mr Munyai and Mr Siwela’s comments. The ANC supported the amendments of section 7(1)(a & c) of the Prevention of and Treatment for Substance Abuse Act. The fragmentation of funding must be prevented. The NHI Fund is the single purchaser to ensure equity.

Ms Gela supported Mr Munyai, Mr Siwela and Mr Xaba’s comments. The ANC supported the proposed deletions of section 41(1)(c-d), this will no longer be applicable as service will be delivered for free at the point of care under NHI.

Ms Ismail said that the Committee had heard about the funds for the NHI over and over again. Where would the money come from? How much monies are needed and where is the financial plan for all of this? Where was the updated financial feasibility study to ensure there are monies for all of this? There is not enough money in the fiscus, the unemployment rate is high. There is no logic to all of these plans.

She reiterated that this Committee is working in silos and agreed with Ms Wilson that the Prevention of and Treatment for Substance Abuse Act falls under the Portfolio Committee on Social Development.

Ms N Chirwa (EFF) asked if the proposed amendments to the Prevention of and Treatment for Substance Abuse Act are solely limited to Western medical intervention. She had asked this, because traditional healers were raised quite strongly during public consultations across the country. There are many traditional medicine interventions in communities on the ground. The NHI does not cover that particular group. She asked what particular amendments include the coverage of traditional healers and their facilities, that are valid medical intervention methods in the country, particularly for black people. This was a relevant question because the primary problem is that the NHI would take money from the public and flood it into the private sector, and then claim to be ushering a one-tier system, when in fact government is outsourcing services from the private sector. The indigenous methods of medical intervention are ignored by government and the NHI.

This particular matter of the prevention of and treatment of substance abuse cannot be ignored because it is happening in the communities. It is happening in silos without the support of government. Besides indigenous methods, there are also other interventions such as non-governmental organisations (NGOs), ground-up facilities and grassroot activists who are fighting the scourge of substance abuse, who have valid methods of intervening. She referred to the particular matter of prevention, because it is unfortunate that the current healthcare system speaks of prevention when someone is already in the hospital, that is not prevention. The current healthcare system is curative not preventative.

She followed up on the EFF request for the Minister of Finance to come before this Committee to appraise the Committee on what the feasibility study is and how government plans to fund the NHI. The EFF requested actual numbers and not what has been heard so far which is very vague and all over the place. She recalled that this is the same reason why the National Health Amendment Bill was rejected, as there was no tangible feasibility study. This is the same case with the NHI Bill. It has been proven time and again that there is no financial plan, financial method or financial feasibility study that encapsulates each and every aspect that has to be discussed. The Minister of Finance has to account about these concerns as he would oversee the financing of this healthcare model.

Ms Harvard said that the ANC supported the proposed deletions in section 41(1) (c-d) of the National Health Act, as all services would be delivered free at the point of care.

The ANC supported the deletion of section 7(2) of the Prevention of and Treatment for Substance Abuse Act, as the NHI would provide cost coverage for all costs necessary for treatment. She supported the comments made by Mr Munyai, Mr Siwela, Mr Xaba and Ms Gela.

Ms Clarke said that the DA opposes in its entirety the Schedule of 11 Acts amended by the NHI Bill,. The NHI Fund would be a single purchaser and a single payer, which the DA does not support. The DA believed that the NHI Fund should be accountable to Parliament for true transparency. It is believed that Parliament should be the accounting body, instead of the Minister being given far too much power to deal with these issues.

She informed the Chairperson that her colleagues in the Finance Standing Committee and the Standing Committee on Appropriations had not discussed the costing of the NHI Bill and its financial model. She had written to the Chairperson requesting that the Minister of Finance address the Committee, but she further suggested that National Treasury address the Committee on the finance model, so that the Committee can understand what the NHI is going to cost and what the affordability is, considering that the country is on the verge of being grey listed.

Mr Xaba said that Members should be factual and not engage in hearsay, one cannot report on what one has discussed with colleagues in Finance. The ANC supported the amendments to the Regulations with the inclusion of the Office of the Health Products Procurement (OHPP) as a structure of the NHI Fund in the development of the essential drug list, and to support the work of the Benefits Advisory Committee. The NHI pulls all resources to create one health system and end inequality of access to quality health care. It is not correct that the private sector would be enriched at the cost of black people, instead it will bring better health care that meets the standards, because it will have the available resources. He supported the comments made by Mr Munyai, Mr Siwela, Ms Gela and Ms Harvard.

The Chairperson said that the ANC supported the amendments to section 90 of the National Health Act, as the Minister may make determination of the fees to be paid to public health establishments through consultation processes.

[Break]

Ms M Sukers (ACDP) noted the objection of the ACDP to the Schedule amendments and the NHI Bill in its current form. It is the ACDP's contention that government does not have the capacity to deliver health care for all. This is in light of the state of the public health system and the corruption that is rampant in the public health sector.

Ms Gela said that she does not know why Ms Sukers rejected something that she never participated in; she does not know about the NHI. The NHI is the only way to ensure that the health system gets what it deserves. It is clear that some Members do not have the interest of the people of South Africa, that is why they have rejected the amendments, they do not see it as a good thing.

Ms Wilson raised a point of order as Ms Sukers had every right to object and she was not the only person that has rejected the amendments – almost every other party has. She asked that Ms Gela stop saying that Members who reject the amendments do not care for the people of South Africa. If Members do not see eye to eye on certain things, it does not mean that they do not care. As a Member of Parliament, she undertook an oath to protect the Constitution and the people of South Africa, which is something that she takes seriously.

Ms Clarke agreed with Ms Wilson as each Member has a democratic right to participate and raise concerns on the issues debated. Ms Gela has no clue what other Members do on the ground for the people of South Africa, so she has no right to consistently say on this platform that they do not care for the people of South Africa. It is absolutely unacceptable to accept Ms Gela’s utterance.

Mr Xaba noted that the Chairperson said that this virtual meeting was a parliamentary precinct. It was not of interest to the people of South Africa for Members to use words such as “I am getting fed up”. Ms Gela was correct because a Member might need to be guided in terms of the resolutions that were already made.

Mr Siwela said that he assumed that the Committee would now be hearing the response by the Minister. He felt that it was unfair for Ms Sukers to have raised her point after the Committee had concluded its discussion on the amendments. He suggested that the Committee proceed with the agenda, because they were wasting time on things that should have been said. There was no problem with Members objecting, but Members must object at the right time.

Ms Ismail said that this Committee always has a collapse of its meetings due to ANC Members interjecting. Each and every Member has the right to state their particular view or their party's view. The DA had clearly stated that it objects the NHI. The Members should not be silenced due to another Member's input. She asked that Members resort to mutual respect, rather than commenting on other Member's input, as this will ensure a more constructive meeting.

Ms Gela said that she was covered by Mr Xaba and Mr Siwela, and agreed that the Committee should move on. She will not entertain the other Members, because it is very clear that they serve their own interest and they do not serve the interest of the poor people, that is why they rejected everything.

Ms Sukers said that she had a lot of respect for the Chairperson, not only for his professionalism but also for who he is as a person. She respected every single colleague that was serving on this Committee, because they serve the people of South Africa. The debates and the differences around the viewpoints delivered in this Parliament, signifies the democratic dispensation that Members are part of. She will not be insulted and told that she does not care for the people of South Africa, she will not even respond to that.

She made it clear that her participation in this Committee was as an alternate Member. She served on three Portfolio Committees – Social Development, Basic Education and Health. She serves on all these Portfolio Committees to the best of her ability and she attends all of them. Her track record spoke for itself. She will not be insulted for the manner in which she was present. She was there to note that the ACDP does not support the NHI. She explained that she had raised her point late, due to load shedding in the Overberg where she serves her constituency.

The Chairperson noted that the DA and ACDP did not support the amendments. He added that Mr P van Staden (FF+) had written a message in the group chat to say that the FF+ did not support any of the Schedule amendments presented yesterday or today.

Minister response to NHI Bill concerns
Dr Joe Phaahla, Minister of Health, recalled that the Deputy Minister started leading this process of the NHI Bill in the Sixth Parliament. He thanked all Members and the many stakeholders for the honest and robust debate on the fundamental proposal of reforming the health system.

The Minister's presentation outlined the following observations:
• There were some calls for more detail in the Bill but South Africa’s laws are generally ‘enabling’ rather than ‘prescriptive’ – it allows a more dynamic management of a rapidly changing environment as healthcare is.
• Appeals were heard from some professional, patient and lobby groups to be explicitly recognised in the Bill
• There were some views that the economy is too weak to support NHI
• There were some stakeholders that called for ‘fixing the public services first’
• Some stakeholders were concerned that too much power is vested in the Minister and called for Parliament to have a direct role in establishing the Fund
• There were stakeholders who had objections to NHI purchasing healthcare services from private healthcare providers
• There were calls for the cost to be spelt out and for a feasibility study
• There were concerns about the independence of Benefits Advisory Committee and Health Care Benefits Pricing Committee
• There was support universal health care without a clear understanding of universal health coverage
• There was concern about erosion of the role and powers of provinces
• There were some concerns over the fate of medical schemes
• There were concerns raised about accreditation of providers
• Corruption was rightfully raised as a concern by several stakeholders
• We have lost time during COVID-19 so the concerns about transitional provisions are expected.
[See document for response to these observations]

Discussion
The Chairperson thanked the Minister for his input, he had shown good leadership on speaking to the points raised by many of the Members. It is understood that the NDOH will come before the Committee to add more detail to what the Minister had presented.

Mr Munyai said on behalf of the ANC he thank the Minister for the dynamic and terrific presentation, it clarified a lot of issues. He asked that the comments on the clauses of the Bill be postponed to next week, on the basis that the ANC would want to consult further before such engagements.

Ms Chirwa said that with all due respect, that was a very low-level presentation from the Minister. It was quite disrespectful for the Minister to come with such mediocre responses after the type of deliberations that were made in this Committee. She never thought that she would see the day that a Minister would come to justify the NHI because his own personal medical aid funds ran out. The Minister was the ambassador of the public healthcare sector. Based on the example that the Minister had given during his presentation, it appeared that the Minister wanted the Members to sympathise with the fact that his medical aid funds had ran out. This justifies what the EFF had been saying, that the NHI is primarily for the elite for the people who live in cosmopolitan areas.

There are no private hospitals in townships, no private hospitals in rural areas and no private hospitals in informal settlements. The NHI is primarily to benefit people like the Minister who run out of medical aid funds by the time it is due. Now the public purse is utilised to cater for people who are supposed to be muscled enough. The Minister has the liberty to choose between the public or the private sector. The NHI would mean that the people of South Africa would have funds reallocated from the public purse to cater for the fact that the Minister ran out of medical aid funds. That was the most disappointing thing that she had heard in the presentation.

The misrepresentation of the NHI being a one-tier system should be stopped. The NHI still presents the idea of a two-tiered system, because the private sector does not disappear. The government will then outsource healthcare services and pay for them. The private services would still exist as the private healthcare sector.

The financing model should not be debated because the Committee does not need words but numbers; money is about numbers. How much money was needed to fund each and every aspect of the NHI. How much money will be put in from the private sector? How much money will be sourced from taxpayers? How much money will be needed to fund the medical needs of each province and each district? What is the estimation study of the Bill? The Committee cannot just receive an essay from the Minister. The Committee needs numbers and a funding model.

She questioned what the reallocation would entail and how it would affect the public sector which requires much more intervention than it is currently getting. This is a necessary concern because the referral system still exists in the Bill, and it has been problematic for some time. The people in rural areas and townships would still need to utilise public facilities as their first point of reference when they need healthcare intervention. Given that funds would be reallocated, what would cater for the public healthcare system in areas that do not have any private hospital? The Minister was able to wake up in the morning and access Netcare within five minutes. What would happen to people in Mamelodi and Taung, North West, who did not have contraceptives at this point.

The private sector prioritised money across the field, and the healthcare system is no different. Government must acknowledge that the NHI is an actual attempt to outsource healthcare, because government had failed to deliver equitable healthcare to the people. The answer given for the qualification of facilities standards also does not suffice. The country is in this situation because there are no tangible intervention methods to better healthcare facilities. The answer given by the Minister basically states that the quality of healthcare facilities will remain as is. The Bill does not encompass an infrastructural plan for bettering facilities.

The Committee needs much more than the essay the Minister had given, which was a very weak attempt at responding to the level of deliberations this Committee has had. Members had raised questions that were very detailed and the Minister’s response today does not suffice. What the Minister had told the Committee is grade one level. The Committee cannot accept this kind of intervention from a Minister of Health, who came to justify the NHI because his personal private medical aid fund had run out. The Minister should come back to the Committee with a proper and detailed funding template, on how he planned to ensure that the NHI is equitable.

Ms Clarke said that the Minister’s presentation was lacklustre and fell very short of the incredibly hard work that the Members have done, in the clause-by-clause deliberations. She hoped that when the Department and State Law Advisors came to address the Committee, they would address the many legal concerns raised about this Bill, that was not addressed by the Minister.

Ms Clarke said that the Minister had spoken about the National Health Service (NHS) of the United Kingdom but if one looks at the current NHS, it has a shortage of about 45 000 nurses and long waiting lists. The UK has a First World environment in terms of its hospitals, which this country does not have. The healthcare in this country is in a terrible state. What the Committee had observed last week in the Eastern Cape was appalling where surgeons had to operate with their cell phones because there was no lighting in theatre et cetera.

Ms Clarke asked the Minister how legal claims and accruals would be dealt with, as it has a huge impact on the health system. The referral system has been addressed but 90% of the facilities do not even have computers or their filing systems are not on electronic which is a huge problem. Another concern is that service providers are currently not being paid within 30 days. She questioned if these same concerns would happen under the NHI. She asked how the flight of nurses and doctors from this country would be addressed under the NHI.

The DA had raised issues about the Minister's powers, particularly with what has happened in the health sector before in terms of tenders and officials not sticking to supply chain management requirements. She noted what happened during Covid-19 where the previous Minister of Health was implicated. How would these issues of transparency be dealt with under the NHI? The Committee got a very wishy-washy explanation from the Minister as to how that would be dealt with. There was only one sentence about Parliament being the oversight body, but the Committee would want to know exactly what kind of role Parliament would be playing in terms of being the oversight body. The Committee would need to be guaranteed that the NHI would not just become another Eskom or Denel.

Ms Clarke was confused when the Minister had said that the funding would be redirected because Dr Crisp made it very clear in the media that taxes would be raised to finance the NHI. She asked for a response on this differentiation.

The Members understood the work of the Office of Health Standards Compliance (OHSC) and the Health Ombuds, but they had informed the Committee that it was only the Western Cape that is in line in terms of the compliance standards.

The DA had raised the concern of political interference, and it is one of the aspects why it is believed that the NHI Bill places far too much power with the Minister. She questioned if this Bill would be implemented transparently. She gave the example of the behaviour in this Committee, where the opposition parties dare not say anything or else it gets trampled on, but they are exercising their democratic rights.

Ms Clarke reiterated that no finance model had been given to the Committee. The Committee would definitely need the Minister of Finance and National Treasury to address the finance model for the implementation of the NHI. She would like to see a proper strategy in terms of how universal healthcare would be upgraded and supported by the private sector in this country. The current healthcare environment in which the country operates is just terrible, particularly the waiting times, cleanliness, drug stock-outs, infection control, safety and security. The Minister cannot blame the Members for being pessimistic about this Bill, because of government's track record in this country. The Members are obviously going to question a lot of things.

She hoped that the Department would come to answer all of the issues that the Members have raised, because it certainly was not in the Minister’s presentation. The presentation was very disappointing.

Ms Gela agreed with Mr Munyai. The Minister spoke very well and articulated the points clearly. Of course, there would be other Members that do not see what the Minister had said, because they have a negative attitude towards the NHI. Whether it is good or not, that is what they see, because they carry their political mandate and oppress the rights of other people. The Committee had engaged in public hearings where people have said that they wanted the NHI. It was not only the Minister who made the example that he had run out of his medical aid fund, as there were people who had also told of their medical aid fund being exhausted. The Minister should not feel offended, as they were there to ensure that the NHI Bill is implemented.

The Committee should respect the constitutional right of the people, because they have been consulted and their views were heard. About 84 to 86% of people had said that they wanted the NHI. Only a minority of people do not support the NHI, especially those who are already covered by medical aid and do not care about the people of South Africa. Mr Munyai had given an example that he was involved in an accident, and he was the only one taken in the ambulance, because he was the only one who was covered by medical aid. So the NHI would address all those challenges and close the gap. It is the right way to move forward with the NHI. She knew that some Members did not support the NHI which is their right, but they must also respect the rights of the people and the rights of the majority. As the leader of society, the ANC cannot mislead the people of South Africa. There is a need for the NHI. She recalled that the Committee had received a presentation from the Ombudsman who informed the Committee of the UK that did not have the funds, but implemented the NHS because they saw it as a good model, to ensure that its people benefit equally in the health system.

Ms Gela welcomed the presentation from the Minister and said he should keep up with the good work. Ms Chirwa will never understand because she is not a medical doctor and does not know what is happening.

Ms Chirwa interjected that the Minister was not taking about medicine, he was taking English. The Minister gave the Committee an English essay.

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

The Chairperson informed Ms Chirwa to raise her hand if she wanted to say something. There are rules in the meeting. He asked Ms Gela to continue.

Ms Gela said that Ms Chirwa was behaving as if she was in grade one. The Minister should keep up with the good work to serve the people of South Africa. The ANC has confidence in the Minister and supports him in implementing the NHI.

Mr Xaba supported Mr Munyai’s suggestion to postpone further engagements on the Bill clauses to 22 November. The Minister had responded very well and proved that he was there for South Africans. He appreciated the challenges that the Minister had. Mr Xaba gave his own example and said his medical aid was depleted which is why he walks with a stick. He would require more funding to recover. He explained that the NHI would be part of assisting that.

Ms Chirwa interjected and said that Mr Xaba could go to a public hospital.

Mr Xaba said that the ANC had never interjected while other Members were speaking.

The Chairperson asked Ms Chirwa not to interject again. It was the second warning that she would be muted.

Mr Xaba said that the ANC is not angry and does not make a noise when it engages but that the ANC is factual. The Deputy Minister of Finance had yesterday passed the Division of Revenue Amendment Bill in the House wherein more funds are coming. One should not expect the Minister to engage with numbers, because this Committee’s concern should be to engage on the NHI and health for the good of all people. There is no reason to critique the Minister about numbers.

Following the Committee’s oversight visit to the Eastern Cape, the Committee is yet to reflect on the report as a collective. So Members should not be making examples to disadvantage the NHI, because the NHI is yet to deal with those matters. The Members need to be orderly and engage with such things when the time comes. He informed Ms Clarke that her concerns about medicines and improving infrastructure are non-negotiables and it is covered by the Presidential Health Compact.

He supported the Minister because he understood the lives of ordinary South Africans.

Ms Wilson referred to the comments made about the NHS in the UK. The UK implemented the NHS after the war and after everything was obliterated; there were no clinics and there were no hospitals. The UK had to start from absolute zero. It is a big difference to compare what the UK had faced and what South Africa currently faces.

Ms Wilson noted that the Minister had spoken about some Members that were not clear on universal health care. She clarified that the DA is very supportive of universal health care, but the DA does not support the NHI Bill in its current format, because it will not address the problems that concern universal health care. The World Health Organisation’s definition of universal health coverage means that “all people have access to the health services they need, when and where they need them, without financial hardship”. The Minister had given his own example where he had to use money out of his pocket, because his dentist had given him a prescription that was not covered by his medical aid. She asked the Minister why he had not gone to one of the public facilities, as he would have not had that problem. The Minister is totally reliant on medical aid to support himself. She thought that his example was bad. People do have clinics and hospitals to access health care when and where they need, without financial hardship. She had been to thousands of public hospitals doing oversight and she had not seen anyone have to pay for the service, but what they are definitely not getting is quality health care. There is universal health coverage, because people do have facilities to access. The fact that those facilities and hospitals are totally disgusting is irrelevant, the NHI is not going to help. There is nothing stopping any person in this country from accessing a public facility when needed and at no cost. There is universal health care but the question is the quality of the health care.

Ms Wilson noted that the Minister had pointed out that majority of people experience hardship when travelling to access health care. She asked the Minister how the NHI would fix this. The Minister had also said that many are denied health care, when it is available next door. It may not be available next door, because nothing has been done to upgrade infrastructure and build facilities. The NHI will not change that.

Ms Wilson attended the public hearings on the NHI Bill. If the people in the poor rural areas were encouraged to support the Bill because they were told that they would get universal quality health care, then the expectation of those people is that they are going to get it tomorrow. She noted that Ms Chirwa had also raised this concern. It gave people the impression that the day that the NHI Bill is passed, they would get ambulances, medicines and that they could go to any private hospital they want. That is not true and the country is years away from that. If people are misled and taken to public hearings where they hear misinformation then it is obvious that they would support the Bill, which is exactly what happened.

Ms Wilson disagreed with the Minister's comment that the NHI had received overwhelming support from stakeholders. She clarified that the stakeholders had overwhelmingly supported universal health care, but do not support the NHI and had many concerns about it.

The DA had raised the feasibility studies. With no proper feasibility study, there is no idea how all of this would be managed, particularly with all the boards, units, directorates, districts and all the other layers in the Bill. The NHI cannot be planned for if there is no feasibility study of how this would be managed.

Ms Wilson questioned if there had been any discussions with National Treasury. The Davis Tax Committee report made it very clear about the shortfalls that the NHI would face, particularly considering the current economy. The Minister would have to inform the Committee if he had discussed it with National Treasury and what National Treasury had said. Where are the starting funds going to come from? Can this be afforded? What are the implications when VAT and personal income tax is increased? What effect will this have on the cost of living? The cost of living right now is so bad and it affects the poorest of the poor of this county. She had raised these issues because she does care and it is problematic.

She informed the Minister that the health system is not battling due to fragmentation, as he had said. It is battling because the right process to maintain infrastructure has not been done. It is not because of fragmentation, but because of mismanagement and corruption.

Ms Wilson noted that the Minister’s presentation pointed out that some stakeholders called for ‘fixing the public services first’, which she agreed with. This can only be done with private providers, if they are in the position to do that. A lot of private providers are not buying into it, because they do not know how they will be reimbursed because they have not been shown from where the money is going to come.

Ms Ismail placed on record that the reason the DA is making inputs is because they care. They care for what is constitutionally right and what is right for the people of this country. The DA was there to serve the best interests of the country. She reminded the Minister that the health professionals had expressed their views at the public hearings. They have taken the Hippocratic Oath and they felt that they would not be adhering to that oath if they had to serve under the NHI, considering the current state of health in this country. At almost every public hearing it was clearly stated that while the NHI seems to be really good, the current system would first have to be fixed.

Ms Ismail noted the Minister’s observation was that the improvement of infrastructure and equipment would require more budget. It was clearly reported that the NDOH has regressed and there is no consequence management. This needs to be addressed immediately as this will stop corruption so that the monies meant for increasing staff and proper refurbishment of facilities will be available. The reality is that more and more medical professionals are leaving the country to look for better pastures abroad. The NDOH is not fixing the things that need to be fixed in this country. Whistleblowers have highlighted the mismanagement and have reported suspicious payments and that invoices are not audited before payments are made. Bearing in mind that this is taxpayers' money, one should imagine the millions that would be available to be abused by mismanagement and corruption under the NHI. It makes more realistic sense to fix the current system rather than splurging more funds to be mismanaged.

The health system already has a problem with service providers not being paid on time. How did this problem validate the NHI? The presentation said that over time, as the Fund covers more comprehensive benefits, there will be no need for medical schemes. She questioned how much time this would take. During this time, delivery of health services would be compromised, which is a further problem because the country already has a fragmented state of its public healthcare system. This will be even worse when considering a phased approach, especially since most hospitals are not compliant with NHI requirements. This Committee knows that the OHSC cannot even oversee more than 8 to 9% of the current public health care facilities. The OHSC is currently understaffed. The Office of the Health Ombud is also understaffed.

The NDP 2030 had clearly stated, “The public service needs to be immersed in the development agenda but insulated from undue political interference”. The National Planning Commission, 2011, stated “Stabilise the political-administrative interface. Build a professional public service that serves government, but is sufficiently autonomous to be insulated from political patronage. This requires a clearer separation between the roles of the political principal and the administrative head”. The insights reflected in the NDP and the associated recommendations are yet to be deliberated on and implemented, and it has still not been addressed. As a consequence the structural inefficiencies are as a result of patronage and this continues unabated. This will be even worse under the NHI.

On the concern for corruption, the Minister had said that there are checks and balances. She questioned how the Minister could say that the Fund must check itself. This must surely be relooked at to ensure independent checks and balances, to ensure transparency and accountability. She referred to the example the Minister had made about his medical aid fund that ran out. She asked how the Minister thought that the NHI would fix this. It will just place a bigger burden on the state. She gave her example of her daughter who needed surgery for multiple fractures. If she had waited in line, considering the surgical backlogs, then her daughter would have probably still been waiting; but because she had the freedom of choice on which hospital, it effectively saved her time in the healing process. She questioned the logic of placing more pressure on a public health system that is already not functioning.

When looking at the referral pathways, there is going to be so many issues where health services will be hampered. The Minister would really need to address the challenges being experienced in the public health care system now and not wait for the NHI. She asked if the Minister accepted that from 1995 up until now, that the public health care sector could not be fixed, and that he is basically saying that it is only the NHI that could fix all of those issues. She questioned how on earth this was justified if after all these years, no thought was put into fixing and improving health services to the country.

The current challenges in the public health sector are frankly due to mismanagement and too much political interference. If there was enough political will and the right skills then the current health care system would have been in a better state. Ms Ismail urged that corruption, mismanagement and irregular expenditure should be stopped. The people of this country wanted facts. There should be a proper financial plan, as well as a proper health services delivery plan in place. The Minister cannot just say that things will be adjusted as time progresses, this is peoples’ lives that is been spoken about. She concluded by stating that the DA supported universal health care.

Mr Xaba said that he had already mentioned that the medicines and improving infrastructure are non-negotiables and are therefore covered by the Presidential Health Compact. He noted that in the group chat, Ms Wilson had written about her helper that was not assisted because she did not have medical aid. As an employer of a helper, it is important to ensure that employees are covered medically. The NHI was there to help people like her helper, but Ms Wilson is not supporting it.

He recalled that this Committee, across all political parties, applauded the Health Ombud, Prof Makgoba. Ms Wilson had made an input to say that the Health Ombud had made a passionate contribution to the Committee that the NHI is a good initiative that needed support. If Members respected the Health Ombud, they should do the honourable thing and also listen to his advice.

Ms Gela supported Mr Xaba’s comments. She noted that Ms Ismail’s input was passionate about the Constitution. She questioned what Ms Ismail thought about Section 27 of the same Constitution. Section 27(3) read “that no person may be refused emergency medical treatment.”. This NHI Bill will ensure that no person is refused medical treatment. It is very clear that the Members who are against the NHI Bill are covered by medical aid. She felt that this Committee must listen to the view of the people and the view of the majority.

For Members that were opposed to the NHI Bill, the NHI is to provide health care to people like Ms Wilson’s helper, that do not have the money. The NHI was to assist people to be picked up by ambulances when they need medical assistance, even if they are not covered by medical aid. She explained to Ms Ismail that everyone would be treated the same, whether it is private or public. The NHI intended to have more ambulances, so that people do not have to wait for hours. The NHI would have more health care professionals hired, including doctors, nurses and paramedics. Those who are opposed to the NHI Bill, should do the right thing and listen to the Health Ombud’s advice. All the Members agreed when the Health Ombud said that the NHI was a good thing, and that it needed to be supported.

Ms Clarke asked for clarity from the Minister, because he had said that Solidarity had lost their court case against the NDOH, but when she looked into the matter, it stated that the case was postponed with costs against the NDOH. She added that she respected the Chairperson, but she does not think that Members do because they do not allow him to chair the meeting. She suggested that the Members should concentrate on the presentation and not be so concerned about the DA and the issues that the DA is raising.

Ms Ismail agreed with Ms Clarke. She respected the Chairperson; it was just unfortunate that some Members in this Committee have more of a say than others. In her example she had made, the freedom of choice prevailed. She had the opportunity to take her daughter to a hospital for immediate health care, because if she had to wait, then she would still be waiting for surgery. She wanted to make the point that the system is not functioning, and with the NHI, the burden will be much more. She pleaded for Ms Gela to move away from her ANC tactics and that she should listen to the inputs.

Ms Gela interjected. Ms Ismail was wrong. She was not there with ANC tactics; she was there to contribute as a Member. She had the right to speak and raise her views. She had no regrets of being a member of the ANC, she is fully supportive of the ANC and she was fully supportive of the NHI Bill because it was the only way to ensure that all people benefit equally from health care. The ANC wanted to correct the imbalance of the health system.

Ms Ismail said that the NHI requires public health care facilities to be compliant with certain criteria. She reminded Members that she had asked the Health Ombud if he felt that the OHSC would be able to inspect all the health establishments in preparation of the NHI. She had also asked the Health Ombud if he felt that most health establishments would meet the NHI prerequisites. She noted that the Health Ombud had clearly said “no” he did not think so.

She referred to Ms Gela’s interjection and said all the Members have the right to contribute. She placed on record that she was a member of the ANC, but she was fed up with the corruption which is why she moved.

Ms Gela said that Ms Ismail was a sell-out, that is why she had moved.

Ms Ismail replied that she was not a sell-out. She stood for what she had the right to do.

Ms Chirwa emphasised that the Minister should give the Committee a quantitative study, and not the mediocre essay that he had presented today. The Minister should stop misleading the country by saying that the NHI is an abolishment of the two-tier system. The Minister should own up that he is leading the country for government to outsource health care to the private sector. The Minister should stop presenting the mirage that people would be able to wake up and go to private hospitals, that is not the case. People would still need to go to their nearest point to access health care. His presentations should not misrepresent the truth. The NHI does not mean that people will have access to private hospitals. Even the Minister is scared of utilising public hospitals, while he is leading the public sector.

The Chairperson told Ms Chirwa that her time was up.

Ms Chirwa replied that it was fine, because the Minister will not tell the Committee anything qualitative, he will give the Committee a grade one English essay. The Minister should come back to the Committee with a qualitative and quantitative study on the NHI.

Ms Gela interjected and told Ms Chirwa to “shut-up”.

There was a back-and-forth between various Members.

The Chairperson reminded Members of the time constraints. He urged Members to stop rambling. He will take Members points of order but that is where it will end.

Ms Clarke asked that the Chairperson deal with Members that shout on this platform for others to “shut up”, that was not parliamentary behaviour. All the Members were there to do a job and to get an outcome.

The Chairperson replied that he would do so next time. He informed Members that the Minister’s presentation were introductory remarks to what the NDOH is yet to present. He was pleased that the Minister had recognised the polarised views, and that the Minister had observed the professional, patient and lobby groups who had made submissions on the Bill. The Minister’s presentation also noted that challenges were identified but that a majority supported the NHI Bill. The Minister’s presentation included the role of provinces and the fate of medical schemes et cetera. The Minister had placed the role and functions of the provinces into context, by saying that it would need to change overtime.

He noted that Ms Wilson had written a message on the group chat that said that government instructed Clicks to vaccinate only people who were on medical aid. He informed Ms Wilson that it was not true. He reminded Members that they should be sure of the information they state on the platform. The Chairperson asked Ms Wilson if she knew that her statement was not true.

Ms Wilson replied that when she had taken her helper to get vaccinated, the Clicks staff had turned her away and told her that they were instructed by government to vaccinate only medical aid members.

The Chairperson said that Ms Wilson had stated her comment as a fact, but he knew that it was not true, because his work functions in that sphere. He handed over to the Minister to respond.

Minister's response
Minister Phaahla said that it has been quite a robust debate, but that some Members have unfortunately degenerated it into insults, innuendos and deliberate distortions. He will not bother to attempt to respond to the insults and innuendos made by Ms Chirwa because it was quite usual.

Ms Chirwa asked to raise a point of order.

The Minister asked the Chairperson if he had the platform to continue, because he had not interrupted Members when they spoke.

Mr Xaba reminded the Chairperson that he made a rule for Members to raise their hands.

Ms Chirwa asked if she could raise a point of order, because the Chairperson had allowed it for ANC Members.

The Chairperson informed Ms Chirwa that when she spoke, no one had interrupted.

Ms Chirwa said that it was a point of order. The Chairperson must be fair because he had taken points of order from ANC Members.

The Chairperson asked Ms Chirwa not to talk over him.

Ms Chirwa told the Chairperson not to shout at her.

There was a back-and-forth between the Chairperson and Ms Chirwa.

The Chairperson asked that Ms Chirwa be removed from the platform. He asked the Minister to continue.

The Minister said that it was a pity that one gets subjected to verbal abuse on this platform. He continued that the NHI would pool funds from what is normally available, through the normal taxes, if that is income tax, company tax, VAT and any other area through which government raises revenue. Within the formulation of possible sources of income for the NHI, as is the case in other countries, it is still expected that those who earn income over and above the normal taxes, would be expected to make contribution. Due to the nature of the pooling of funds, it would result in a less onerous burden on individual members that must still contribute in terms of the full pool, which would become available for upgrading and provision of health services.

The provision of services is expected to be integrated in the form of universal access. Primary health services up to tertiary health services, would include public and private providers of health services. He explained that the pilot project schemes envisaged integrating private providers into the pool of providers to provide to the public. This included primary health care clinics, general practitioners, dentists, audiologists and obstetricians, especially those classified as the primary contact and included access to basic pharmaceutical products.

The Minister explained that it is a good solidarity that ordinary working South Africans would make additional contributions, because they do earn income. This is towards a solidarity of funding that would pool the funds to bring together those who are employed, as well as those who are contracted, to ensure that in future services would be provided to a wider range of society. Those who provide primary health in the private sector would also be integrated into the services.

The Minister emphasised that there is no expectation that there is going to be a magic wand in terms of the improvement of services. The public health system, which is already providing services to 85% of the population will continue to be the backdrop of the provision of services, even with an integrated system. It is not an option; it is a must that the quality of services must be improved, and this is not waiting for the passing of the NHI Act, that is a process that is ongoing. It is an expectation that as the services become more integrated, and the funding becomes more integrated, then more funds would be available to speedily improve the health services. With the integration of services, it is expected that more people will set up group practices and individual practices, even in rural areas. It is not encouraging for general practitioners, audiologists and dentists and so on to set up practices in rural areas because many people in rural areas do not have income. However, once they become part and parcel of the primary health care then they will be reimbursed to provide those services.

Based on a concern he heard from several Members, he clarified that when there is a universal health system, then it is not up to the provider to call the shots. All of the services that are provided will be negotiated and benchmarked in terms of the cost complexity and it will ensure that the providers make an income to sustain themselves, but not super profits.

At this stage the NDOH does not envisage that the current 8.5% of the GDP would be inadequate. In fact it is believed that if it is properly rationalised then it will be more than what will be needed. Therefore, he felt that the issues raised about increasing VAT and income tax et cetera is totally unfounded.

He informed Ms Clarke that it was not true that the OHSC reported that it was only the Western Cape that was in line with compliance standards. There are hospitals and health establishments in other parts of the country that have scored very well, and some have scored even better than some health establishments in the Western Cape.

The Minister acknowledged that there are shortcomings, particularly that the public health system is overburdened. There are improvements which should and can be made, which the NDOH is dealing with, together with their colleagues in the provincial departments. The NDOH is not working alone, it works with various other stakeholders. The Presidential Health Compact recognises that there are private providers and individual service providers that can also make an impact in improving the quality of service.

This is a long journey that would have to be traversed. There is no other option. He wanted to dispel the myth that the NHI would imply that the private health sector would benefit. The private health sector would not be able to call the shots, they would need to accept the conditions and would not make the exorbitant profits which they are currently making.

The Minister welcomed the support by ANC Members, because there is a need to build this equitable system.

He was pleased that the Chairperson already corrected the misinformation on the chat. It is indeed untrue that government instructed Clicks to only vaccinate those on medical aid. He reminded the Members that the NDOH had differed with the Auditor-General on the reimbursement system to ensure that those who were covered by medical aid could be vaccinated at public sites, and those who were not insured could be vaccinated at private sites.

On feasibility studies, Members assumed that the NHI would be starting something from scratch. Feasibility studies are done for something that is completely new when there is no idea of what to expect. He explained that the health system is already there, but need to be integrated and streamlined to operate in a sustainable way.

The NDOH is not denying that the current problems must first be fixed. The NDOH meant that this should run concurrently and that there are a lot of areas to be improved. He explained that there are areas where the population has grown. For example Kalafong Hospital was built more than 40 years ago, when the population in the area was a quarter of what it is today. There are improvements that have to be made. Many of the public health establishments are overwhelmed, because the services have not been increased in tandem with the rise in population.

He noted that Ms Ismail had quoted from the NDP, but she had not gone further to indicate that the very same NDP had called for universal health coverage. He agreed that the long waiting list in public health establishments and the backlog in surgeries are due to the inequitable way in which the resources are available.

The NDOH want to rectify the anomaly to ensure that all institutions that have been built with the sweat and blood of South Africans must be available to all South Africans. He disagreed with the comment that fragmentation was not the issue. The burden exists because there is an increase in population, there is a burden of disease and accidents et cetera, but there is also fragmentation. He made the example that one would hardly find people being treated for HIV or tuberculosis in private hospitals because it is not profitable. Many private establishments do not provide primary health care, or family planning because it is not profitable. There is indeed a system of the haves and the have nots. The NDOH want to ensure that all these facilities are available to provide comprehensive health services.

The Minister replied that Solidarity has a lot of cases against the state, which include the NDOH. Solidarity lost the case when they challenged the activation of the NHI branch within the NDOH on an urgent basis. There is a plethora of other cases, which are ongoing and the NDOH is still appealing.

He thanked all Members for their contributions, as well as the Chairperson for making corrections. He noted that this was only part of the journey but he looked forward to this journey being concluded, and to move forward with what South Africans are waiting for, a situation where they can access health services without the fear of a catastrophic financial crisis.

The Chairperson thanked the Minister and Members who have participated in the discussion. He appreciated all the good work from Members, the Minister and the NDOH.

The meeting was adjourned.