National Health Insurance (NHI) Bill: Department briefing (with Minister); DWYPD Budget Vote Report

Meeting report

The Chairperson welcomed the Members of the Committee and the Minister of Health to the meeting. The Committee would be briefed on the NHI Bill, which was a Section 76 Bill. Thereafter, the Committee would have deliberations.

Briefing by the Department of Health on the National Health Insurance Bill [B11B-2019]

Mr Joe Phaahla, Minister of Health, made introductory remarks. The Department was pleased to be at the meeting. The Department was pleased with the speed at which the Committee had moved. It was only seven days ago that the NHI Bill had been debated in the National Assembly, and the National Assembly had passed it. It had then been forwarded to the National Council of Provinces (NCOP). The Department was pleased that it had been called so speedily to come and brief the Committee. Over the past seven days, the passing of the NHI Bill by the National Assembly had been met with mixed reactions from various stakeholders and commentators. This Bill provided an enabling framework for massive reforms to the entire health landscape in the country. It was not surprising that it had generated varied reactions, especially from those who had vested interests. The point of departure for the reforms was that access to health care was a human right, as provided for in section 27 of the Constitution. Attainment of this human right should not be a matter of negotiation. The Department appealed to the Members to take that approach. It was important that all South Africans engaged with the content of the Bill and its intended impact on the well-being of South Africans. South Africa would remain one of the most unequal societies in the world unless citizens stood up and demanded the acceleration of the transformation agenda to address the current imbalances in society, including in the way health services were provided. This Bill described the framework for reconfiguration of the way healthcare services are accessed by both public and private sector providers of healthcare services. It also described significant changes to the way these services would be paid for in the future. These reforms aimed to achieve a system that ensured every person received the healthcare they needed when they need it. People needed to be able to access healthcare services without incurring financial hardships, as a result of receiving health services. There was much misinformation about the NHI which was being peddled by those who had a vested interest in protecting their financial interests and who failed to see the future of the rest of the people in the country. The Department asked that the Committee focused on the very vulnerable individuals, who were the majority of people in the country. These were the people who needed this care. The Committee should not look at the narrow interests of those who feared losing some of their super profits and privileges which they currently enjoyed. He noted that the process of passing the Bill in the National Assembly, which was tabled in 2019, had taken some time. The Department was pleased that the Bill had finally been passed. The Department hoped that the Committee would manage the Bill in the various provinces such that there would be a positive result. The Minister noted that there were members of the Department present, including the Director General of the Department. The Deputy Minister would not be able to attend the meeting because of other commitments.

Prof Nicholas Crisp, Deputy Director General: National Health Insurance, Department of Health, briefed the Committee on the NHI Bill. The presentation summarised the 11 chapters of the Bill. The Bill establishes an NHI Fund as a legally defined organ of the state.

The Bill provides for the control of the NHI Fund by the Board, the composition of the Board, the appointment of members of Board, the appointment of Chairperson and Vice-Chairperson of Board, the meetings of the Board, the appointment of Committees of the Board and the disqualification from membership of Board and vacation of office. The Bill seeks to define beneficiaries of services covered by the NHI Fund, including population registration. The Bill also provides for the contracting of accredited providers of personal health care services and allows for the Minister to determine criteria for accreditation and reimbursement of Health care providers. The Bill provides for the Minister to determine health care benefits that will be reimbursed through the NHI Fund, as well as the service coverage and cost measurement provisions.

(See Presentation)

Discussion

Ms S Luthuli (EFF, KZN) said that she appreciated the Department presenting the Bill to the Committee. What did the passing of the NHI Bill mean for South African health providers and users? Many South Africans did not have IDs. How would the Department assist those people? She asked the Department to clarify how the NHI Fund registration process would work. There had been concerns over the state of infrastructure in public hospitals. How would the registration database function given the current infrastructure challenges at State hospitals? Would individuals be able to use any health facilities of their choice?

Ms D Christians (DA, Northern Cape) said that there were a host of concerns regarding the NHI Bill. These concerns could not be overlooked. These concerns needed to be properly interrogated before the Bill was passed. She noted that there were a host of people in the public sector that had issues with the NHI Bill. She discussed the implementation challenges. How did the Department plan to address the current issues of poor service delivery? Across the country, there were issues with service delivery. There was a lack of staff. There was inadequate infrastructure. All of this would hinder the implementation of the NHI. How would the Department overcome that? What measures would be taken to ensure that strict requirements for obtaining healthcare did not exclude the poorest of the poor? That was really the main concern. How did the Department plan to address the potential threats of tender corruption, fraud, and looting of the NHI Fund?

She discussed certificates of need. It had been briefly mentioned in the Bill. The Department needed to provide more clarity on that. She asked the Department to provide clarity on the constitutional scrutiny of the certificates of need. How would this affect the Bill’s provision if the certificates of need were deemed unconstitutional? How would the Department address the material aspects of the Bill that relied on these certificates?

She discussed the ministerial powers. What steps would be taken to prevent an overreach of powers by the Minister of Health to ensure the autonomy of the NHI Fund? The Minister of Health would not only oversee the board but also how the board was constituted. The Minister would also oversee the appointment of board members. How would the Department ensure transparency and prevent cadre deployment to the appointment of board members and the chairperson of the NHI Fund? This was a huge concern.

She discussed financial feasibility. It was another huge issue. Had the Department conducted a feasibility study? If the Department had, it had not indicated it anywhere to the Committee in any presentation, neither to the Portfolio Committee nor the Select Committee in any of the briefings. Had the Department conducted a feasibility study to determine the exact costing model and the ability of both Parliament and National Treasury to provide sustainable funding for the NHI Fund without compromising healthcare quality? How would the Department address the concerns of taxpayers regarding additional taxes and the potential impact on the working population? She asked the Department to expand on that. The Department needed to explain the potential impact on the taxes of the working population.

She discussed infrastructure and service delivery. What plans were in place to address infrastructure challenges? There was a lack of budget and understaffing. All the provinces would agree that there was a lack of budget and understaffing. Most hospitals did not have adequate medical supplies. How would the Department deal with that through the implementation of the NHI Bill? How would the Department provide adequate healthcare if the basic infrastructure was not improved in provinces?

She discussed the accredited healthcare providers. How would the Department address the lack of resources for inspecting and accrediting healthcare service providers? What measures would be taken to prevent a catastrophic situation where public hospitals were unable to provide services due to non-accreditation? Non-accreditation was a huge issue. She asked the Department to provide the Members with some clarity on that matter. How would the Department ensure that the centralisation of powers from provincial authorities complied with the constitutional framework and respected the existing health legislation?

She discussed medical aid providers. Could the Department clarify how the removal of the option to choose medical aid schemes aligned with the individual’s right to choose freedom of association and access to medical care, as protected by the Constitution? How would the Department ensure that individuals who relied on medical aid schemes did not experience delays or decreased quality of healthcare under the NHI?

She discussed the National Health Information System (NHIS). In relation to the POPI Act, what measures would be implemented to address concerns of data breaches and breaches of the POPI Act when establishing and maintaining single databases for the NHI? How would the Department ensure that all healthcare facilities, including those with limited access to technology, could effectively capture and utilise data within the proposed information system?

She discussed the single fund purchaser. How would the Department establish guidelines and criteria for the purchasing of medical aid services by the NHI Fund to ensure transparency and fairness to all? She noted that something that was of concern was the complaints procedure. What steps would be taken to establish an independent and impartial complaints procedure that was not under the direct influence of the Minister of Health? Could the Department provide the timeframes when dealing with such complaints, especially in cases where medical procedures were pending or urgent? This was a huge issue in most of the provinces where people waited for months for procedures to be done. There was just not the necessary assistance for these people.  

Ms N Ndongeni (ANC Eastern Cape) asked what the Department was doing in terms of on-boarding the workforce, especially with the district managers on the implementation of the NHI. What were the plans of the Department to ensure that there was enough workforce for the implementation of the NHI? Was there a retention strategy by the Department? What were the lessons learned from the NHIS? Even countries with developed countries with functional national healthcare experienced challenges, as seen during the Covid-19 pandemic. How was the issue of inadequate and overburdened human resources for health being addressed?

Mr E Nchabeleng (ANC, Limpopo) said that it was good that Members were asking these questions in the meeting so that when they went to the provinces to make presentations they would go with complete information. It was important for the Department to know what the Members’ concerns were about the Bill and what still needed to be done going forward. He noted that there were problems with the infrastructure of health. It was not only a phenomenon in South Africa. It happened all over the world. Covid had shown that there were gaps. Societies that cared about their citizens were doing something to close those gaps. How would the NHI Bill help the Department to improve healthcare infrastructure and increase the number of health professionals, particularly specialists in areas where they were not easily reachable like in deep rural areas? Young doctors found it difficult to stay in areas where there were no facilities. Young doctors found it difficult to operate within those kinds of environments. Many of them would prefer working in cities where there were amenities. How would the Bill help attract these young professionals to work in deep rural areas? How would the Bill help enhance the technology in hospitals? Some of the hospital equipment came at a very high price. How would this Bill help South African hospitals to acquire that equipment? Where would the funding come from to ensure that South Africa had a healthcare system that could cater to those who could not cater for themselves? Would the NHI close all private healthcare facilities? If not, how would they coexist? Was there going to be a cap on how much medical practitioners could charge? In many instances, people charged ridiculously high fares for surgery. Were there going to be limitations on how much people could charge and not charge?

Ms E Nkosi (ANC, Mpumalanga) said that she was covered by the previous speakers. She welcomed the detailed presentation made by the Department.

Mr M Bara (DA, Gauteng) asked how the Department envisaged implementing the NHI once the Bill is passed. Could the Department share its practical plan with the Committee in terms of the funding modalities? Having gotten the presentation, whereto from here? What was the plan regarding holding public hearings to get a sense of what the people’s views were? He discussed the public and private institutions of health. What were the views of the private sector in terms of support for the NHI? Would individuals be able to use any healthcare facility of their choice at a minimal cost with the rollout of NHI? 

Ms S Lehihi (EFF, North West) asked if the NHI Fund would also be offered to unemployed people. Would the employed be able to afford the monthly payments? Would foreigners and South African citizens who had no legal documents be allowed to be insured by the NHI?

Mr I Ntsube (ANC, Free State) said that he had been largely covered by the previous Members. What would the rollout look like of the NHI? He discussed the timeframes. When did the Department think that it would begin with the NHI? The Bill was to be processed by the NCOP. Were there any measures made in the Bill to make sure that nobody would tamper with the NHI Fund? There were times when the people who were tasked with managing funds were tempted to fiddle with the funds. What measures had the Department deployed to ensure that there would be no corruption or malfeasance of funds?

The Chairperson discussed the way forward for the Bill. The Bill would follow a six-week cycle. The next step would be provincial briefings. Thereafter, there would be public hearings in the provinces, as well as a call for written submissions in the coming weeks. The finalisation of the Bill would happen in October, due to the Parliamentary recess. That was how the Bill would move forward.

The Chairperson allowed the Department to respond to the comments and questions from Members.

Minister Phaahla responded to the comments and questions of Members. There was no dispute about where the healthcare system was. Over time, a two-tier healthcare system had evolved. The public healthcare system carried the care of the large majority of South Africans. About 85% of the population depended on the public healthcare system. It was overburdened in terms of demand for services. It was under a lot of pressure.

He discussed the amount of money spent on private health. There were large contributions to medical schemes. There were also contributions by employers, including a huge contribution by the State. This was through tax rebates and a big chunk of medical schemes depended on public service workers. The total health expenditure only serviced a small portion of the population. There were high levels of contributions by individuals and their employers. There were rising levels of contributions. This suffocated what people could take home for other spending. Private healthcare was already at a very high cost. The public healthcare system was under pressure and depended exclusively on what was allocated by the fiscus. This was an Act that was meant to be an equaliser. The Act was meant to address the huge resources that were used to service a small percentage of people. There was a huge investment in infrastructure, equipment, and human resources in the private healthcare system. All of that could be pooled together to ensure that there was a single funding health entity, which could pool all those resources. This would make sure that there was an improvement in services for the whole population. The Act was meant to open up the resources which the large majority of South Africans were not able to access. The Department was not oblivious to the fact that there were people who were concerned, especially those who earned a good income and were able to access private facilities through private insurance. Those who provided the services also had anxiety. The Department did not have the option of just leaving the status quo as it was. The very high-income individuals were a small component of society. The majority of people who carried private healthcare facilities were middle-income earners. The contributions were starting to suffocate the employers and the employees. There were often defaults. The primary members of medical schemes had been reducing, rather than increasing. The Department believed that through this equalisation even those who were contributing to private insurance would have relief. There would be a pooling of resources and a single purchaser, who was able to use both public and private facilities. The Department would be able to negotiate the prices with private providers.

He discussed the role of private providers, including private hospitals. In countries where there was a universal health system, using the size of the entire population as a single purchaser, Government would be able to negotiate better prices. There could also be other ways of reimbursement and not a fee for service. There was an opportunity for those providing private services to service a bigger population. Many private providers had huge facilities, and huge equipment, which were working between 40% to 60%. They would have an opportunity to service a bigger population. That meant there needed to be a better negotiation in terms of how much they were reimbursed in terms of providing those services. The Department believed that this could be a win-win situation. What was key was that each and every person needed to have at least a primary healthcare facility in which they received their first line of health services. It could be a doctor or a general practitioner. It could be a health service clinic, where both nurses and doctors would be able to provide the service. Through that, if specialist attention was needed they would then be referred to those specialist services, which would be contracted to be service providers within the NHI.

He discussed current infrastructure challenges. A number of Members had raised that question. The Bill was clear that the NHI would be implemented in stages. It would start with primary health, as the main foundation of providing services. Then it would be built up to the highest level. This would provide time for the overburdened public sector, which needed a lot more investment. This would provide time for increased investment and further improvement, both in terms of infrastructure and equipment. That was why there was also the Office of Health Standards and Compliance to continue to assess those facilities and to indicate the areas where there was a need for improvement. As more facilities become ready to provide secondary and then tertiary services, those facilities could then be accredited. That would spur the others to come on board. The approach was to build incrementally, and through the Office of Health Standards identify the shortcomings in public health so that they could be addressed. That way more and more facilities would be able to come onboard.

Prof Crisp responded to the question of IDs. During Covid, it had been identified that there were around 3 million people who did not have IDs. The majority of those were South Africans. That was why the Department spoke about biometric identification, using fingerprints. The Department was collaborating with the Department of Home Affairs. They worked together to improve the way in which Government got people their identities. The Department would continue to do that. It had a specific births and deaths collaboration with the Department of Home Affairs. It was an ongoing process. If the Department used biometric identification and single registration numbers, then it was very easy to have a portal health record that followed the individual in the system. He discussed the registration process. During Covid, or when an individual visits a doctor or clinic for the first time, the person would fill in a form. The person would provide their name, ID, and where they lived. Some other information might be filled in as well. That was the registration. It was simple. With the NHI system, it was only necessary for the individual to do that once. If a person was unconscious or unable to speak for any reason, their fingerprint or ID document could be used to open their record. It was not a complicated process at all. It did not exclude anybody. During Covid, the Department was able to register a large number of undocumented people using system-generated ID numbers so that they could be vaccinated.

He responded to the question about what measures would be taken by the Department to not exclude the poorest. The NHI was designed to include the poorest. The phasing process was to deliberately include the poorest. Those were often the people who only had access to public health facilities, which may or may not comply with the Office of Health Standards and Compliance certification. Eventually, it would be gazetted and go for comment. The Department could not gazette regulations or anything to do with this until there was an Act. Once the Department had that, it would publish for comment a process for systematically increasing access for people to the Office of Health Standards and Compliance and other accreditation criteria. This had been discussed in the Portfolio Committee and an amendment had been made to the Bill to approve conditional registration or accreditation so that the Department was able to use a phasing-in period. The details needed to be worked out and published for public comment in due course.

He responded to the concerns about tender corruption. The NHI Fund would handle very few tenders. The accreditation was not a tender process. It was a voluntary registration by a service provider, public or private. There was no tender to go out. The prices would be fixed, and the way services would be delivered would be fixed. It would be regulated through what that provider was able to provide. He discussed the procurement process for goods, particularly health products. The NHI Fund was only doing the first stage. The Department would be pursuing a price-fixing process. The Fund would not go about the logistics of purchasing anything. The providers needed to purchase once those prices were set. There was far less vulnerability in the Fund than first thought when one looked at the Bill. He discussed the certificate of need. The Department had been taken to court, and it had nothing to do with the NHI Bill. Sections of the National Health Act had been challenged in the court. The Department had not been informed and did not represent itself. There had been a rescission hearing and the judgement had been handed down. The judgement had been in favour of the Department. There were already provisions in the Pharmacy Act, and other places, for pharmacies to comply with certificates of need. There were many other examples of this in the country where one could not just open a school, or various other things, at any place one wanted. It was deliberate for planning. In the Health Market Inquiry, there was a very strong motivation for a supply-side regulator to ensure that facilities were in the appropriate places. The Department agreed with all of those things. Those would be functions of the Fund. The Department was not too perturbed about that right now. The Department would deal with this as the cases arose.

He responded to the question about feasibility studies. This had been discussed, published, and presented by the Department many times over the years. In 2012 a costing had been done and it was in the white paper. There had also been many discussion papers by various academics, the Actuarial Society, and others, that had all been published. There had been strong guidance from the World Health Organization (WHO) that it was ill-advised to try and do a detailed costing of this kind of reform. No other country had done it. The NHI Fund would be done incrementally. The Department would set the target in which it would design and manage the system. The Department would only introduce the benefits it knew that it could afford within that envelope. The Department could refer the Members to those various studies that had been done and comments that had been made. They were wide in range because there was no agreed global methodology for doing this.

He discussed the infrastructure and service delivery budgets. The Department agreed that it was not reasonable to continue to cut the Department of Health budget every year. He appealed to the Members of Parliament to support the Department. When these budgets arrived at Parliament, the Members should not approve them. The Members should request that the budgets be increased so that the health services were protected. It did not help that Parliament continued to approve reduced budgets and then complained that the Department was not able to fill posts and fix infrastructure. The Department needed to protect what it had. Everyone needed to play a role in making sure that happened. The Department would do everything possible with the 10 budgets it had, but there was a limit to what was possible in the medium term. He discussed the accreditation of providers. The Department did not want a situation where it excluded any provider. These would be introduced gradually. The Department would start with conditional accreditation. It would slowly strengthen. It was an expensive process and it needed to be done slowly. It was not necessary to have inspectors. Much of this could be done by self-assessment and then by peer assessments. Only those who were already ready could be physically inspected by objective mechanisms and accreditation mechanisms. The Department was trying to find solutions and ensure that everyone was included in this. He discussed the provincial powers. The Acts of Parliament were created in terms of provisions of the Constitution. It was Parliament who amended the Acts. This Bill proposed amendments to the National Health Act, which assigned the functions to national and provinces. If this Act, with the amendments in Schedule 1, was adopted it meant that the functions of the various role-players would be reassigned. The Department did not believe that it was a constitutional issue at all. There was a legislative mandate in the Act for the Minister to ensure that the functions were appropriately provided. He discussed the onboarding of everybody, including district health managers. This was a systematic process. The National Department had been working with the Provincial Departments, in the beginning, to go through the practical implementations. The Department recently had a two-day workshop where a lot of questions had been asked and people could engage with the details. The Provincial Departments would now organise various sessions for their head offices and district managers. It was an educational process, and it would take some time for everybody to get onboard.

He discussed the protection of personal information. The Department was very rigid about this. The Department continued to be audited by the Auditor-General. The Department believed that the systems that were in place were very rigorous. In healthcare, this was, particularly private medical information. Health records were very private. The Department had a whole section that dealt with this whenever it dealt with personal information. He responded to the question of where the funds would come from. The complexity of the current system was that the money was all over the place. Even in the public sector, the money that was used for purchasing health services was in ten different Government Departments. Even in the public sector, it was complicated. Bits and pieces that were used to purchase healthcare services needed to be moved into the Fund, according to where they were and what the statutory provisions were. It needed to be moved systematically and slowly so as to not break the system. A huge amount of money was spent on healthcare in the country. Unfortunately, large amounts of it were spent on duplication, and unnecessary administration, because of the complexity of the system, and due to fraud and corruption in both the public and private sectors. The Department believed that there was more than enough money in the system, and it would take time to redirect it. He responded to the question of whether the Department would close private facilities. The Department would absolutely not close private facilities. Private healthcare facilities were a critical and cardinal part of the resources of the health system of the country. Two-thirds of all the medical specialists in the country worked in the private sector. 90% of the dentists were in the private sector. It would not be a good idea at all to close them. The Department wanted to limit what the private sector charged and how they were paid. He responded to the question about whether there was a cap on how much practitioners could charge. The answer was yes. The Fund would be purchasing. The user of the service would not pay a cent at the point of contact. That was the whole point of an insurance system. The user would pay in advance. The money would be pooled together into one common pool. That money would not be deposited into an account and just sit there as billions of rand. It would come in weekly transfers, as it did now with Government Departments. It would go out on a daily basis, paying to providers. There were never going to be huge sums of money sitting in a bank account. This was similar to how the Treasury and provincial treasuries would work. All public entities did not get lump sums of money that sat in a bank account waiting to be spent.

He discussed whether the Department had a practical plan for funding modalities. The Department did have a practical plan. There were very different sources, and the Department knew where they were and that they needed to be moved. The Department had engaged with many private providers and establishments. It was a mixed bag of reactions. There were some who felt threatened and who did not like what they heard. There were many who did not understand and were hearing misinformation in the public space. Overall, particularly in the big hospital environment, the Department had not had negative comments. It was mostly positive comments with some concerns for discussion. The Department met with the pharmaceutical industry regularly, through the Pharmaceutical Task Group. The Department met with laboratories and other providers of services. It had not been negative. The Department knew that the funders were anxious. It had seen the negative comments in the media space from the funders. It was obvious why the funders were more negative than the providers.

He responded to the question of whether the unemployed would be able to make monthly payments. The unemployed would not make any payments. There was no payment. If an individual was unemployed and had no income or had a grant and was buying goods, that individual was contributing through VAT and other taxes. Every person who lived in the country paid some form of tax. There was no monthly payment to be made by the unemployed. He discussed the issue relating to foreigners. Foreigners may access health services. It was specified which foreigners may access which services. If an individual was legally in the country and was legally part of the operations of the society then that person would be paying tax. That individual would benefit from the provisions of the Bill. For those in the country illegally, the Bill provided that the fund had to pay for emergency services. The Bill stipulated that Government would look after all children. The NHI Fund would look after all children in the country.

The Minister discussed ministerial overreach. This had been a point of discussion in the National Assembly. There were proposals from some political parties that the appointment of the NHI Fund Board should be by Parliament. Then the board would appoint a CEO. That had been a point of discussion for a while. Cabinet had looked into the matter. He discussed the concerns Cabinet had. He provided the example of the SABC. The board of that body was appointed in Parliament. It became a site of political machinations, in one way or another. The thought process was that the NHI Fund Board would be overseeing basic services. Cabinet did not want that board to become stuck in terms of the balance of forces in Parliament. It could become paralysed in that process. The final decision was that it should rather be the Minister who appointed the board, after approval by Cabinet. He was aware that there were some Members of Parliament who were not happy with that. He was sure that the NCOP would have certain discussions on this matter. This would be subjected to public scrutiny. The members of the board would be subject to public nomination. It would be a very transparent process. The members of the board would have relevant skills to be able to oversee a function like this. The board should recommend a CEO who was competent. That board would then take responsibility for the rest of the executive and management.

He responded to the question of whether an individual could choose their medical schemes. The Bill made provision that incrementally the NHI Fund, as it got stronger, should cover more and more service packages. As it covered a particular service, the private schemes should only cover services that were not covered. Otherwise, the ability to negotiate particular services would then collapse. He noted that health was a concurrent function. There would continue to be certain responsibilities in terms of services at the provincial level. Those responsibilities would be further negotiated in terms of the Act. The functions and responsibilities between national and provincial would be under discussion.

He discussed the details of complaints procedures. An Act like this could not take care of all those details. The details would be covered through the regulations. He discussed workforce retention and lessons learned. The Department was learning from the national health service in the UK, its strengths, and challenges. There were a number of different countries with slightly different models. The Department was also looking at the lessons learned from those countries. The workforce would include public service workers. There would also be an opportunity for private providers, GPs, physiotherapists, and specialists. There were specialists who were earning a high income because of the current fee for service, where providers could just close their eyes and just ask for a price. However, there would be certainty for service providers. There would be certainty over the services that each service provider would be contracted to supply. Some service providers that were smiling all the way to the back may feel threatened at the moment. He noted that issues of constitutionality had been a major issue in the National Assembly.

Dr Sandile Buthelezi, Director General, Department of Health, asked Dr Thulare to respond to any questions that had not been answered.

Dr Aquina Thulare, Technical Specialist on Health Economics for the NHI, Department of Health, said that Prof Crisp had provided a comprehensive response. She discussed the issue of choice and the role of medical schemes. As this Bill was developed, there were many studies that were undertaken to understand what happened in other contexts. She noted that section 33 of the NHI Bill made provision for medical schemes to provide for what was not reimbursable by the NHI. This was similar to what happened in France and Canada. All of the provinces in Canada did not allow for supplementarity. There was no complimentary insurance other than the national health insurance of Canada. The decision on how section 33 was structured was to ensure that the Department could pool so that everyone was covered. The pooling needed to be maximised to ensure that services were extended to cover everybody, irrespective of where they came from. Whether they were rich or poor, they would be covered. She discussed the complaints and procedures. The Bill had made provisions for internal complaints mechanisms inside the Fund. There would be a tribunal that had the status of a court. There was also the Health Ombud whom the public was at liberty to complain to. There were also other Section Nine Institutions that could be used by the public to make complaints. If an individual was unhappy with their provider they could contact the Health Professions Council. These were the routes for complaining, which was not directly related to how the Minister exercised his authority, even though some of the institutions accounted to the Minister. She discussed the timeframes for implementing the NHI. The Department had outlined in the section on transitional arrangements that the NHI would be implemented over phases. The Department was looking at a time horizon of up to 2029. The Department expected that by that time it would have implemented fully what it intended to do.

Adv Kgorohlo Moabelo, Director: Legal Services, Department of Health, discussed the issue relating to sections 36 to 40 of the Act that had been declared unconstitutional by the court. The Department had approached the court to apply for a rescission of the decision. There had been a default judgment, meaning the judgement was made without the Department presenting its side. Because of that decision, sections 36 to 40 were still valid and part of the National Health Act. The Department would now have an opportunity to present its case to the court before the court takes a decision. The matter was still ongoing. The court would hear both parties and then make a decision. This was a constitutional matter. Even if the High Court found that sections 36 to 40 was unconstitutional, the matter would still need to be taken to the Constitutional Court for the Constitutional Court to confirm whether those sections were constitutional or not. If it was found to be unconstitutional then the court usually gave Government two years to make the amendment. He discussed the constitutionality of the NHI Bill, as it had been passed by the National Assembly. The State Law Advisor and the Department scrutinised the Bill during the preparation period before it had even been submitted to Cabinet to check the constitutionality. It was found to be constitutional. The amendments relating to other Acts, which were now contained in the schedules to the Bill were constitutional and valid. That was how Parliament amended other Acts that were not part of that Act. There would be a new law coming, but this law would amend various other Acts. That was usually done through the schedules attached to the Act. A lot of the National Health Act was being amended. There were sections of other Acts also being amended. Those sections were valid and would be processed by the NCOP. He noted that in South Africa any individual had the right to test the constitutionality of an Act that had been passed by Parliament. It was only the Constitutional Court that could take a decision that an Act, or particular sections of an Act, were unconstitutional.

Dr Buthelezi said that sections 36 to 40 were part of the National Health Act. Those were the sections that dealt with the certificate of need.

Minister Phaahla said that the Department had tried its best to respond to the comments and questions of Members. He noted that there would be more opportunities for the Committee to engage with the Department.

The Chairperson thanked the Minister and the Department for the responses. He thanked the Department for a detailed overview and briefing on the NHI Bill. The Bill had been passed by the National Assembly and was now being referred to the NCOP. Members had engaged with the NHI Bill at large, asking for clarity and asking questions. The legal issues and legislative matters had been very well covered. The NCOP would now move forward with the Bill. The Bill was on a six-week cycle. The next step would be the provincial briefings, public hearings in the provinces, and a call for submissions by the Committee. Finally, there would be the finalisation of the timeframes for the NCOP. That was how the process would unfold. This would not be the last time that the Committee was engaging with the Department. This was a process. At the end of this process, it needed to be ensured that a healthy community was provided for in South Africa. The Chairperson thanked the Minister, and all stakeholders present, for attending the meeting.

Consideration and adoption of Committee Minutes

The Committee considered the draft minutes of the meeting of the Select Committee on Health and Social Services, dated 16 May 2023.

Ms Nkosi moved for the adoption of the minutes.

Mr Nchabeleng seconded the adoption of the minutes.

The minutes were adopted by the Committee.

Consideration and adoption of DWYPD Budget Vote report

The Committee considered the Policy Assessment and Recommendations Report of the Select Committee on Health and Social Services on the Annual Performance Plan and Budget of the Department of Women, Youth, and Persons with Disabilities, Vote 20, dated 20 June 2023.

Mr Nchabeleng moved for the adoption of the report.

Ms Nkosi seconded the adoption of the report.

The report was adopted by the Committee.

Consideration and adoption of the Draft Third Term Programme

The Committee considered its draft third term programme.

Mr Nchabeleng moved for the adoption of the draft programme.

Ms Ndongeni seconded the adoption of the draft programme.

The draft programme was adopted by the Committee.

Consideration and adoption of the Draft Fourth Term Programme

The Committee considered its draft fourth term programme.

Ms Nkosi moved for the adoption of the draft programme.

Mr Ntsube seconded the adoption of the draft programme.

The draft programme was adopted by the Committee.

The Chairperson thanked the Members for attending the meeting.

The meeting was adjourned.