NHI Bill: Western Cape public hearings

Meeting report

Opening Remarks
The Chairperson provided background to the legislative process The Bill was referred to the Committee by the WCPP Speaker on 23 June 2023. On 4 August the Committee was briefed by Dr Nicholas Crisp from NDOH on the Bill. The Bill was then advertised in mainstream and community newspapers in three official languages to reach stakeholders from different communities to encourage public participation on the Bill. In addition, a notice about the public hearings was sent to municipalities and health stakeholders to give verbal and written submissions on the NHI Bill. The Committee is complying with section 118 of the Constitution and Standing Rule 72 of the Provincial Parliament Standing Rules which states, ‘The provincial parliament must facilitate public involvement in the process of its committees as required by the Constitution.’

After the public hearings, the Committee will consider the input made by the public and formulate the negotiating mandate of the province on the Bill. Once the negotiating mandate is submitted to the National Council of Provinces (NCOP), the Committee will meet again later to consider its final mandate on the Bill and submit this to the NCOP for consideration.

National Department of Health (NDOH) overview of NHI Bill
Adv Micro Moabelo, NDOH Head of Legal Services, explained that NHI is a funding model where resources are pooled together to create a fund that is responsible for paying services rendered to patients in health institutions. These institutions must be accredited and registered with the NHI Fund. In other words, NHI will act as a national medical aid service with mandatory pre-payment sources which means that members of the public are not going to contribute by virtue of the NHI being a public fund financed by the government.

The Bill aims to achieve universal access to quality healthcare services in the country in accordance with section 27 of the Constitution on the progressive realisation to healthcare for all. The Bill establishes the NHI Fund. Money will be pooled into this Fund which is responsible for the payment of healthcare services. The Bill sets out the powers, functions, and governance structures of the Fund. It provides a framework for the strategic purchasing of healthcare services which means the payment of an individual’s medical cost once they have received quality healthcare services from healthcare institutions accredited and registered with the Fund. In sum this Bill establishes the NHI Fund as a legally defined organ of the state so the Fund is a stand-alone structure not tied to the Department of Health.

There is a limitation on what the Fund can pay. In the case where the Fund does not cover certain services, users will have a right to have their own medical aid. Clause 33 talks about the role of medical aid schemes once the NHI Bill has been fully implemented in phase two in 2029. Medical aid schemes will still exist but for complementary medical services excluded by the Fund. The cost of medical services is free at the point of care. This means users will not pay unless services are not covered by the Fund.

Financial Intermediary Association of South Africa submission
Mr Gary Feldman, representing FIA, explained that although the organisation supports the goal of expanded universal healthcare FIA recognises that the Fund should not be centralised, in other words it should be a ward-based primary healthcare fund. Each region and province must determine what is needed and how to allocate resources at ground level. There are many barriers to universal healthcare in South Africa and the funding of the NHI is a major concern for the organisation and these concerns have equally been raised by the Minister of Finance recently.

The roll out of universal healthcare will require a collective effort with sound policy decisions that do not adopt a one-size-fits-all approach. Private healthcare is a national asset delivering innovative and world class services, but it is not sustainable in this current environment and should be subject to accommodating broader society. FIA believes that the two-tier system is important because the system offers people the right to choose different forms of healthcare coverage available to them.

The notion of a minimum benefit package is appreciated but everyone already has access to this. People have diverse medical needs and preferences in how they navigate fulfilling those needs. However, FIA is excited with the prospect of incentivising employers to promote a healthy workforce. If employers are incentivised correctly this would take the pressure off the public healthcare system. The unfortunate consequence of the Bill being passed in its current form is the potential court challenges it will likely be subjected to. The risk of lengthy court battles cannot be underestimated, and this may delay the Bill coming into effect and its implementation. FIA proposes that the Bill be amended as a precautionary measure.

Momentum Health Solutions submission on NHI Bill
Dr Boshoff Steenekamp, Momentum Health Solutions Epidemiologist & Healthcare Strategist, said the organisation is in full support of the steps taken towards universal health coverage because access to healthcare for all people is critical. Achieving universal health coverage is not easy and very few countries have succeeded in doing it well. The introduction of the NHI will reduce the provincial health budget by about 28% which will weaken the provincial health departments. All healthcare purchasing decisions will no longer be taken at provincial level but will be made by the NHI Fund. This reduction in funding of the provincial public sector could destroy it. This will be an additional blow on top of the current budget cuts, compounded by high levels of accruals and the medico-legal claims the provinces face.

Pilot studies must be done before these funds are withdrawn from the provincial budget allocation. These pilots must demonstrate that it is feasible for a central fund to purchase equitable quality and affordable healthcare services for the population across all provinces with diverse health profiles. The organisation is particularly concerned about the rural poor. How will a central fund support those living in these far-off locations. Provinces and government must do extensive work before the NHI can be implemented. There needs to be further development on the concept of the purchaser-provider split because this is a technical and complex relationship which is required for the successful transition towards the NHI. The Bill must be amended to allow for a systematically planned gradual implementation so that we can implement only that which has been tested and proved to be a workable solution.

Clause 33 of the Bill restricts the role of medical health insurance and therefore reduces the availability of resources to fund universal health coverage. The clause restricts the role of medical schemes to that of a complementary cover only. The clause is vague and does nothing to promote the attainment of universal health coverage. This means that current private contributions to medical schemes often subsidised by employers will no longer be available to fund healthcare, meaning that taxes would have to be increased to fund care. Low-cost primary care insurance is important to achieve universal health coverage. These products support millions of South Africans assisting them to access primary care.

To raise the R200 billion required for the NHI means that the VAT rate would have to be increased from 15% to 21%. Higher taxes to fund the NHI will contribute to lower income, higher unemployment, increased poverty and inequality, higher inflation and interest rates, and lower company profits. All of this will contribute to a lower standard of living. The parliamentary legal advisor during the Portfolio Committee of Health deliberations had raised concerns about the Bill not meeting constitutional muster. Concerns about constitutionality will delay the reforms required to transform the health system.

Section 27 of the Constitution provides that everyone has the right to have access to healthcare and the NHI Bill in its current form infringes on this right to care in numerous ways. The Bill reduces access to care for refugees and asylum seekers and it limits coverage to adherence to referral channels, it also limits access to care for medical scheme members in a manner that is inconsistent with the ruling of the Constitutional Court in the Grootboom judgment. The onus is on the National Department of Health to do a full review and analysis of the NHI benefits and the impact of the infringement of these constitutional rights.

Ms A Bans (ANC) said that the two representatives that had just spoken on behalf of their organisations stated that they are supporting the Bill but with the necessary amendments suggested in their written submissions. She asked the Chairperson to guide the speakers in their submissions to clarify if they support or oppose the current Bill when they voice their views.

The Chairperson stated that it was clear from the first two submissions support the Bill but with the necessary amendments. He asked that the speakers clearly share their stance on the Bill by indicating support or dissent or supported with amendments.

Business Unity South Africa (BUSA) submission on NHI Bill
Dr Stavros Nicolaou, BUSA Non-Executive Director, said that while BUSA supports the aims of the NHI Bill, the reality is that a single fund approach is unworkable and it would exacerbate, rather than reduce health inequality in South Africa. BUSA proposed a few critical changes to the NHI Bill to allow for the private sector to support the NHI in a collaborative effort with the public sector. The country is at its best when the private and public sector work together.

Prof Roseanne Harris, BUSA Member, spoke to the funding and the cost. Concerns arise from the fact that after a lengthy deliberation on the NHI proposals, the cost has not been updated since 2011. The World Health Organisation is clear that health system planning for universal health coverage needs to consider realistic scenarios. BUSA would like to be part of the process of contributing to developing these scenarios on a realistic basis. The WHO also says that we should work in the context of our existing health systems to build on what we have. The National Department has estimated that R200 billion will be required to be raised through taxes. This suggests an increase of about 30% of what citizens are paying in income tax. These kinds of numbers have already damaged investor confidence and are negatively affecting our economic climate. Raising an amount like that will result in funding per person that is only around a third of what medical schemes currently have. So the kind of limits to benefits that were suggested in the opening presentation would be significant in order to deliver based on that funding.

It is important to recognise that section 77 of the Constitution provides that changes to taxes is the ambit of National Treasury, and it requires a Money Bill. This clause 49 of the NHI Bill conflicts with section 77. On the risks of single fund models, the NHI as a single purchaser of healthcare products and services means that it is entirely dependent on tax funding to cover the entire population even the portion of the population that is currently paying for themselves. This is not an efficient way of funding healthcare particularly in a country with resources like ours and it deters investment into the country and limits the growth of innovation. It is health technologies and these kinds of innovations that will help this country expand access to healthcare.

There is also an increasing healthcare shortage in the country and the challenge with the single purchaser approach is that once the Fund has dictated the contractual terms, there is no role for healthcare providers who do not contract with the Fund, and this means that we will lose them. We cannot afford to lose any more healthcare providers. In fact, we need to be investing in training platforms to build our healthcare personnel and upskill them to deliver care to the population.

There is no basis for restricting medical aid schemes. This is a provision in clause 33 that was only introduced in the 2019 version of the NHI Bill. There is no real reason for restricting that role. The kinds of objectives that have been set out including mandatory pre-payment can still be met on a collaborative basis without these restrictions to the role of medical schemes. The single fund approach also comes at a risk of accumulating a deficit. We have seen this in countries like Ghana and Indonesia which also adopted a single fund approach. It either requires a bail-out from tax funding or a reduction in benefits. These are the kinds of things that a collaborative approach to building an incremental innovative implementation can help us to achieve.

Board of Healthcare Funders (BHF) submission on NHI Bill
Mr Khaya Skhosana, BHF representative, said that BHF supports the concept of universal healthcare coverage but not the NHI Bill in its current form. There are certain areas of the Bill that require amendments and those areas have been identified in its written submission accompanied by recommendations.

Funding and the availability of infrastructure are two preconditions for the NHI to function optimally. It presents the Fund as a panacea to all the healthcare challenges in the country. This is misleading. BHF would like to see the government place as much emphasis on other aspects of healthcare provision such as healthcare infrastructure.

The Minister of Health has been quoted as saying that we require at least R200 billion to transform our infrastructure in a manner that will enable access to quality healthcare. We are not aware about how that money is going to be raised and what the project plan is to ensure that our public healthcare infrastructure is ready and up to standard to service South Africans when the NHI comes into force. The Bill is being introduced to alleviate pressure from the poor but increasing VAT from 15% to 21.5% to fund the NHI is going to do the exact opposite. It is going to make life difficult for the majority of South Africans.

The medical schemes industry is playing a huge role in assisting with funding of access to healthcare in the country therefore the BHF position is that medical schemes should be allowed to exist. Clause 33 of the Bill states that once NHI has been fully implemented as determined by the Minister, medical aid schemes will only provide complementary services. Given that this discussion is about universal health coverage, meaning a comprehensive or full range of services, the effect of this means that medical aid schemes will cease to exist because there will be nothing left to cover except cosmetic surgeries which are not healthcare services. BHF rejects clause 33. Dictating to citizens what they should do with their hard-earned money is unconstitutional and therefore cannot be supported.

Through NHI the government seeks to nationalise and monopolise healthcare funding in the country. Unfortunately, the government's track record of running monopolies and funds leaves much to be desired.

For example, today and for the past 15 years the country has been battling load shedding because of government’s monopoly on electricity generation and they are running to the private sector for solutions. The private medical sector is thriving so why destroy it at the expense of the NHI when eventually the Fund itself collapses, government will look back to the very same private sector for solutions.

Another example is the Road Accident Fund. It is bankrupt to the tune of R322 billion as of 31 March 2023. Their results for 2021, 2022, and 2023 have not yet been published. This is most likely the fate that awaits NHI. The medical schemes industry should be allowed to exist along with NHI to help alleviate such pressures. Medical schemes as of December 2021 had accumulated reserves of well over R100 billion which is a sign of financial sustainability for the industry. We cannot afford for the industry to be legislated out of existence through nationalisation. While BHF supports the concept of universal coverage and understands that the government is using NHI as a tool to achieve this, it proposes that clause 33 be scrapped from the Bill in its entirety. Medical schemes must be allowed to exist alongside NHI and to cover everything that NHI covers. This will alleviate financial pressure from the Fund itself.

Clicks submission on NHI Bill
Ms Bronwyn Macauley, Clicks Healthcare Services Manager, said that Clicks is in support of what the NHI seeks to achieve but in its written submission to the Committee it has expressed concerns about clause 33.

Mediclinic submission on NHI Bill
Ms Clara Findley, Mediclinic Chief Legal Officer, said there are serious concerns about the constitutionality of the Bill, but Mediclinic believes there are mechanisms to address these. If these concerns are not addressed the result may be that the problematic provisions will be set aside by the court. The Bill breaches the right to access to health services, the very right on which the Bill itself is based. The Bill is vague as it does not describe with reasonable certainty the nature and scope of the services which will be provided under the scheme and how registered users will be able to access them. The Bill also does not comply with the public procurement standards in section 217 of the Constitution.

Cape Metropolitan Health Forum submission on NHI Bill
Ms Damaris Kiewiets, CMHF Chairperson, said that the current dysfunctionality of the healthcare system must be fixed first because clients are not being cared for in the manner that they should be. The NHI will bring quality universal health care for everyone. The NHI will bring South Africans peace of mind because it will guarantee citizens that if anything happens to them, they will be prioritised whether they are in Timbuktu or Blouberg. There will no longer be a divide in access to healthcare which is critical to eradicate the perception that healthcare is a privilege.

Questions from the Public
Members of the public in attendance were given an opportunity to ask questions and submit their views on the Bill.

Mr Michael Zondi, ANC Parliamentary Caucus Secretary, said that the NHI is long overdue. Many people have been suffering due to the unequal and subpar access to healthcare services. He was a victim of South Africa’s healthcare system when he was diagnosed with leukaemia. The private healthcare providers refused to continue treating him after his medical aid funds had been exhausted by the expensive cancer treatment. He reiterated that his constituency was in support of the NHI Bill, and he supported the Bill in his personal capacity as well.

Mr Bongikhaya Qhama, Deputy-General Secretary: South African National Civic Organisation (SANCO) said the organisation is in support of the NHI Bill because it will put an end to the exorbitant prices charged by the private sector, hospitals and specialists enabling all South Africans to receive good medical care. The Bill aims to eradicate the inequalities in accessing quality healthcare. One of the first questions you are asked when injured is if you have medical aid. If you do not have medical aid, you are turned away and your life becomes useless and degraded by virtue of your inability to afford quality care. Under NHI people will no longer be expected to pay additional fees because the Fund will reimburse the healthcare providers for their services and prescription fees.

Mr Silverton Ntushelo, Drafter and Speech Writer for ANC Parliamentary Caucus: The ANC supports the Bill in line with the government’s Constitutional imperative of accessible healthcare as a basic human right. The Bill is also in line with the ruling party’s vision for a better life for all. It is critical for the government to improve and upgrade the healthcare infrastructure but what needs to be done before this is achieved is to eliminate the imbalances between the private and public health sectors. The request is that the NCOP moves with speed so that the legislation can be passedfor the President to put their signature and seal this Bill.

Mr Luthando Nogcinisa, ANC Chief Whip Advisor and COSATU member, said as we mark the painful and unfortunate 75th anniversary of Apartheid, one wonders after hearing the commentary of the private healthcare provider organisations that represent business if business in 1948 had the courage to say that apartheid would be unworkable and would effectively exclude most people and it would be an inefficient system. If they had had the courage, then maybe we would not be where we are today. Apartheid created a system where the majority of South Africans were excluded from benefiting from quality education, quality healthcare and so on. Today we must correct this. Those who have benefitted and continue to profit from this unequal system do not want change. They prefer government to pass a law that tinkers on the periphery and does not address the core contradictions in our society. This Bill must address these contradictions and workers are in full support of this Bill as is.

Mr Benson Ngcintsu, South African Communist Party (SACP) representative, said that the SACP supports the NHI Bill. It believes that the Bill marks an end to an era of commodification of access to basic healthcare. Presently access has become a commodity and it is only accessed by those who are rich and have money and they are predominantly white. Government must move towards implementing the Bill because access to healthcare as a right and not a privilege is urgent. The NHI Fund must be adequately protected from the forces of corruption.

Mr Sipho Roma from Ward 52 said that those who are not poor do not understand the plight of inaccessible healthcare. We are a constitutional country and therefore we must be concerned with the lawfulness of the Bill, but we cannot forget the urgency of access to quality healthcare for the majority. The crux of the matter is that it is either the people or monopoly capital. It is either we support business and forget people altogether or we prioritise people. Healthcare is racially divided because the services in the black areas and the poor areas is different from the services of the white and affluent areas. The people of the country have been patient and waited long enough. The government have been dragging its feet. The Bill is overdue, and it makes room for the private sector to work hand in hand with the public sector.

Mr Stewart Collins, representing an insurance brokerage, stated that South Africa has both the best and the worst medical healthcare services in the world which is why this Bill is welcomed to even out the playing field. Item 5.1 sets out the objectives of the Bill and refers to social solidarity and opportunity to expand healthcare. He suggested that this section be amended to include the concept of a national medical aid. The Bill will be more widely supported if the legislatures refer to the NHI Fund as a medical aid for all. In South Africa 10% of the wealthiest people earn 70% of the wealth in South Africa. On the other end of the scale 70% of South Africans only earn 10%. These are rough figures, but it is close to the lived reality.

The Bill answers questions about the unequal treatment and services of healthcare providers. Less than 20% of South African are members of medical aid schemes, the rest rely on government hospitals and yet 70% of specialists serve the private industry. This needs to change and the only way it will change is by all parties in the private and public sector coming together to give their support to the Bill. On the issue of funding, medical aid schemes should be allowed to continue to exist but they must contribute a portion of members’ medical aid premium to the NHI Fund.

An ANC Ward 46 City of Cape Town representative noted that one of the speakers had misquoted clause 33 as doing away with medical aid schemes. She clarified that the clause was not in any way excluding medical aid schemes from playing a role in the Fund. Once the NHI Fund has been fully implemented, medical aid schemes will be allowed to provide complementary services which are not provided by the Fund. Currently some of the medical aid schemes offer services that are not readily used by their members but those services that are most used are not readily available or offered by these medical aid schemes. This is why their members run out of benefits in most cases. There is something inherently dysfunctional with the way that these schemes package their services.

When the Fund is fully implemented, will the contributions of members of medical aid schemes decrease? She fully supported the Bill and stated that she prefers the Bill to remain an insurance rather than an aid. On the Clause 54(1)(b) offences, which persons are being referred to? Also the fine of R100 000 does not make sense. Cuba provides free transport and healthcare. For a country that has suffered an embargo for many years, this is commendable and it is possible to attain national health coverage.

Dr Paul Nkurunziza, City of Cape Town Health Director, said the Bill mentions municipal health services in passing in the definition of healthcare services but it does not mention this anywhere else so it is not clear if they will be funded by the Bill or if they are outside the scope of the Bill.

Ms Samantha September-February, Nehawu Provincial Treasurer, said that Nehawu believes that the NHI Bill is progressive in addressing the challenges of the two-tier healthcare system. The public health sector is on the verge of collapse while the private healthcare sector is characterised by high cost of care which limits access to a minority. On the other end of the spectrum is the public health sector which is under resourced and overcrowded. If the country continues with the existing healthcare system that discriminates against people according to their socio-economic status, there will be no progress in addressing the triple burden of disease that the country is faced with. Nehawu supports the NHI Bill because it wants a healthcare system that is fair and equal. The private healthcare system is far from perfect, with the spiralling cost of care and lack of competition in the market. The price of care is increasing but the benefits are being reduced at a very fast pace. The government can no longer be a bystander to this kind of corporate abuse.

It goes without saying that South Africa’s public healthcare system is resource restrained and lacks in its provision of quality healthcare. As much as it is known for being unreliable with long waiting times and bad service, but the core of the problem is the lack of financial and human resources. There is a need for a more equal distribution of resources between private and public healthcare. Nehawu believes that the NHI will enable the equal distribution of resources by enforcing a single healthcare system for all.

A disproportionately large amount of money is spent on the private healthcare system whereas the public healthcare system is treating far more individuals than the private sector. The WHO and the OECD have conceded that South Africa is the only country in the world where so much money is spent on very few people. The majority of South Africans depend on public healthcare and even those with medical insurance turn to public healthcare for services not offered by the private healthcare system.

The greatest killer of South Africans is TB. There are more than 400 000 South Africans being treated for TB each year. All of them, regardless of socio-economic status are treated by the public sector. The private sector is not treating any TB patients. The TB cure rate used to be 67% in 2009. In 2016 it increased to 85%. The second biggest killer is HIV/AIDS, there are 6 million South Africans infected by the virus with the public sector treating 3.5 million HIV/AIDS patients whereas the private sector despite its huge resources only treats 200 000 HIV/AIDS patients. This shows that although the public healthcare system is underfunded and under resourced it is achieving a lot and with the NHI Bill it will be able to improve the quality and care of the public sector.

Ms Siyathemba Sokopo, ANC Parliamentary Researcher, said the size of her pocket should not dictate whether she is deserving of human dignity, the right to equality, and the right to affordable and accessible healthcare. Currently the two-tier healthcare system takes away the majority of South Africans dignity because their rights are undermined by the fact that their socio-economic status bars them from accessing quality healthcare. The NHI Bill speaks to the right to healthcare, equality for all and human dignity. The private sector is more concerned with protecting their pocket rather than genuinely advocating for the health of all South Africans and not just a minority.

Mr Lizo Khalipa from Ward 16 in Eerste River, said that Ward 16 is in full support of the NHI Bill as is. South Africa is one of the most unequal societies in the world and the healthcare system in the country reflects this. It reflects the unequal access to services. All South Africans no matter the race will have access to quality health services through the NHI Bill. This will alleviate the economic burden on so many South Africans who can no longer afford medical aid. The amendments that has been suggested are simply a delay tactic to postpone the implementation of this Bill.

Mr Letlhogonolo Lebenya, representing the South African Communist Party, said businesses in the private sector are all echoing the same sentiment, which is whether South Africa is prepared to usher in the NHI Fund. This is tantamount to saying that a farmer must refrain from planting because it is not raining. This means that we will have to wait until the conditions are suitable for us to implement the NHI. In the meantime we should neglect the poorest of the poor who are the mass population of South Africa just because the conditions are not suitable. Public policy in its nature is not value-free hence the private sector is coming forward guns blazing and threatening the proponents of the Bill with legalities as they represent their values which is profit maximisation because sickness is their business. The SACP is fully behind the NHI in its entirety.

Nkoti Maleka, representing Ward 69 in Masiphumelele, said the residents of Masiphumelele fully support the NHI Bill in its entirety. The private medical health sector has missed the point of this Bill. The Bill’s intention is not to do away with medical aid schemes. The Freedom Charter says that people shall share in the country’s wealth. Those who are wealthy must share with those who are not wealthy. People are concerned about how the Bill will be implemented at the provincial and district level. These questions have already been responded to in the presentation. There will be a district health management office at the district level and their responsibility will be to facilitate, support, and coordinate provision of the healthcare services.

Ms Jackie Mariman, representing Mitchells Plain stated that she fully supports the NHI Bill because medical aid schemes have failed her dismally. After paying her premiums every month when she needed the aid the most, she was told that her funds were depleted. This Bill caters for everyone. It does not discriminate against those with or without funds. Everyone benefits.

Ms Adrienne Williams said that she was born with a hole in her heart and had to undergo open heart surgery at the age of two and a half years. The surgery was done by a public hospital, Red Cross. A few years ago she collapsed at work and was rushed to a hospital in Constantia. The first question she was asked when she entered the hospital was if she had medical aid. As she did not, she had to pay R3000 out of pocket within 90 days. Her health problems persisted but since she could not afford to go back to the Constantia hospital she visited a public hospital with equipment nowhere near as advanced and technical as Constantia. However, the medication she received from the public hospital got her back on her feet fit for work. The public healthcare system has done very good work. In her closing remarks she emphasised her support for the NHI Bill.

Ms Latoya Nzimande, representing Manenberg, welcomed the adoption of the Bill. Are there mechanisms in place to educate communities about the NHI Bill? Is government intending to implement services in the rural areas as well and educate the rural population about the Bill? Will this Bill improve infrastructure and services in existing public healthcare facilities?

Ms Halema Isaacs, representing the Manenberg Health Forum, said the forum supports the Bill. How is the NHI Fund going to be split? There are more people using public facilities than the private sector.

Ms Vanessa Kati, representing the Manenberg Health Forum, asked if there will be two health budgets – one for health infrastructure and the other for health services? Will provinces still get their equitable share from Treasury, or will it get funded only through the NHI for services provided? Has the package of services that will be provided by NHI been defined?

NDOH response
Adv Micro Moabelo, NDOH Head of Legal Services, replied that the NHI is going to be a financing model and it is going to be implemented by district management offices. There is going to be a single budget contributing to the Fund. The Fund is going to distribute resources according to the health needs of each district. This is why clause 5 speaks to the registration and accreditation of healthcare providers so that there can be appropriate planning well in advance to meet the needs that are proportional to each district.

There is a Benefits Advisory Committee that will advise the Minister and the Minister will issue regulations to determine the necessary benefit packages. There is no set or defined package in the NHI Bill. The services to be reimbursed for will be determined by the clinician at the point of service. On the provincial equitable share, the Bill in clause 49 states that there will be a shift from the provincial equitable share.

It is the NCOP through the provinces that will take public inputs into consideration. For instance, there are suggestions about removing clause 33. It is up to the NCOP to decide if they agree with that proposal and, if they agree, then it will be amended. If it is amended it will have to go back to the National Assembly for reconsideration until there is consensus between the two houses.

On clause 54 which deals with offences and penalties, the word 'any person in law' refers to a natural person and a juristic person. Juristic persons are companies. So clause 54 includes warm-bodied humans and companies as well. The clause covers both. The R100 000 cap and five-year imprisonment will be up to the court to take into consideration if the penalties should be combined. In other words, it will be left to the discretion of the courts if you are not only fined but also imprisoned. If the clause 54 sentence is too light, the public can submit proposals to suggest what would be fair and just

Clause 33 refers to the Minister making regulations on how medical aids will continue to exist and it clearly indicates that this will be for the purpose of prescribing benefits that are not covered by the NHI Fund. This means that those benefits will be complementary. In terms of municipal health services, the Bill creates a body that will reimburse service providers if they are municipalities or public clinics or hospitals.

Closing remarks
Mr E Njandu (ANC) acknowledged the inputs and submissions made by stakeholders and the public at large and appreciated those submissions that supported the Bill’s transformative aims. The government has an obligation to ensure that every citizen has accessible and equal health services which is in line with the Constitution and that can only happen through the implementation of the Bill. Three months ago, a government delegation visited South Korea for the purpose of a knowledge exchange of best practices. The delegation received advice for each phase of the NHI legislation. South Korea fully implemented its national health insurance successfully. The National Assembly has endorsed the Bill, and it is now with the provinces for public hearings. The Bill will come back to the NCOP for consideration and then tabled in the NCOP Chamber and then sent to the President for his signature. Thereafter the implementation of the different phases will begin.

The Chairperson thanked everyone for their contributions and inputs.

The meeting was adjourned.