National Health Insurance (NHI) Bill: Consideration of Public Submissions

Meeting report

Opening Remarks and Discussions
The Chairperson opened the meeting by reminding all that the meeting was convened following the postponement of the last sitting on 31 October 2023. The decision was taken then that more time was required to capture the submissions received from the public, including those received after the set time on the day of the deadline. These would then be sent to the Department for analysis.

Mr E Nchabeleng (ANC, Limpopo) confirmed this resolution of the Committee but noted it had become apparent that not all submissions were sent to the Department. He wished to know what challenges had led to the Secretariat not implementing the resolution, and if any support was required in this regard.

Ms E Nkosi (ANC, Mpumalanga) also enquired from the Secretariat about the reasons behind this.

The Chairperson emphasised that the resolutions of the Committee must be implemented by the Secretariat as taken.

The Committee Secretary explained that, after the last meeting, the submissions received were sent to the State Law Advisors, the parliamentary legal advisor and the Content Advisor. The report was compiled and shared with the Members of the Committee. She was unaware these were expected to be shared with the Department. She was not sure where the confusion emanated from.

Ms Nkosi was not satisfied with the explanation. She requested the Secretariat ensure that Committee resolutions are implemented as taken, so as not to delay the progress made by the Committee. Where the support staff encounters challenges, this must be communicated to the Members on time.

The Chairperson noted an outstanding submission form from the Free State needs to be captured and sent to the Department.

Mr M Bara (DA, Gauteng) also wished for the meeting to note that there is a similar issue of a submission from the Western Cape which also needs to be correctly captured and sent to the Chairperson of the NCOP.

The Chairperson informed the meeting that he was aware of that communication, and that it would be dealt with. He noted that on 14 November, final mandates from provinces would be tabled, and the Bill would be considered on 21 November 2023. The Western Cape matter will also be attended to in the next meeting.

Briefing by the Department of Health: Additional Written Comments Review
The Minister of Health, Dr Joe Phaahla, noted that some submissions supported the NHI and were appreciated. The responses on the day would deal with those that had raised specific issues and concerns. He further acknowledged the decision by the Committee to send any outstanding submissions to the Department for further response at the meeting scheduled for the next week. A number of the issues that came up overlapped but would be responded to.

Dr Nicholas Crisp, Deputy Director-General: National Health Insurance, DOH, led the presentation to the Committee. He informed the meeting that the purpose of the presentation was to provide updated responses to the NCOP Select Committee based on the additional 15 written submissions on the NHI Bill provided to the Department. The Department has previously responded to nearly all of the comments submitted, and this presentation focused on the few that were left out. It was noted that the submissions were from diverse stakeholders, which included, amongst others, medical schemes, labour unions and civil society formations. In the main, the presentation covered the following areas:
- Constitutional concerns raised by the submissions;
- Ministerial overreach: Too much power over the Fund and its structures/governance;
- The package of benefits is not outlined in the NHI Bill;
- Comments that the NHI Bill is a procurement bill and will constrain rather than promote competition in the health sector;
- Comments that the public health sector is facing several challenges, so the NHI should not be implemented until these are resolved;
- Medical Scheme nuances which have been responded directly to the stakeholders by the Director-General and the Minister.

(See presentation document for more details)

Discussion
The Minister informed the meeting that the Department does not have a comprehensive report from the Committee that outlines issues that emanated from the public hearings, as was done when the Bill was before the Portfolio Committee on Health. He sought clarity on how this would be dealt with, considering that, according to the programme, the next meeting would be the last interaction between the Committee and the Department. He noted the comment that the Bill was not approved by the National Health Council (NHC) and was surprised that this came from the MEC of Health in the Western Cape. The National Health Act prescribes that, when there is a policy proposal, the Minister should present it to the NHC so that it advises. The Bill has been presented to NHC several times, but she (MEC) assumed this had to be done before Cabinet approval. This cannot be done, as the process requires that consultations begin after the Cabinet has approved the processes. As a ministerial advisory structure with no executive responsibilities, the NHC is not required to approve the Bill processes beforehand.

Ms D Christians (DA, Northern Cape) wished for the Department to expand on how they will ensure that there is sufficient and meaningful consultation and participation in the development and implementation of NHI policies and regulations. She also wanted to know how the NHI would ensure that accessibility and quality are upheld. How will professional councils be affected in their responsibilities to regulate the scope and ethics in the sector? She also wanted to know the Department’s response to the concerns that the SA economy may not be able to afford the NHI.

Mr Nchabeleng commented that he understood that there would be no wholesale, immediate changes around medical aids and laws that govern their existence. He referred to a study tour the Committee had undertaken in South Korea. They learnt that a similar law in that country was passed around 1968, but the country had taken around 15 years to implement it. This is what he understood to be the intention with the South Africa scenario, where the law will be passed, and the implementation will be gradual as the country builds and invests in the required infrastructure. Is there a credible reason for people to worry about the impact of this legislation on the economy yet?

Responses
Minister Phaahla responded that the details on the implementation come in as the regulations are passed and the Act is proclaimed. The National Health Act is clear on the promulgation of regulations. It requires that they must first be gazetted for public comments for 90 days, which should allay the concerns on sufficient consultation. The Medical Schemes Act will remain in place and will not be repealed immediately. The Bill does propose that, when the implementation takes place, there will be changes that require that private schemes only cover complimentary services that the NHI does not cover. This will not be done overnight but will take time. The DOH envisages a two-stage implementation of three years each, where preparation will happen first, and then full implementation later while improvements are made along the way. Private healthcare providers will be affected in the long run.

Dr Crisp emphasised the built-in consultation period of 90 days as required by the NHA. This must be read with section 59(2) which provides that the President can bring different sections of the legislation into implementation on different dates. This is done deliberately to ensure that many functions are not given to a new entity that has not yet built-up capacity. He noted that the Fund does not exist currently, but only the NHI branch in the Department that is doing the preparatory work. What is envisaged is that, once passed, the President will bring into law those sections that will trigger the transitional processes like the appointment of the Board, board committees and other governance structures, and the general setting up of the Fund. This will happen during the 2023-2026 preparatory stage. The Bill requires that the Minister appoint an ad hoc committee and does not say how. The details will be put into the governance regulations at the right time. Only once that has happened can monies be moved to the Fund. These processes will take time. It will be important for those concerned to go back to the legislation and read up on these amendments in this context.

The economy is not envisaged to be static during the implementation period, but it will dictate the pace at which the changes can happen, including the shifting of funds. On affordability, the country cannot afford not to change the status quo because the current system is complicated, duplicative, depletes resources, and undermines the ability to deliver services.

He further informed the meeting that DOH jealously guards the work of the regulatory councils. As health professionals, they are weary of doing anything that will disturb the important work of the councils. They will continue to be autonomous, but there will be an exchange of information on such things as the registration or suspension of a professional, so that the Fund is aware. Quality is a fundamental part of what the NHI seeks to achieve. It is mentioned at least 39 times in the Bill. National and provincial departments must ensure that deliberate improvement strategies are there and implemented. The Bill is clear on the consequences where quality has been compromised and affords the Fund the powers to deal with those accordingly.

The Department has visited many countries, many of which have had successful transitions and some more complex. The delegates learnt a lot. Although the changes will be gradual, many things can be achieved in the short term. These include getting hold of the runaway costs and addressing issues of equity in terms of access to services.

Closing Remarks
The Chairperson instructed that any outstanding submissions must be submitted to the Department today. On Thursday, 09 November, the Department will give final responses to any outstanding submissions as discussed. On 14 November, all provinces will provide their final mandates, and the Committee plans to finalise the process by adopting its report on 21 November 2023.

The Chairperson thanked everyone for attending the meeting.

The meeting was adjourned.