National Health Insurance (NHI) Bill deliberations; with Deputy Minister
24 August 2022
Chairperson: Dr K Jacobs (ANC)
Meeting Summary
Video (Part 1)
Video (Part 2)
NHI: Tracking the Bill through Parliament
The Portfolio Committee met to continue its deliberations on the National Health Insurance (NHI) Bill. In the meeting, the Committee deliberated on the NHI Bill from Clause 23 to Clause 33 – which were all supported by the ANC with little or no proposals for amendments. The DA and the EFF raised concerns about the constitutionality of most of the clauses deliberated on and proposed amendments to almost every clause. The FF+ raised concerns about how some of the clauses could negatively impact the economy, and the IFP requested more context/clarity on the wording in certain clauses of the Bill.
Clause 23, Committees of Board.
The ANC supported Clause 31 because the clause stipulated a normal practice, which was usually governed by the Board Charter and the Terms of Reference of the committees. The DA agreed that it was standard practice for the committees to be established by the Board, despite the possibility of severe financial implications, and added that those committees would have to present to the Portfolio Committee on a quarterly basis. The EFF said Clause 23(4) created an opportunity of bullying by the board of the committees that were to be established, because there was little understanding of what was meant by the phrase 'good cause shown'.
Clause 24, Technical Committees
The ANC supported Clause 24(1) because the Board would establish technical committees with expertise in research, health, technology, and risk and fraud prevention. The DA highlighted that there was a need to know what the financial implications of the committees would be, how many members would the committees have, how the members were going to be appointed, the amount of annual meetings the committees would have, the fitness of persons who might be appointed, the procedures to fill vacancies, who was not allowed to be on the committees, how remuneration of members would be determined, and on what basis the members of the committees could be removed or disqualified. The EFF proposed that a clause be added after Clause 24(4)(b) that would exclude immediate family members of the board members of the committees that were to be established from benefiting from the proceeds of the NHI.
Clause 25, Benefits Advisory Committee
The ANC supported Clause 25 because the Benefits Advisory Committee, supported by various committees, would make evidence-based recommendations, and it was important for the Benefits Advisory Committee to attract requisite skills to deliver on the said mandate. The DA said Clause 25 gave too much power to the Minister, and it would be good for accountability purposes for the Minister not to be the one appointing all the members of the committee.
Clause 26, Health Care Benefits Pricing Committee
The ANC supported Clause 26 because establishing the Health Care Benefits Pricing Committee would advise the Minister to ensure financial protection from the costs of healthcare and ensure the provision of access to quality healthcare services, by determining the most affordable prices to be reimbursed by the Fund. The DA said there needed to be more transparency and participation on who would be appointed. The Minister could not have full power to do so without public participation, and there was no need for the Minister to be represented on such a technical committee. The EFF indicated that there had been a lack of social science expertise, legal health, geographic health, and political health expertise represented in Clause 26(2), and proposed that those be included as well.
Clause 27, Stakeholder Advisory Committee
The DA proposed that Clauses 24(2)-(4) be included under all the committee-specific clauses, including the Stakeholder Advisory Committee, and that if there were going to be any regulations that would dictate how the committees were to function, those regulations had to be included in the Bill too. The ANC supported Clause 27 because the composition of the Stakeholder Advisory Committee would address the concerns raised by a number of stakeholders who had expressed an interest in being included in the structures of the Fund.
Clause 28, Disclosure of interests
The DA proposed an addition to the clause, that disclosure of interest should include "any civil or legal litigations regardless of the outcomes, that had been launched against a member of any committee, and information about ever being once bankrupted or liquidated or being under administration". The ANC supported Clause 28 because the provision was in line with good governance principles and promoted transparency and accountability.
Clause 29, Procedures and Remuneration
The DA said the concern was around the costing model -- would South Africans have to pay more tax for senior and mid-management levels going forward? The FF+ indicated that Parliament should be involved, and not the Minister, in the appointment of committee members. It remained unclear how many members would serve on all of the committees and what cost the taxpayers would pay per annum. The ANC supported Clause 29, because it was in line with the provisions of section 91 of the National Health Act, it allowed the Minister the opportunity to comply with the provisions of the National Health Act, and was aligned with National Treasury prescripts. The EFF emphasised that the issues relating to costing that had been constantly raised in the Portfolio Committee, were not to be overlooked because there was a high possibility that those issues might affect the existing legislation and may require amendments, or may require that other legislation be repealed
Clause 30, Vacation of office
The DA said that the specific clause that stipulated the disqualification criteria had to be specified in the Bill and the specifications of conflict of interest, and a provision needed to be made for deceased members. The ANC supported Clause 30 because the clause was very clear and was in line with good governance practices. The EFF said the clause reflected the undue over-exertion of the powers of the Minister by giving him power to terminate membership of the committees without even stating why the members could be terminated.
Clause 31, Role of Minister
The ANC supported Clause 31 because the Minister had overall executive authority in the health sector, particularly the national health system and how it functioned and performed. The DA said the grant and extent of power of the Minister would affect the making of key decisions, which could then be subject to arbitrary political decision making. The legal requirements and clinical elements of the system had to be rational, objective, transparent etc, and not left to political intervention. The EFF opposed the clause and labelled it as 'high level hypocrisy.'
Clause 32, Role of Department
The ANC entirely supported Clause 32. The DA said it was not the role of the NHI Fund to override the Constitutional mandates of the Department, as that would require a constitutional change. Clause 32 showed that all the revenue that would have been allocated by the provincial equitable share and conditional grants would now be re-directed to the NHI Fund – meaning that the provincial governments would not receive transfers from the national government's constitutional obligation to national healthcare. The EFF indicated a contradiction in Clause 32 concerning Clause 31(2). It pointed out that Clause 31(2) had specified the powers that were given to the Minister, by stating that the Minister would delegate roles and functions to the provincial departments in the context of the NHI, while in Clause 32, the roles of the 'provinces' were contracting the powers that had been given to the Minister. The IFP asked what the role of the provinces would be, as they had now been described as 'management agents' of healthcare services. What would the role of the municipality be?
Clause 33, Role of medical schemes
The FF+ stated that the clause was very vague. It was still unclear what the functions of the private doctors and medical aid schemes would be. In effect, the clause would result in doctors and medical practitioners going to look for other opportunities abroad, thus reducing the medical expertise of the country, and that would affect the South African economy. The DA indicated that it had a serious concern about the legality of Clause 33, and the State Law Advisers would have to provide more information on it. The ANC supported Clause 33 because it was essential to achieving equity in the financial and non-financial resources of the national healthcare system. The IFP requested a definition for "complementary services," as stipulated in Clause 33 of the NHI Bill. The EFF asked what the impact of the NHI concerning medical insurance would be, and how would the persons who chose not to register for the NHI be treated?
The Committee decided it would continue with the deliberations on the NHI Bill on 31 August.
Meeting report
The Chairperson welcomed the Members of the Committee, the delegation from the Department of Health, led by Deputy Minister Dr Sibongiseni Dhlomo, the delegation from the State Law Advisers, and the delegation from the Parliamentary Legal Services. He said the meeting would be a continuation of the meeting that had been held the previous day, with clause-by-clause deliberations on the National Health Insurance (NHI) Bill.
On the previous day, there had been a request from Ms E Wilson (DA) for some inputs and discussions to be held before the Committee could continue with the deliberations. Mr P van Staden (FF+) had also requested to make some input before the deliberations continued.
Mr N Xaba (ANC) asked if the inputs that were going to be made were generic comments not related to the core business of the day, or whether the inputs were "love messages". "Love messages" would be accepted, but if the inputs were on the NHI, then more clarity needed to have been provided.
Ms Wilson clarified that the inputs to be made had nothing to do with the NHI. The first input was that it was important for the Portfolio Committee to start getting provinces to present their annual reports and annual performance plans ( APPs) etc, so that the Committee could be well prepared for the Budgetary Review and Recommendations Reports (BRRRs) which were scheduled to come up in October. Secondly, the Committee needed to start looking into oversight, as horrific stories emanated from various provinces relating to health. The Committee had not done oversight for a long time and there was a need to address the problems highlighted in the media.
Mr Van Staden asked when the Committee would look at the over 300 000 submissions on the NHI. On the proposed amendments to the National Health Act, would it be possible for the Minister to come before the Committee before the regulations were promulgated in the Gazette?
Mr T Munyai (ANC) said the Portfolio Committee had resolved the matter on the issue of the Minister's response -- it had been agreed that the Minister would come before the Committee after it had resolved its work on the NHI Bill.
Mr van Staden clarified that it was not about the NHI Bill, but about the proposed amendments to the National Health Act that the Committee had not discussed, as to when the Minister would come before the Committee.
Mr Munyai said the Committee's key priority was on the NHI, and oversight could be done at least when the Committee had exhausted six sittings on the NHI Bill, or after it had concluded its work on the NHI Bill.
The Chairperson said it was understood that the normal sessions of Parliament would be starting on the week that was to follow, and would include BRRRs etc, and this would take precedence over any other work that the Committee had to focus on. The Committee had made two requests for oversight, but those applications had been rejected by the office that was responsible. An email had also been received, stating that no committees would be allowed to do oversight in the new term, as priority had to be given to legislation. The Committee would consider doing virtual oversight, if that would be allowed.
On the issue of submissions, be they oral or written, the reports on those processes had been sent to the Committee Members the previous day. The reports on the submissions would also be discussed eventually, but the Committee's priority was the NHI Bill.
The Minister was fully aware that he would have to come and brief the Committee on the proposed amendments to the National Health Act before gazetting those amendments.
Mr Munyai made a plea that any other issues that the Members might want to raise, should be raised in a normal Portfolio Committee meeting, as the discussion of other issues would affect the progress of the NHI Bill deliberations.
Deliberations on NHI Bill
The Chairperson said the Committee would start the deliberations on Chapter 6 -- Committees established by Board -- of the NHI Bill.
.
Clause 23, Committees of Board
This stated that:
"(1) The Board may establish a committee and, subject to such conditions as it may impose, delegate or assign any of its powers or duties to a committee so established.
(2) Each committee established in terms of subsection (1) must have at least one Board member appointed in terms of section 13(1) as a member of that committee.
(3) Committees of the Board as established in subsection (1) must meet at least four times per year in order to report to the meeting of the full Board and may convene special meetings to discuss urgent matters when necessary.
(4) The Board may dissolve or reconstitute a committee on good cause shown."
Mr Munyai said the ANC supported Clause 23 because it believed that the contributions stipulated in Clause 23(1) – (4) would help the committees that were to be established, as was the practice with any other committees.
Ms X Havard (ANC) supported Mr Munyai's submission. She said the ANC supported Clause 23(1) because those committees "may push the conditions of employment and the annual audit circle, and any other relevant provisions of the functioning of the Fund."
Mr Xaba also supported Mr Munyai's submission. He said the ANC supported Clause 23(4) because the clause stipulated a normal practice, which was usually governed by the Board Charter and the terms of reference of the committees.
Ms E Wilson (DA) said committees being established by the Board had been a common practice. The only issue with Clause 23 was that establishing a committee by the Board might have severe financial implications. In Clause 23(3), there was no problem with the committees having meetings with the Board, but the committees would have to present to the Portfolio Committee quarterly.
Ms H Ismail (DA) said more clarity was needed concerning the membership of the committees to be established. The Portfolio Committee had to receive quarterly reports from those committees.
Ms N Chirwa (EFF), raising a concern on Clause 23(4), and said it was always important for the Portfolio Committee to think beyond what was given and what was on offer, by thinking of different ways of protecting the different stakeholders. There was an opportunity for bullying by the Board of the committees to be established. There was little understanding of what was meant by 'good cause shown'. The EFF was obviously against the NHI, because it saw opportunities for the private sector to exploit the state. The private sector would benefit from the public purse. Clause 23(4) had to be broken down into much more detail, and the clause should not suffice as it was currently.
Ms A Gela (ANC) said the ANC supported Clause 23(2) because the representation of the Board in the committees would establish good governance practices and ensure compliance with the Public Finance Management Act (PFMA). External members would bring different expertise to the committees.
The Chairperson supported the submissions made by Mr Xaba, Mr Munyai and Ms Havard.
Clause 24,Technical committees
This states that:
"(1) (a) The Board may establish such number of technical committees as may be necessary to achieve the purpose of this Act.
(b) The provisions of section 29 apply to paragraph (a) with the changes required by the context.
(2) A committee established in terms of subsection (1)(a) must perform its functions impartially and without fear, favour or prejudice.
(3) A person appointed as a member of such a committee must -
(a) be a fit and proper person;
(b) have appropriate expertise or experience; and
(c) have the ability to perform effectively as a member of that committee.
(4) A member of such a committee must not—
(a) act in any way that is inconsistent with subsection (2) or expose himself or herself to any situation in which the risk of a conflict between his or her official responsibilities and private interests may arise; or
(b) use his or her position, or any information entrusted to him or her, for self-enrichment or to improperly benefit any other person."
Ms Wilson said that in Clause 24, subsections (2),(3), and (4) had to be fitted into Clause 23 as well so that they govern any committee that would be established by the Board, and not only the technical committees. In establishing the technical committees, there might be a need to bring in consultants from outside, which would cause the costs to escalate. That would impact the entire budget, and the Members of Parliament needed to be advised of that to avoid dealing with irregular expenditure at the beginning of a financial year.
Mr Xaba said the ANC supported Clause 24. The Committee was happy to be discussing the Bill, and it was advisable that the discussion be confined only to the Bill, and not include implementation. The ANC supported Clause 24(1) because the Board would establish a technical committee that had expertise in research, health, technology, and risk and fraud prevention. The technical committees would have to be aligned with subsection Clause 20(3). National Treasury would regulate the remuneration of the committees.
Ms M Clarke (DA), on Clause 24(1), said committees could not be established for the sake of being remunerated at taxpayers' expense. There was a need to know the financial implications of the committees and how many members the committees would have. For the Bill to work, it would be important to consider the cost factor.
Ms Havard said the ANC supported Clause 24(3) because "competencies and skills in the areas of functioning of the Fund required expertise, and the Fund may wish to deploy on an ad hoc basis, not as part of the staff complement of the Fund."
Ms Gela supported Ms Havard and Mr Xaba's submissions. She said the Portfolio Committee Members had to be positive that the committees to be established would do an incredible job. The ANC supported Clause 24(2) because the functioning of a technical committee had to be guided by clearly articulated terms of reference to ensure objective support for the Board.
Ms Chirwa said it was interesting to see the Members of the Committee no longer caring about the cost impact. When the National Health Amendment Bill had proposed that clinics be open for 24 hours, the Committee rejected that, citing the cost impact. The Members had now seemingly found their conscience again, and were now advocating for the cost impact to be overlooked. The NHI Bill was going to benefit mainly the private sector. There had to be a clause included after Clause 24(4)(b) that would exclude immediate family members of board members of the committees to be established, from benefiting from the proceeds of the NHI.
Ms Ismail, on Clause 24, said it was unclear what' technical committee' meant, and what functions such committees would actually carry out without violating corporate governance principles and interfering in the day-to-day management of the Fund. There needed to be more specification on the terms of appointment of members of the committees, such as the procedure for appointing members, the number of annual meetings, the fitness of persons who might be appointed, the procedures to fill vacancies, who was not allowed to be on the committees, how remuneration of members would be determined, and on what basis the members of the committees could be removed or disqualified. All of that had to be highlighted in the Bill.
Mr Munyai supported the submissions of Ms Gela, Mr Xaba and Ms Havard. To save South Africa from both communicable and non-communicable diseases, it was important for the Committee not to be worried about the cost impact.
Ms Chirwa said there were inconsistencies within the Portfolio Committee. The Committee had to be led by principle. The Committee had turned down a National Health Amendment Bill because of cost implications, and now the Committee was seeking to overlook the NHI's cost implications because of the ANC's comrades.
The Chairperson said he had noted what Ms Chirwa had said earlier, and was going to respond to that.
Mr Xaba said Ms Chirwa had completed speaking and the Chairperson had ruled that her input had been accepted, and it was not understood what point of order she was rising on.
Ms Chirwa said: "You talk too much, but you say nothing!"
The Chairperson, addressing Ms Chirwa, said there was a system that the Portfolio Committee used. It was incorrect to just shout from the side. The Committee secretary was assisting the Chairperson in noting the show of hands on both the virtual and physical platforms. The ANC supported Clause 24(4) because the technical work that was to be performed by such committees would likely be influenced by different interests from suppliers/providers, and the clause would ensure that members of the committees were not encumbered by conflicts of interest of either an ethical or financial nature. Ms Chirwa had twice referred to the Private Members' Bill, which spoke to the 24-hour clinics being open; one would recall that there had been a process for that, which the Committee had embarked upon – it had deliberated and had made a decision on it. The Committee had not yet decided not to entertain the NHI Bill, nor had the Committee made any decision on the cost implications of the NHI Bill.
Mr Xaba supported the Chairperson, and clarified that the remuneration of committees, as stipulated in the Bill, was in line with the National Treasury regulations, which had an ethos of good governance, and accountability, and provided for the payment of service providers within 30 days.
The Chairperson said the Committee would deliberate on Chapter 7, Advisory Committees Established by the Minister.
Clause 25, Benefits Advisory Committee
This states that:
"(1) The Minister must, after consultation with the Board and by notice in the Gazette, establish a committee to be known as the Benefits Advisory Committee as one of the advisory committees of the Fund.
(2) The membership of the Benefits Advisory Committee, appointed by the Minister, must consist of persons with technical expertise in medicine, public health, health economics, epidemiology, and the rights of patients, and one member must represent the Minister.
(3) A person appointed in terms of subsection (2) -
(a) serves for a term of not more than five years and may be reappointed for one more term only; and
(b) ceases to be a member of the Committee when he or she is no longer a member of the institution that nominated him or her or when he or she resigns.
(4) A vacancy in the Benefits Advisory Committee must be filled by the appointment of a person for the unexpired portion of the term of office of the member in whose place the person is appointed, and in the same manner in which the member was appointed in terms of subsection (2).
(5) The Benefits Advisory Committee must determine and review -
(a) the health care service benefits and types of services to be reimbursed at each level of care at primary health care facilities and at district, regional and tertiary hospitals;
(b) detailed and cost-effective treatment guidelines that take into account the emergence of new technologies; and
(c) in consultation with the Minister and the Board, the health service benefits provided by the Fund.
(6) The Minister must appoint the chairperson from amongst the members of the Committee.
(7) The Minister must, by notice in the Gazette, publish the guidelines contemplated in subsection (5)(b) and may prescribe additional functions to the Benefits Advisory Committee."
Mr Xaba said the ANC supported Clause 25(2) because the benefits advisory committee, supported by various committees, would make evidence-based recommendations. It was important for the benefits advisory committee to attract the requisite skills to deliver on its mandate. The ANC supported Clause 25(5) because the benefits advisory committee was an important component in ensuring that, through the advice it would provide to the Minister, the healthcare benefits that the NHI would cover would be inclusive and would not disadvantage any communities.
Ms Gela supported Mr Xaba. The ANC supported Clause 25(6) that the Minister would have to appoint the chairperson from among the members of the committee. The ANC supported the clause because it was in line with the processes for appointing chairpersons for committees.
Ms Clarke, on Clause 25(1), said the positions on the Benefits Advisory Committee should call for nominations, as currently, the Minister had exclusive power to determine who sat on the committee and there was a problem with that. There had to be no member in the Benefits Advisory Committee as a representative of the Minister. The committee had to be independent and make decisions based on scientific evidence, and those decisions were not to be affected by elements of a political nature. "How could the Act be enacted, and only after this, decisions be made on which treatments would be considered or not?" There should be some additional oversight, if possible. What would be the levels of reimbursement? The Minister need not be consulted on which health benefits would be allowed or not. The Minister should not be allowed to choose the chairperson -- that would be determined either by the board or the members of the committee or Parliament. The Minister should not have powers to hire or fire any persons from such an entity, as that would only lead to cases of abuse. The guidelines had to be published for public comment.
Ms Ismail said Ms Clarke had mostly covered her. It was unclear how many members the committee would consist of. There had to be a cap on every committee to avoid the abuse of funds. Clause 25 gave too much power to the Minister, and it would be good for accountability purposes for the Minister not to be the one appointing all those members. It was also important to ensure that the Minister did not appoint his representative as the chairperson of the board. The issue with Clause 25(5) was that it did not include private health establishments. There was a need to align the Bill with specifications so that when going into the implementation phase, there would be no accounts of maladministration.
Ms Wilson said the NHI was going to be influenced mostly by the sections of the Bill that were under deliberation. The success or failure of the Bill would be based on what the Benefits Advisory Committee would come up with, and what they would decide on. It was absolutely essential that the Minister not establish the committees -- they could be established either by Parliament, or Parliament could establish an ad hoc committee to do that. On Clause 25(3)(b), it was not understood why a person would be taken off the committee if they were no longer a member of the institution that nominated them – unless they had caused reputational damage. Such persons would have been nominated based on their expertise and not on the institution they represented.
Ms Havard supported the submissions of Mr Xaba and Ms Gela. She said the ANC supported Clause 25(4) because it was standard practice for committees, including the Benefits Advisory Committee, to fill vacancies that occurred prior to the expiry of the term of the committee. The ANC supported Clause 25(7) because publishing the details of cost-effective treatments that consider the emergence of new technologies would inform and make transparent the benefits that the Fund would cover to the public. Those guidelines would be reviewed on an ongoing bases.
Mr Munyai supported Ms Gela, Mr Xaba and Ms Havard. The ANC supported Clause 25(1) because the Benefits Advisory Committee would develop comprehensive healthcare services... (He requested Mr Xaba to continue on his behalf, as he had been asked to stop speaking on the phone in the aircraft)
Mr Xaba said the ANC supported Clause 25(1) because the benefits advisory committee would develop comprehensive healthcare services for all levels of care: primary, secondary, and tertiary. The healthcare service would also include sexual and reproductive health, rare diseases and dread diseases.
The Chairperson supported the submissions of Ms Havard, Ms Gela, Mr Xaba and Mr Munyai. Speaking on Clause 25(3), he reminded the Committee that the appointment of the Benefits Advisory Committee would be aligned with section 91 of the National Health Act on the appointment of the Ministerial Advisory Committees. A minor amendment proposed would be for the members of the Benefits Advisory Committee, to be appointed based on their technical competencies and not on the institutions they represented. Clause 25(3)(b) would then read, "ceases to be a member of the Committee when he or she resigns."
Clause 26, Health Care Benefits Pricing Committee
This states that:
"(1) The Minister must, after consultation with the Board and by notice in the Gazette, establish a Health Care Benefits Pricing Committee as one of the advisory committees of the Fund, consisting of not less than 16 and not more than 24 members.
(2) The Health Care Benefits Pricing Committee consists of persons with expertise in actuarial science, medicines, epidemiology, health management, health economics, health financing, labour and rights of patients, and one member must represent the Minister.
(3) The Committee must recommend the prices of health service benefits to the Fund.
(4) The Minister must appoint the chairperson from amongst the members of the Committee."
Mr Xaba said the ANC supported Clause 26(1) because the establishment of the Health Care Benefits Pricing Committee would advise the Minister to ensure financial protection from the costs of healthcare, and also ensure the provision of access to quality healthcare services by determining the most affordable prices to be reimbursed by the Fund. As a strategic purchaser, it was important that the Fund paid providers in a manner that would create incentives -- for efficiency and the provision of accessible healthcare.
The ANC supported Clause 26(2) because the Health Care Benefits Pricing Committee was critical for the Fund's ability to determine provider mechanisms that contributed to a responsive healthcare system, ensuring that the delivery of healthcare services would be efficient and affordable. The ANC also supported Clause 26(3) because the committee had to recommend the most effective pricing of healthcare services to be funded under the NHI. That would also allow the Fund to determine the most appropriate pricing options to be used, to ensure the sustainability of the Fund.
Ms Clarke, on Clause 26(1), said there needed to be more transparency and participation as to who would be appointed -- the Minister could not have full power to do so without public participation. There was no need for the Minister to be represented in such a technical committee. What would the effects be if the registered providers could not comply with the set pricing? The Minister should not have the power to appoint the chairperson of the committee.
Ms Wilson said Ms Clarke had covered her. The Minister could not have so much power, because the NHI Bill would last a very long time. If a Cabinet reshuffle occurred, the next Minister would have all the power to change the committee according to his or her liking. That had to be avoided at all costs, and it was important for Parliament to be involved in appointing the Cabinet members.
Ms Ismail said Ms Clarke and Ms Wilson covered her. The meetings needed to be open, transparent and accountable to Parliament in all aspects. On Clause 26(2), the area of expertise had to include individuals with experience in medical devices and vital diagnostics, coding and the costing of healthcare, the pricing of private healthcare sector and medical provisions, costing of research and new healthcare technology, and the costing of medical care infrastructure, goods and services.
Ms Havard supported Mr Xaba. She said the ANC supported Clause 26(4) because it was in line with other processes of appointing chairpersons of the Ministerial Advisory Committees. That had been the case with the Ministerial Advisory Committee advising the Minister through the provisions of section 91 of the National Health Act.
Ms Chirwa said that in Clause 26(2) there had been a lack of social science expertise, legal health, geographic health, and political health expertise. It was important to note that the monetary part was more political than not – those who were part of the Bill and Melinda Gates meeting that had contextualised the NHI in 2009 could attest to that. There was no need for the Minister to have a representative in the committee, as that would limit discussions and contributions of the members that formed part of the committee.
The Chairperson supported Mr Xaba's and Ms Havard's submissions. The appointment of the members of the committee would be transparent, as it would also be published in the Government Gazette and nothing stopped Parliament from asking questions regarding that process. On Clause 26(4), the Minister would be appointing the chairperson from the members of committee, and that was considered to be fair.
Ms Gela supported Mr Xaba's, the Chairperson's and Ms Havard's submissions. She said the ANC supported Clause 26(3) because the committee had to recommend the most cost effective pricing of healthcare services to be funded under the NHI, whilst driving maximum value for the users of the healthcare system. That would also allow the Fund to determine the most appropriate pricing options to be used to ensure its sustainability.
Ms Wilson, adding a recommendation for all the committees -- be it the Benefits Advisory Committee or the Health Care Benefits Pricing Committee -- said that Clauses 24(2)-(4) were very clear on the types of persons that would be included in the committee. Those clauses needed to be included for every committee that was to be established.
Mr Xaba supported the Chairperson's clarification on 26(1). He said it was important for the Committee to admit when it had passed a clause -- the Committee was done with Clause 24, and was now addressing Clause 26.
Ms Clarke emphasised Clause 26(3), which stated that the committee would have to recommend pricing health care services to the Fund. She said that had to be published publicly, because a lot of 'shenanigans' were bound to happen in the hospitals. During oversight, the hospitals reported that they had been told to use only certain service providers, which was a huge cautionary measure.
Ms Ismail seconded Ms Wilson in stating that all the committee-specific clauses had to include the provisions of Clause 24(2)-(4) to avoid legal issues later on. In support of Ms Clarke, she said the hospitals had indeed highlighted the issues referred to during oversight, and it was important to resolve those issues now so that they would not get out of hand.
The Chairperson said all the issues that had been raised by the Members had been noted. The Parliamentary Legal Services were also present to note what needed to be addressed.
Clause 27, Stakeholder Advisory Committee
This stated that:
"The Minister must, after consultation with the Board and by notice in the Gazette, appoint a Stakeholder Advisory Committee comprised of representatives from the statutory health professions councils, health public entities, organised labour, civil society organisations, associations of health professionals and providers as well as patient advocacy groups in such a manner as may be prescribed."
Ms Ismail said there were no specifications or criteria on the actual functions of the Stakeholder Advisory Committee, and it was important that all that be clarified from the outset. It was not clear as to how the functions of the Stakeholder Advisory Committee would particularly impact the decision-making processes. It was also not clear as to whom the Stakeholder Advisory Committee would be accountable. The purpose of that committee needed to be refined in the context of the NHI Bill.
Mr Xaba said the ANC supported Clause 27 because the composition of the Stakeholder Advisory Committee would address the concerns raised by a number of stakeholders who had expressed an interest in being included in the structures of the Fund. Regulations were going to be provided to address the procedures under which the committee would operate.
Ms Clarke said her concerns were once again on how the committee would be appointed. Why should the Minister have exclusive powers to appoint members of the committee? What was the purpose of the committee? What were the committee's powers and functions? The same issues had been raised around every committee that was going to be appointed, and it was important to have a terms of reference and costing model for each of the committees.
Ms Wilson said Clause 24(2)-(4) had to be included under the clause for every committee, including the Stakeholder Advisory Committee. If there were going to be any regulations that would dictate how the committees were to function, those regulations had to be included in the Bill. The Portfolio Committee's meeting was based on regulating the Fund, and all required regulations had to be in the Bill.
Ms Havard and Ms Gela supported Mr Xaba's submission.
Ms Ismail said the regulations had to be specified in the Bill, as stated by Ms Wilson. There was a need to review the regulations in the very same process that the Portfolio Committee had been currently busy with. All the meetings had to be open, transparent and accountable to Parliament -- that was essential for all the committees.
The Chairperson said Ms Ismail was correct to say that the Portfolio Committee was a part of the extension of Parliament, and the Committee's meetings were open, transparent and accountable to Parliament. If she was referring to something else, she would need to clarify. It was understood that some things contained in the regulations were not in the Bill, including costing models.
Ms Ismail emphasised that nothing in the Bill referred to the regulations, and there was no part of the clause that said "regulations". If some existing regulations applied to a clause, it needed to be stated in the particular clause that such regulations would apply. On the openness and accountability when it came to meetings, that had indeed been in reference to the current Portfolio Committee meeting, and also included all the committees that were going to be established. The meetings of those committees also had to be transparent to everybody.
Mr Xaba highlighted that Clause 27 said "as prescribed," which would be through regulations. Regulations were to be published, and were open and transparent. The useful information for inclusion would be in the regulations, not the Bill. "We do not specify regulations in the Bill and by definition, regulations are not in the Act -- they support the Act."
The Chairperson said that Ms Ismail had to remember that the Portfolio Committee meetings were open to the public. Even the current meeting was an open and transparent meeting.
Clause 28, Disclosure of interests
This stated that:
"A member of a committee established by the Minister in terms of this Act who has a personal or financial interest in any matter on which such committee gives advice, must disclose that interest when that matter is discussed and be recused during the discussion."
Ms Wilson said the disclosures of interests were very important. It was one thing to disclose personal and financial interests, but what needed to be included in the clause was any civil or legal litigations, regardless of the outcomes, that had been launched against a member of any committee. Information about ever being once bankrupted, liquidated, or under administration also needed to be included.
Ms Gela said the ANC supported Clause 28 because the provision was in line with good governance principles and promoted transparency and accountability. The provision would ensure that members of the committees would take decisions that would benefit the public.
Mr Xaba supported Ms Gela.
Ms Havard supported Ms Gela by seconding Mr Xaba.
The Chairperson supported Ms Gela on Clause 28.
Clause 29, Procedures and Remuneration
This stated that:
"When establishing a committee under this Chapter, the Minister must determine
by notice in the Gazette -
(a) its composition, functions and working procedures;
(b) in consultation with the Minister of Finance, the terms, conditions, remuneration and allowances applicable to its members; and
(c) any incidental matter relating to the committee."
Ms Clarke said the concern was once again around the costing model. Would South Africans have to cough up more tax to pay for senior and mid-management levels going forward?
Mr van Staden said Parliament should be involved, not the Minister, in appointing committee members. It still remained unclear how many members would serve on all of the committees and what cost the taxpayers would pay per annum.
The Chairperson said the ANC supported Clause 29 because it was in line with the provisions of section 91 of the National Health Act. It allowed the Minister the opportunity to comply with the provisions of the National Health Act, and was aligned with the National Treasury prescripts.
Mr Xaba supported the Chairperson. He re-emphasised that the costing models were never in the Bill -- they change over time and go into the regulations. The regulations were published and were open and transparent.
Ms Wilson said she would prefer to see the remuneration being done in consultation with the National Treasury, and not the Minister of Finance.
Ms Gela supported the Chairperson's and Mr Xaba's submissions. It was unclear what was wrong with the Minister being assigned to oversee the functions of the Department, and tasked with ensuring that the Department was healthy and functioning.
Ms Havard supported the Chairperson's, Mr Xaba's and Ms Gela's submissions.
Ms Chirwa, on the issue of the inclusion of regulations, said the Bill did encapsulate the legislation that would be affected by the Act, whether they had to be repealed, extended or amended. It was important for the Chairperson to guide the meeting with care, because some of the Members' concerns were being overlooked. The issues relating to costing, which had been constantly raised in the Portfolio Committee, should not be overlooked because there was a high possibility that those issues might affect the existing legislation and may require amendments or may require that others be repealed. The Portfolio Committee was overlooking those matters because of political party bias. People were getting things written on paper for them or via WhatsApp messaging to read out, and were not thinking about what the issue of costing might affect. The Parliamentary Legal Services were present and would be able to assist with those issues that might affect legislation.
Ms Ismail said considering the amount of corruption that the country had gone through, even before COVID, as well as the number of Special Investigating Unit (SIU) investigations across almost all the departments, it was objectionable that the Bill provided the Minister with such "overpowering powers". The Bill had to set out the committees' composition, functions and working procedures. It needed to be understood that the issues of oversight were of essence.
The Chairperson reiterated to Ms Ismail that the process that the Portfolio Committee was busy with, was transparent. The Bill was sent to Parliament in August 2019, and very particular processes had been followed. Written and oral submissions have been received. All the inputs that the Members made during the proceedings were noted, and Members even had a right to submit written responses on the Bill. Regarding Ms Chirwa's concerns, offence was taken when she said that notes were being sent via messages etc. Each political party had its own processes relating to how Bills were processed. It was incorrect to come to the meeting and "make wild allegations" as Ms Chirwa had done.
Ms Chirwa asked how her statements were "wild allegations" when the Chairperson had admitted that that was how political parties functioned. Why then was the Chairperson being offended?
The Chairperson said Ms Chirwa needed to go and have some training about what she ought to be doing in the meeting. Ms Chirwa had to go and look at the entire Bill -- there was a page 31 that started with a schedule.
Ms Chirwa interjected, and the Chairperson asked for her to be muted on the platform. He said he was not going to entertain Ms Chirwa's behaviour.
Clause 30, Vacation of office
This stated that:
"A member of a committee established in terms of this Act ceases to be a member if -
(a) that person resigns from that committee;
(b) the Minister terminates that person's membership for adequate reason; or
(c) the term for which the member was appointed has expired and the membership has not been renewed."
Ms Wilson said there was a need to stipulate what was meant by "adequate reasoning," because the meaning might differ from person to person. A person's membership in the committee had to be discontinued for reasons such as that member having caused reputational damage, dishonesty, putting the Fund into disrepute, having legal proceedings against him or her, etc.
Mr Xaba said the ANC supported Clause 30 because the clause was very clear and was in line with good governance practices.
Ms Clarke asked what the grounds of termination would be, as there had to be some criteria followed in terms of termination. Should it not be the Board, not the Minister, that had the power to terminate a person? There was a need for a separation between the Minister and the day-to-day running of the Fund.
Ms Havard supported Mr Xaba's submission.
Ms Ismail said the specific clause that stipulated the disqualification criteria had to be specified in the Bill and the specifications of conflict of interest, and a provision needed to be made for deceased members. The termination of a member needed to not be the Minister's decision, but that of the Board.
Ms Chirwa said Clause 30 reflected the undue over-exertion of powers of the Minister. In the other clauses, there had been discussions on how the Minister's involvement in the committees would stifle communications, create political bias etc. Clause 30 was now giving the Minister power to terminate committee members. The clause had not even stated why the persons could be terminated. The Members of the Committee had not been just opining for inputs -- they were dealing with legislation which could affect other forms of legislation. When Members raised issues, if there was a possibility that those issues might affect other forms of legislation, they had to be looked at. It was important for the Members or the Portfolio Committee not to be offended by basic things. The Chairperson had agreed that political parties ran their affairs differently, so why was the Chairperson being offended when the issue about messages being passed around had been highlighted?
Ms Gela supported Mr Xaba. She said Ms Chirwa just opened her mouth and ranted without understanding what was happening. That was insulting because the Committee was raising issues on the Bill.
Ms Chirwa said the effects of ageing had affected Ms Gela. The topic under discussion had been legislation, and the Members of the Committee needed to wake up and listen carefully. She shouted: "Do not be 'sleepists' here. You are 'sleepists' in Committees, you are 'sleepists' on the job, you do not even want to do oversight as Members of Parliament."
The Chairperson called Ms Chirwa to order, but the meeting erupted into chaos as Ms Gela repeatedly shouted out that Ms Chirwa was stupid, Ms Chirwa was shouting out that Ms Gela was stupid and old, adding that a person could not be stupid and old at the same time -- one struggle had to be chosen.
The Chairperson said that he would write a letter of complaint against both Ms Gela and Ms Chirwa if they continued shouting insults at each other. The Committee had a wonderful meeting on the previous day with no complications now being observed.
Mr Xaba said it was cumbersome for any Member of the Portfolio Committee not to give respect to the Chairperson during a meeting. Ms Gela was still on the platform and it was not acceptable for another Member to jump in. The Chairperson had the right to rule a Member out of the discussion -- the Member was not being orderly.
The Chairperson said the Member had to follow the rules of engagement of the National Assembly, as they applied to the meetings of the Portfolio Committee. Ms Gela and Ms Chirwa were on probation to engage further in the meeting, but would be removed from the platform if they once more did not follow the rules of engagement.
Moving on to Chapter 8: General provisions applicable to operation of Fund.
Clause 31, Role of Minister
This stated that:
"(1) Without derogating from any responsibilities and powers conferred on him or her by the Constitution, the National Health Act, this Act or any other applicable law, the Minister is responsible for -
(a) governance and stewardship of the national health system; and
(b) governance and stewardship of the Fund in terms of the provisions of this Act.
(2) The Minister must clearly delineate in appropriate legislation the respective roles and responsibilities of the Fund and the national and provincial Departments, taking into consideration the Constitution, this Act and the National Health Act, in order to prevent duplication of services and the wasting of resources and to ensure the equitable provision and financing of health services."
Mr Xaba said the ANC supported Clause 31 because the Minister had overall executive authority in the health sector, particularly the national health system and how it functioned and performed. Section 92 of the Constitution indicated that the members of the Cabinet were accountable collectively and individually to Parliament for the exercise of their powers and performance functions. The section also allowed the Minister to report regularly to Parliament on matters under his or her control. The ANC supported Clause 31(2) because section 99 of the Constitution allowed the Minister to assign any power or function that was to be exercised in terms of the Acts of Parliament, to a member of the Provincial Executive Council or a municipal Council.
Ms Ismail said the grant and extent of power of the Minister would affect the making of key decisions, which could then be subject to arbitrary political decision making. The legal requirements and clinical elements of the system had to be rational, objective, transparent etc. and not left to political intervention. It was worrying that so much power was being given to the Minister where the healthcare services of the country were concerned, and the Committee could not align that to politics.
The proposed governance structures of the NHI raised concerns, as they did not reflect good governance principles, and were going to entrench significant political power. That had to be avoided in the context of the country's current political and economic challenges. When it came to the appointment of the Board, too much power had been given to the Minister of Health. There were no mechanisms to ensure that the Minister, who was a political appointee, would not appoint his or her party's preferences to the Board. This would allow for political appointees rather than technical experts who would be capable of overseeing the NHI. Clause 31(2) was very vague and had to specify clearly the different roles and responsibilities upfront. The clause had to state the relationship between the Fund and the national commercial departments.
Ms Wilson said the Committee knew what the role of the Minister was, and there was a difference between governance and overseeing the stewardship of the national health system. That was different from what the Bill was proposing, giving the Minister centralised power to run the entire Fund as he saw fit. The framework of the Bill substantially undermined the constitutional powers of provinces to finance, plan and run healthcare services. The constitutionality of the framework was clearly in question. The Committee had to be very clear about the role of the Minister. The Constitution could not be circumvented by "trying to enter through [the] back door and not coming in through the front door."
Ms Clarke supported Ms Wilson, and said the big issue around the Bill was the centralisation of powers and the constitutional issues around the framework of the Bill. The same issues kept appearing in every section of the Bill, so it could not be supported as a lot of issues needed to be tightened up first.
Ms Gela supported Mr Xaba's submission. She said It was worth noting that the opposition would never support the NHI Bill. During oversight in the Western Cape, it was observed that the people had been misled regarding the Bill. The people had said they wanted the NHI Bill to be implemented as of yesterday, and it was the mandate of the ANC to implement what the people wanted.
Ms Chirwa said Clause 31 was a high level manifestation of hypocrisy. The Minister had already failed to prevent wasteful expenditure. The establishment of the committees, the meetings that were going to be held, the accommodation for the current deliberations etc., all had monetary value that could be utilised to improve healthcare services, bettering the infrastructure and increase the workforce of the public health services. It was very intentional that the Minister was given so much power, and it was purely political. That was what had happened to a Cabinet and an Executive that had pledged loyalty to Bill Gates, who had conceptualised the implementation of the Bill step by step. The Parliamentary Legal Services had to report back to the Committee on the distinct impact and consequences that would surface from the current form of centralisation on the Constitution and legislation, and what the impact would be on patient care services.
She said it was unfair that when other Members were calling her names, the Chairperson had said nothing and had responded only when she (Ms Chirwa) had responded in retaliation to the insults that had been hurled at her and ignored. Every Member of the Committee deserved to be protected by the Chairperson equally. She was nobody's daughter or child in the Committee, and deserved to be respected like all Members of the Committee.
The Chairperson agreed that Ms Chirwa was no Committee Member's daughter, but that it was important for her to express good ethical behaviour in the meeting. The Committee had had very wonderful meetings when Ms Chirwa had not been present, and the moment she came in, she caused disruptions. She had been saying offensive things that were unparliamentary, and there were rules for addressing those things. As from that moment, everyone would be muted on the system and would only be unmuted when it was their opportunity to speak.
Ms Chirwa said that she had not offended anybody and had not said anything that was unpaliamentary. Every Member deserved to be given time to deliberate on the platform and engage equally with other Members. Ms Gela had said insulting things to her and the Chairperson had said nothing, but "when I respond, I am the one who should be muted and kicked out of the meeting." That was wrong and unethical of the Chairperson.
The Chairperson said Ms Chirwa would speak only when recognised to speak, and would speak only on the matters before the Committee, which would apply to all of the Members. Both Ms Gela and Ms Chirwa were muted and both of them had been given a warning. The matter had been ruled on and was now closed. The Committee would continue with the deliberations.
Clause 32, Role of Department
This stated that:
"(1) The functions of the Department are outlined in the National Health Act and the Constitution, and include:
(a) issuing and promoting guidelines for norms and standards related to health matters;
(b) implementing human resources planning, development, production and management;
(c) coordinating health care services rendered by the Department with the health care services rendered by provinces, districts and municipalities, as well as providing such additional health services as may be necessary to establish an integrated and comprehensive national health system;
(d) planning the development of public and private hospitals, other health establishments and health agencies as contemplated in section 36 of the National Health Act; and
(e) integrating the annual health plans of the Department and the provincial and district health departments and submitting the integrated health plans to the National Health Council.
(2) Subject to the transitional provisions provided for in section 57, the Minister may introduce in Parliament proposed amendments to the National Health Act for the purpose of centralising the funding of health care services as required by this Act, and in such cases the Minister may -
(a) delegate to provinces as management agents, for the purposes of provision of health care services, and in those cases the Fund must contract with sections within the province such as provincial tertiary, regional and emergency medical services;
(b) designate provincial tertiary and regional hospitals or groups of hospitals as autonomous legal entities accountable to the Minister through regulation; and
(c) establish District Health Management Offices as government components to manage personal and non-personal health care services.
(3) Without derogating from the Constitution or any other law, the functions of a provincial Department must be amended to comply with the purpose and provisions of this Act, subject to the provisions of section 57."
Mr Xaba said the ANC entirely supported Clause 32. Clause 32(1)(a)-(e) was supported because it enabled the introduction of the National Health Insurance Bill as an Act that would be directed at reforming several provisions of the National Health Act, towards creating a legislative and regulatory regime that would move the country progressively towards universal health coverage. Clause 32(2) was supported because it would empower and legislate the demands of the health professionals to control the budgets and the staffing of their hospitals, so that accountability would not be fragmented.
Ms Clarke, on Clause 32(1), noted that the NHI would actually override the existing constitutional framework. Would Clause 32(2) not raise a constitutional issue, overriding the duties of the provincial departments in terms of the Constitution? In drafting the legislation, the Department had not undertaken a proper impact assessment as far as the relationship of the existing health legislation was concerned. The vague wording in the current clause made it clear that the Department had no idea how the Bill would impact existing structures and authorising legislation. More clarity was needed on what Clause 32(3) would entail.
Ms Wilson said what was being discussed was the role of the Department, which was laid out in legislation and the Constitution. It was not the role of the NHI Fund to override the Constitutional mandates of the Department -- that would require a Constitutional change. Clause 32 showed that all the revenue that would have been allocated by the provincial equitable share (PES) and conditional grants, would now be re-directed to the NHI Fund – meaning that the provincial governments would not receive transfers from National Government's constitutional obligation to national healthcare. In effect, the provincial governments would now become agents of the NHI Fund.
Control over financing also implied control over service distribution (effectively provisional health administration). Health services would cease to be a concurrent function between national and provincial governments, nullifying the Constitution's allocation of those functions. There was a very big concern about the constitutionality of the clauses. To change something constitutionally mandated, one would have to change the Constitution. The proposed structures would strip away the powers of the provinces to finance and plan district health services, and would allocate them to the Minister of Health. A government component could be established only if a prescribed feasibility study was conducted, and its findings recommended the establishment of such a component. There had been no feasibility study to support what was stipulated in Clause 32. No framework was proposed in the Bill that made the proposed District Health Management Offices accountable to the communities for which they would provide services, which was very concerning.
Ms Ismail said Ms Clarke and Ms Wilson covered her. Clause 32(1)(c) mentioned health care services rendered by districts and municipalities, but it was also unclear whether that was referring to municipal health services. Clause 32(2)(a) was unclear what provinces would have to be management agents of. The second largest function of provincial departments was to provide healthcare services. Clause 32 infringed on the constitutional mandate of the provinces. Clause 32(2)(b) was unclear who would oversee the hospitals.
Ms Gela supported Mr Xaba. Schedule 4 of the Constitution was clear, and there was nothing in Clause 32 that was against the Constitution.
Mr Munyai supported Mr Xaba's and Ms Gela's submissions. The ANC supported Clause 32(1)(b) as it was reflected, because it affirmed the provisions of the National Health Act. During the deliberations, 'unconstitutionality' had become a buzzword, and it was important for the Members to remember that the Bill had been scrutinised first by the State Law Advisers, who had then issued a certificate to say the Bill met the Constitutional requirements.
Ms Chirwa said there might be a contradiction in Clause 32 concerning Clause 31(2). Clause 31(2) specified the powers given to the Minister, by stating that the Minister would delegate roles and functions to the provincial departments in the context of the NHI. In Clause 32, the roles of the 'provinces', were contracting the powers that had been given to the Minister. Where would the Minister's delegation of roles to provinces and hospitals end, and where would they begin? Comments had been received from provinces on the NHI, stripping them of their autonomy, noting that the NHI would be centralised. On Clause 32(2)(b), where would the legal autonomy of hospitals begin and where would it end? How would it affect litigation processes of patients against the National Department of Health? Who would carry the litigation costs of those hospitals?
Ms M Hlengwa (IFP) said the Department had various functions, including coordinating healthcare services that were rendered by the provinces, districts and municipalities. What was the role of the provinces when they were now described as 'management agents' of healthcare services? What was the role of the municipality?
Ms Clarke said in terms of the constitutional muster, there were many cases where legislation had been ruled unconstitutional, invalidating the argument that the NHI Bill was within the confines of the Constitution.
Ms Havard supported the submissions of Ms Gela, Mr Xaba and Mr Munyai. She said the ANC supported Clause 32(2)(a) because delegation to provinces was key to achieving equity, and would do away with the need for complex and duplicative funding arrangements and would ensure that all services were made available to all people without boundaries. The ANC supported Clause 32(3) because it would see the amendment of the function of the provinces.
The Chairperson supported the contributions that were made by Mr Xaba, Mr Munyai, Ms Gela and Ms Havard. He said Clause 32(2) was key to shifting public health sector funds to the NHI Fund, as the functions would be amended to enable the strategic purchasing of personal healthcare services. Clause 32(2)(c) aimed to give greater responsibility to the districts to implement reforms that supported proactive planning and management of the resources for health services from the public purse closer to the communities to benefit. Introducing the District Health Management Offices would allow for localised services, planning and provision.
Clause 33, Role of medical schemes
This stated that:
"Once National Health Insurance has been fully implemented as determined by the Minister through regulations in the Gazette, medical schemes may only offer complementary cover to services not reimbursable by the Fund."
Mr van Staden said the clause was very vague. It was still unclear what the functions of the private doctors and medical aids would be. In effect, the clause would result in doctors and medical practitioners looking for other opportunities abroad, thus reducing the country's medical expertise, which would affect the South African economy. It was also unclear what impact the NHI would have on Chapter 3, section 12 of the Medical Schemes Act 103 of 1998. What would happen with the reversed funds remained unknown.
There was a question mark hanging over the assets of the medical aids under the NHI. Government had to take note of South African doctors, especially in the private sector, who had been quoted as saying they strongly opposed the NHI and would not be supporting its current format, as it would lead to corruption. Doctors would emigrate if the universal healthcare system was implemented. The South African Medical Association, which had a membership of more than 70 000, had also stated that as an organisation, it could not support the NHI Bill since it would create a monopoly in the healthcare sector. A great concern was that the NHI would restrict the functioning of the 80 registered medical aid companies in South Africa. With the country's alarmingly high unemployment rate, that was a great concern. Approximately 9.4 million people in South Africa were members of medical aid schemes, and the job creation in that field alone was significant.
Ms Clarke concurred with Mr van Staden, and said Clause 33 was very vague. There was a concern about the quality of health care that the state healthcare system would be able to provide. The environment under which the state was currently operating could certainly not claim that it was providing quality healthcare. Universal healthcare was supported 100%, but the infrastructure had to be re-looked at to ensure that it was possible to produce that kind of healthcare. There was a serious concern about the legality of Clause 33, and the state law advisers would have to provide more information on it. Was there a guarantee that the quality of healthcare would be the same, and how would that be achieved? There were also serious concerns that the funds would be open to corruption and mismanagement. Medical clinicians in the country were already concerned about the NHI Bill, while there was a severe shortage of doctors and nurses nationwide.
Mr Xaba said the membership of medical aid schemes over and above the NHI Fund would be a duplication of payment for cover once the NHI started paying for benefits. The upper-middle class may choose to purchase additional medical cover by schemes that the health system would have deemed to be of unproven value. The ANC supported Clause 33, because it was essential to achieving equity in the financial and non-financial resources in the national healthcare system. The introduction of the NHI ensured that the Fund would strategically utilise its capabilities to purchase healthcare services.
Ms Wilson referred to section 27 of the Bill of Rights, which stated that everyone had the right to access healthcare services, including reproductive healthcare, and that the state had to take legislative and other measures within its available resources to achieve the progressive realisation of those rights. First, the state did not have the resources available to implement the NHI Bill. A progressive realisation of the said rights had not been seen -- instead, what had been seen was a collapse and regression of the system. What would happen to the protected coverages, like the Road Accident Fund and the compensation for injuries on duty? What was implied by the Bill was that general taxes would be increased to at least the equivalent of what medical scheme members were contributing for their own coverage.
Ms Ismail said there were concerns as to what would happen to medical schemes, since most members would not be able to afford both the NHI and medical scheme contributions. The complementary nature of the NHI medical scheme benefits needed to be clarified in line with the Medical Schemes Act Amendment Bill. Medical schemes would be prohibited from providing care that duplicated the care provided by the NHI Fund. South Africa would be globally unique in that its system of NHI would not only apply to the NHI, which would make the NHI unconstitutional. There were fewer details on the role of medical schemes presented in the NHI Bill (Clause 33) compared to the White Paper. Clause 33 referred to the medical schemes, but there was no reference in the NHI Bill to other funders of healthcare in South Africa. The NHI might never be fully implemented -- and where would that leave the people who usually had medical aid? There was also no indication of how medical malpractices would be dealt with in the NHI environment.
Ms Hlengwa concurred with Ms Clarke. There was no definition of "complementary services" as stipulated in Clause 33 of the NHI, so more clarity was needed on that.
Ms Chirwa said for the past few years, the issue of medical insurance had been wrongfully regulated by the Council for Medical Schemes (CMS), despite the fact that the issue had been raised on countless occasions. Nothing had been done due to the abuse of power by Ministers who did not want to do anything. What would be the impact of the NHI in relation to medical insurance? What would happen in the instance where a person, out of their respective rights, did not want to register to form part of the NHI? How would the persons who did not register for the NHI be treated? It was sad that black people continued to be used in the desperation for quality healthcare estates – for instance, on the issue of the two tier system that was being used to lure black people into supporting the NHI. The NHI was not going to bring equity and access; the people who lived in the most rural and remote areas would still have to use the facilities they had used before.
Mr Xaba said there was no way that the Portfolio Committee could seek to exploit black people. Ms Chirwa had to be careful in saying the Portfolio Committee was using black people on the basis of the NHI.
The Chairperson and Ms Chirwa went back and forth on whether Ms Chirwa's comments were reasonable in the context of the meeting. Ms Chirwa kept emphasising that she had the right to give opinions on black people. The Chairperson had indicated that there was nothing that made Ms Chirwa a specialist on black people as he too was a black person.
The Chairperson gave Ms Chirwa another opportunity to continue her comments on the Bill.
Ms Chirwa, in conclusion, said there was no such thing as the two tier system being abolished by the NHI. The private sector would still exist and claim back from the state. Access and equity were not issues that the NHI would resolve -- the NHI was not for the people who lived in rural and remote areas. Sustainability was going to be an issue, because taking money from medical aid schemes that could not even cater for 10% of the population to supplement access for 70% of the population would not resolve the issues of access to quality healthcare.
Ms Havard supported Mr Xaba's submissions, and said the NHI had to be implemented quickly for the sake of the people of South Africa.
Mr Xaba said the role of medical aid schemes within the future of universal healthcare had to be considered within the context of the existing two tier healthcare system. It was important for government to intervene decisively. It was also incumbent on government to protect the public from products that the public believed covered their health requirements, when in fact that was not the case. South Africa had not yet achieved universal health coverage, and financial risk protection was one of the main obstacles. The current fragmentation in the healthcare systems was because of the multiple funding pulls. Medical aid funding often ended with a person's employment, and upon retirement, such people would then come under the NHI.
The Chairperson said the meeting had come to its conclusion, and the deliberations would continue on 31 August. It was worth noting that it was inappropriate for anyone to use the NHI Bill to raise some of the populist agendas. The deliberations were not a platform for that, and debates had to be held in the National Assembly. The common good of the people of South Africa was what was important.
The meeting was adjourned