National Health Insurance (NHI) Bill: public hearings day 29

Meeting Summary

Video

NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee held the final public hearings on the National Health Insurance Bill. The Democratic Alliance (DA) and the African National Congress (ANC) gave oral inputs.

The DA supported equal access to universal healthcare but did not support the bill as it would not meet its intended objectives and was not compliant with key constitutional principles or rights. The manner in which the Bill sought to achieve equal access was regressive.

The party said that the Bill misdiagnosed what had gone wrong in healthcare. What had gone wrong, was not the fact that the rich were getting quality healthcare, because they could afford it. What had gone wrong was that 84 percent of South Africans had been let down by a system that had not catered for them. When fixing that, one did not propose that the 16 percent become the 84 percent. What one put forward was to allow for the 84 percent to enjoy quality healthcare like those who were covered by medical aid. One needed to bring the country up and not down in a race to the bottom.
 

The DA highlighted that public healthcare institutions had suffered from a culture of corruption and incompetence which had led to poor management, underfunding, understaffing, a loss of skilled staff and deteriorating infrastructure. It argued that the Bill should be tagged as a money bill, given the massive financial consequences it would have. Concerns about the referral pathways were raised, particularly where it would result in unnecessary costs and delays, such as where a pregnant women would be required to see a General Practitioner before a gynaecologist or obstetrician. It highlighted that the Bill discriminated against asylum seekers and foreign nationals. Section 27 of the Constitution stated that ‘everyone’ had the right to access healthcare, and it did not expressly exclude persons with the status of asylum seekers.

Members raised concern about the role of the Competition Commission under National Health Insurance and the potential for price collusion. A Member asked if the Bill unjustifiably limited a person’s constitutional right to freedom of association, as it effectively forced a person to become a user of the Fund to access certain healthcare services. A Member raised concerns about how medico-legal claims would be covered under National Health Insurance and if this would result in the undermining of healthcare services provision. It was asked why there was such a high vaccine wastage in the Western Cape. It was noted that the Western Cape did not face the same challenges as other provinces, in terms of international land borders and inherited homelands. A Member asked if the private sector was involved in corruption. It was asked how it was less burdensome to the health system for patients with minor ailments to seek care with a specialist rather than be referred from a General Practitioner.

The ANC said that it ‘unequivocally supported’ the National Health Insurance Bill. The ANC was committed to good governance at all levels led by a Board that was professional, charged with fiduciary accountability and had zero tolerance to corruption and unnecessary interference. The party proposed that the Bill be explicit about the need for all, especially illegal immigrants, to comply with the provisions of all South African laws especially the South African Immigration Act. To enhance sources of revenue for the fund and to cover immigrants, the role of multilateral bodies such as the United Nations High Commissioner for Refugees and the African Renaissance Fund be indicated in the Act to ensure the sustainability and affordability of the Fund. The ANC recommended that clause 15(3) of the NHI Bill be enhanced to ensure that the Board, or its representatives, and the Minister meet every six months to share information, as a practical expression of the relationship between the Executive Authority, and Accounting Authority.

Members pointed out that according to the Financial and Fiscal Commission and the Auditor General’s report, the management of resources and service provision were the biggest sources of failure in the Department of Health. A Member highlighted that the challenge of malnutrition was downplayed in the African National Congress’s submission. It was asked how government would deal with systemic corruption and the lack of will to end it. It was suggested that the initial cost estimations did not take into account the debt situation, current economic situation nor overburdened tax base. Clarity was requested about the constitutionality of the Bill, given that other stakeholders had highlighted this issue, specifically its impact on the freedom of choice. A Member highlighted that the pilot projects had not been an adequate measure of assessing the feasibility of the Fund. A Member asked how the African National Congress would respond to allegations that the Bill was irrational. It was asked that the issue of extra taxation being a ‘myth’ be explained. Clarity was requested about the support of National Treasury and the Minister of Finance on the Bill.
 

Meeting report

Opening Remarks
The Chairperson made brief opening remarks and welcomed those in attendance.

The apologies were noted.

Presentation by the Democratic Alliance (DA)
Ms Siviwe Gwarube, Member of Parliament (MP) and Deputy Chief Whip of the Opposition in the National Assembly, and Mr Werner Horn, MP in the National Assembly, presented the DA’s submission on the NHI Bill.

The DA supported the realisation to equal access to universal healthcare envisioned in the NHI Bill. The DA did not support the NHI Bill as it would not reach its intended objectives and was not compliant with key constitutional principles or rights. Given the current state of the economy and especially State-run enterprises, it was common knowledge that the Government would not be able to effectively establish and maintain such a large scale undertaking. Public healthcare Institutions had suffered from a culture of corruption and incompetence which had led to poor management, underfunding, understaffing, a loss of skilled staff and deteriorating infrastructure.

The Bill had a massive financial consequence but had not been tagged as a money Bill.

The DA argued that the exclusion of asylum seekers from enjoying the right to universal access to quality health care services, as purported by this Bill, was unconstitutional.

The regulatory powers afforded to the Minister did not give proper effect to the legislative or oversight powers and responsibilities of Parliament as the legislative authority. The power of the Minister to appoint the Board was neither consistent with the minimum standards applicable to public entities, nor did it allow for public participation or parliamentary oversight and accountability.

The manner in which private healthcare could effectively be outlawed once the Bill was fully implemented was not regulation, but abolishment and prohibition by stealth. Similarly, the way in which medical practitioners would be subjected to the decision-making powers of the Minister would not merely limit or regulate their freedom to practice their profession, it would redefine it to a point where one could merely enjoy the choice to practice as medical practitioners or not.

The NHI Bill was justified by its proponents by the imperative to attain equal access to health care. However, the manner in which the Bill sought to attain equality was regressive. Therefore, it must fall foul of the Bill of Rights in as far as a contextual interpretation of the Equality clause makes it clear that where inequality was not caused by “unfair discrimination” equality may not be brought about by any other means than adding to the way in which those who do not enjoy equal access to health opportunity. The Bill cannot pass constitutional muster in that it was inconsistent with the values that was underlying to an open society, as required by the limitation clause in order for a limitation to be valid. The main characteristics of the open society is “individual freedom or autonomy”. This Bill did not merely limit these freedoms, but in many respects took them away.

It was unclear what services or package of care would be included under the NHI system. SOE’S were failing, an SOE NHI fund would be very vulnerable to mismanagement and corruption. Referral pathways were an unnecessary and burdensome provision, which may lead to users being unreasonably excluded from being covered by the Fund. For example, what would happen to a pregnant woman who decided to skip the general practitioner (the primary care provider) and go straight to her regular gynaecologist or obstetrician? This placed unnecessary pressure on the health system and could lead to additional costs, especially in cases where a visit to the general practitioner could have been avoided. The Bill discriminated against asylum seekers and foreign nationals. Section 27 of the Constitution stated that ‘everyone’ has the right to access health care, and it did not expressly exclude persons on the ground of their status as asylum seekers.

(See the DA’s presentation for further information)

Discussion
Mr A Shaik Emam (NFP) accepted and understood that there were serious challenges with the fiscal constraints. At the same time, people were dying, people over 60 years were being turned away from hospitals. The level of inequality in the healthcare sector was a massive problem. The majority of South Africans did not have the luxury of medical aid nor their next meal. What was the alternative, given the fact that the DA accepted and understood the challenges of SOEs and how these were run within fiscal constraints? What should happen? Should the country not start somewhere in providing better access to equal healthcare to all South Africans? Did the DA accept and agree that every life was valuable and equal? The problem was that for many years, many of those vulnerable people were left out of the system. This went for every province in the country. What would the DA suggest be done in the interim to provide universal healthcare to everybody irrespective of their economic or financial situation?

Ms E Wilson (DA) agreed that this should be a money bill – it was not termed as a money bill. It was questionable what the role of the Treasury was in this instance. If this was not registered as a money bill, it became harder to manage without Treasury’s involvement. NHI made large sections of the current National Health Act mute. If the NHI was passed – which it could not be, due to the unconstitutionality of large parts of it, one would have to assess how it would affect the National Health Act. She understood that it was a lengthy process to amend other pieces of legislation and align them.

Sugar tax was imposed in the country, the principle behind that tax at the time, was that due to high sugar usage in the country there was excessive diabetes and sugar-related diseases. That sugar tax was supposed to be set aside for the promotion of health and to deal with issues of diabetes etc. The tax was introduced – no one could ascertain how much was garnered from that tax and where it was being spent. In actual fact it had likely gone into the national fiscus – that was not the intention of that tax. Was the country not running the same risks with the NHI Fund, where one would have no idea if it was being appropriately spent, as there was nothing in the Bill stating the way in which it should be spent.

She was glad the DA had mentioned the separation of powers. That was a huge issue. There was a clause in the Bill that principally entirely cut-out the Competition Commission. The Competition Commission was there for a reason. The Bill implied that there needed to be a single purchaser and that purchaser would dictate where one could buy one’s medical resources. Was the Bill not opening up a bigger door to corruption? To cut-out the Competition Commission was concerning.

She appreciated the reference to medico-legal claims. Currently, the medico-legal claims were in excess of R120 billion – about half of the current budget allocated to health. If half of those claims were won – one was looking at R60 to R80 billion in costs. Where would that money come from? If that money came out of the NHI Fund it would go up to R400 billion which would be beyond devastating. Medico-legal claims were not something that could be budgeted for, and yet it had not been taken into account at all. In the last few months, the country had spent well over R200 million on legal claims to fight some of those issues. 

In the last presentation from the Auditor General (AG) and the Department, some NHI grants which were there to uplift – ended up going back to Treasury. This meant that the money that was available to uplift the health system was not even being used. How could one ever hope to have quality, when money that should have been put to good use was returned to Treasury. This was concerning for NHI.

Ms H Ismail (DA) stated that she had asked in a previous meeting about the NHI submission documents being safe in the parliamentary precinct after the fire that took place. She noted that a response was given at that time, but the response had not been minuted adequately in the minutes of 15 February 2022. This was the last day of NHI submissions and hearings, it was essential to know that everything was in order, otherwise the whole process would have to take place again from scratch.

The Chairperson noted that the question was raised the week before. He had requested a response from Parliament, who had given him the assurance that those documents were safe, both the electronic and written submissions. He asked if the Member had a reason for asking the question again – he offered to go back and confirm the response.

Ms Ismail stated that she simply wanted it to be minuted in the minutes of the meeting.

She asked how did one protect the system from price collusion if there was a single purchaser? Tenders had previously been awarded to companies that had over-charged for services. While the country was experiencing the pandemic, there had been major COVID-19 corruption of Personal Protective Equipment (PPE). Did the DA think that the country would see worse under NHI, than what was seen with COVID-19? What suggestions could be made to protect the Fund from political interference, considering the corruption and abuse of funds by the previous Minister, in the Digital Vibes saga? The Office of Health Standards Compliance (OHSC) presently could not manage to monitor 20 percent of the country’s healthcare facilities; there would be certain compliance requirements under NHI. Would this stifle innovation and impact the provision of health services to communities rather than increasing quality health services to the country? In addition, the Health Ombudsman could not manage to oversee compliance currently – how would compliance be ensured under the NHI? Were the referral pathways labour intensive, negatively impacting timelines for treatment? In order to access quality universal healthcare for all – one needed to first ensure that skilled healthcare workers were appointed, the number of healthcare workers needed to be increased in the public healthcare sector and public healthcare facilities needed to be upgraded in order to provide efficient healthcare services to the Country.

Considering that the country was 27 years into democracy under the present government, nothing constructive had been done to fix the dysfunctional health sector. Did the DA contemplate that in a few years, after the implementation of NHI, there would be an efficient professional healthcare system in the country – or not?

Ms M Clarke (DA) asked how the supply of healthcare services should be increased to match the demand. It was noted that the scheme faced a supply/demand problem with many public facilities not qualifying to practice in the scheme. Private healthcare practitioners, as well as nurses could opt to emigrate. Assessments of the NHI trials revealed major issues at some state hospitals in the early testing stages for the scheme. The issue of healthcare workers being willing to leave, and actively leaving the country ahead of the system, was well-reported. How did one mitigate the risk of a brain-drain of critical skills within the health sector? Would the NHI be more competent than the ‘current universal healthcare system?’

Under the NHI, would the State be able to provide quality healthcare, considering that most of the hospitals did not comply to the 80 percent compliance standard set by the National Department of Health? When requesting inspections of certain facilities, one waited months before outcomes were received. There were no corrective measures to remedy the required standards. There was no accountability nor consequences. Would the NHI be in a position to remedy the severe state of decline of hospitals. The State was currently reliant on private medical aids, and the contributions they brought in. If private medical aids no longer played a significant role, how would this impact the implementation of the NHI? The DA often faced criticisms of being ‘anti-poor.’ Considering that the Bill sought to provide for equal quality access to healthcare for all South Africans, the DA’s stance was clearly against the Bill. Could the DA’s position be described as anti-poor?

Procurement processes were not followed during the pandemic, as one had seen from the SIU investigations, the COVID-19 report stated that R3.3 billion was under investigation. It was important to note that the Western Cape was the only province to setup a full tender list, it was also the province with the least investigations of this. What had the province done differently? Would the centralisation of the procurement processes solve the flaws in the current system to effectively provide healthcare services?

Mr M Sokatsha (ANC) stated that the DA created the perception that the Western Cape was the most well-run and efficient province. Could the DA explain, based on the reports that were received, why there was such high vaccine wastage compared to other provinces. If, as claimed by the DA, the private sector was ‘so much more efficient than the public sector,’ how did the wastage occur in the private sector? Were private companies involved in the corruption? The DA raised the issue of medical malpractice in its presentation. Could the DA state if there was any medical malpractice in the private sector and the figure?

The DA argued that the current economic context had changed and that the NHI Bill needed to be re-evaluated. Was the DA disagreeing with National Treasury, which expected the Gross Domestic Product (GDP) to return to pre-pandemic levels as soon as the end of 2022? Did the DA disagree with the Reserve Bank, which expected GDP to grow by 1.8 percent in 2023 and 2.0 percent in 2024? Would the country not benefit from strong global economic growth, less restrictive lockdown regulations and increased vaccination rates. Did the DA undertake its own economic analysis on GDP growth to arrive at this recommendation, of re-evaluating the feasibility of the NHI Bill? If so, he asked that this ‘report’ be shared with the Committee.

The Committee was concerned about access to healthcare for South Africans, especially the poor. He asked that the DA comment on the following statements. The important and urgent implementation of the NHI was emphasised in the points made by Members of the Committee during the public hearings and other meetings of the Committee. Dr S Thembekwayo (EFF) and Ms N Chirwa (EFF) brought to Parliament a private member’s bill that sought to have all clinics operating for 24 hours. The Committee unfortunately could not pass the bill due to the lack of resources, however the Committee had agreed with Dr Thembekwayo and Ms Chirwa on the matter. The NHI Bill sought to do exactly what was suggested by the EFF. Mr T Munyai (ANC) had shared a painful story about himself and his brother having been involved in an accident. Sadly, only Mr Munyai was attended to as he had medical aid and his brother was not. This had been said all along, NHI needed to be implemented to ensure that such discrimination did not happen again. It was well-known that Section 27 of the Constitution was clear about the fact that no one could be refused emergency medical treatment. Unfortunately, this in-human act was happening unabated. Ms Wilson lamented that she had gone to a health facility, where she was attended to but her ‘helper’ was not. The ‘helper’ was refused treatment because she did not have medical aid. NHI would not allow for this kind of discrimination.

Dr X Havard (ANC) asked that the DA explain how it was less-burdensome to the health system for patients with minor ailments to seek care with a specialist and their primary care givers, rather than be referred from a General Practitioner (GP). She asked that the DA highlight any country or medical aid in South Africa that had no exclusions or rationing of health services. The DA was worried that it was unclear what services and medications would be covered or excluded under NHI. Healthcare services and delivery mechanisms changed over time according to the health status of the population and advances in technology. Should these services be included in the Bill? These services would need to be reviewed every two to three years to keep up with the changes in health status and health technology. If that was the case, did the DA recommend that once the NHI Bill became law, the Act would need to be amended every two to three years. If so, how practical was this recommendation. Which country had done this? Should these services not be included in the regulations, which were easier to change? She noted that the DA was worried about the failing SOEs – the NHI was not an SOE. It was a public entity. Was the DA aware that most public entities had performed well in terms of governance and financial management. Did the DA undertake an analysis of how SOEs were performing – she asked that this be shared with the Committee, if this was the case.

Was the DA aware that the Western Cape inherited two medical schools and four health sciences faculties from the previous apartheid dispensation. Did the DA acknowledge that it had no significant international land borders nor inherited homelands; it had the highest proportion of the population on medical aid. Was this a fair comparison when compared to the challenges experienced in the rest of the Country?

Ms A Gela (ANC) noted the point that the Bill would not contain the list of comprehensive healthcare services to be covered under NHI. She asked that the DA explain the difference between SOE and Schedule 3A public entities and how the Public Finance Management Act (PFMA) applied to each. The DA was of the view that the Bill sought to abolish the private sector providers – did the DA overlook chapter 2, clause 8(2) of the Bill as well as other clauses, where the role of the private sector establishment was covered? Given that the DA was against the provisions of clause 7(4) of the Bill, which provided for service providers to limit their scope within the confines of cost effective services, as would be determined through health technology analysis. She noted that Ms Gwarube was part of the NHI public hearings previously; South Africans had stated clearly that NHI be implemented as it was the only way to create equality. [Another language spoken 1:27:30].

Mr Munyai noted the DA had put forward that it supported the implementation of the policies aimed at improving healthcare access to South Africans. Yet, the rest of the DA’s submission was contradictory to their initial statement. How did the DA believe improved access to healthcare would be realised? He did not hear any proposals being made in the DA’s presentation. The DA was against the proposed referral pathways and believed that it would exclude individuals – he was not sure how this was possible. Why should the DA expect everyone to access healthcare at the highest level of care, even if the ailments were minor and could be resolved at the entry level facilities? The DA wanted universal health coverage without NHI. What were the key alternative proposals that the DA wanted to advance? Did the DA believe in a ‘laissez-faire’ philosophy and the monopoly of private sector medical aids? In the current two-tier arrangement, the private sector was receiving over R400 billion. 84 Percent of the population was not served by the private sector, yet the private sector contributed significantly to the GDP of the Country. Was this the inequality the DA wanted to serve? The international convention was not segregation. It was important for the DA to explain its understanding of Section 27 of the Constitution. In the City of Tshwane the Mayor was involved in the appointment of the board and the entities of the City – what was the case in the Western Cape? Why did the DA not want the Minister to be involved in such appointments?

Mr E Siwela (ANC) stated that the DA claimed that the whole NHI Bill was myopic – in what way? Was that not an ‘extreme form’ of expression? Could the DA explain how the powers of the provinces, to deliver healthcare services, were allocated and funded prior to 1994? Was there not a central national health budget – had this not work favourably for the minority privileged white population? Was the DA against this benefit being afforded to the entire population? Could the DA remind the Committee how many health departments there were? The DA had just argued that creating one central health budget or Fund was not acceptable as it created ‘fragmentation’ – something was missing from this argument. The DA argued that the economic context under which the country was operating had changed – therefore the NHI feasibility needed to be re-evaluated. Was the DA disagreeing with National Treasury – which expected the GDP to return to the pre-pandemic levels by the end of 2022? Was the DA disagreeing with the Reserve Bank, which expected the GDP to grow by 1.8 percent in 2023 and 2.0 percent in 2024. Was the DA suggesting that the country would not benefit from strong global economic growth, less restrictive lockdown regulations and rising vaccination rates? Did the DA undertake its own economic analysis on the GDP growth to arrive at these recommendations of re-evaluating the feasibility of the NHI Bill? If so, he asked that the report be shared with the Committee. How did the NHI Fund describe the ‘severely limited options’ for private practitioners. The Bill defined healthcare service providers as persons in the public or private sectors providing healthcare services in line with any law. It treated public and private providers equally. In slide 34, he asked that the countries, that conducted feasibility studies prior to reforming their health system to universal healthcare financing models, be listed. Feasibility studies were done through the Socio-Economic Impact Assessment (SEIA) for this policy.

The Chairperson asked a number of questions on behalf of Ms M Hlengwa (IFP). The DA highlighted many constitutional concerns about the proposed Bill. Did the Bill unjustifiably limit a person’s constitutional right to freedom of association, as it effectively forced a person to become a user of the Fund to access certain healthcare services? Private healthcare would be limited to provide complementary healthcare services – it was still not known what this meant. What accountability measures would the DA recommend to strengthen the corruption investigatory unit? Had the DA conducted any feasibility studies on the proposed alternatives to healthcare reform that could be considered? Considering the urgent need for healthcare reform, workable solutions needed to be found to address the inequality in the healthcare provision.

The Chairperson asked a number of his own questions. Where did the Constitution guarantee choice? He asked why there was a need to go straight to specialists rather than via the referral system. The Bill stated that the Fund would investigate complaints – nowhere did it give policing powers to the Fund – was the DA not aware of the Health Sector Anti-Corruption Forum? This was established in 2018. Clause 4 of the Bill required proof of address for registration – more than 50 million people had already registered on the Electronic Vaccination Data System (EVDS) system. The DA seemed to believe that ordinary South Africans could not be subjected to yet another tax – would the DA prefer that thousands of South Africans pay medical scheme contributions and then still pay for care not covered by the schemes? Many South Africans were denied healthcare due to not being able to afford healthcare. What proportion of the GDP spent on health did the DA think was affordable? Was DA against the redistribution of the 8.5 percent of GDP to the entire population? Medical aids refused to cover treatment that was not available in the treatment protocols or formularies – this was a limitation. How would such limitations be addressed? Should the Fund not protect itself from risk – why should it cover everything? The private sector would offer complementary services not offered by the Fund.

Ms Gwarube noted that it was raised by a number of Members, that only 16 percent of South Africans were covered by medical aid, while 84 percent were not. It would be naïve to not see how deeply unequal the health system was. That was why the DA supported universal healthcare. The mechanisms to get there needed to be financially viable and needed to guarantee that people would get the quality care needed. When one spoke of equality, it was the DA’s desire to show the Committee where the pitfalls in the legislation. The Committee should address some of the challenges that had been raised by many of the entities that had appeared before the Committee.

The DA had not only seen the pitfalls of the legislation but had applied its mind to the alternatives that could be looked at. There could be the creation of a universal subsidy to every South African citizen, irrespective of being covered by the public or private sector. The two-tier system was of concern – there could not be one standard of care for those who had medical aid and those who did not. The DA was proposing, as an alternative, that money be used to develop a universal subsidy that would be afforded to all South Africans. It would be affordable and would allow all 60 million South Africans to have a subsidy to go to whatever healthcare provider they wanted to access a basket of services. There was an opportunity to then top-up. This was why the DA had not raised the issue about topping-up of medical aid schemes as a problem, because it was believed that having that subsidy would equalise the system. Services would be free at the point of service. This was important as it went to the head of some of the concerns raised by Members about an alternative. This alternative would not bankrupt the country and would not open the Fund to rampant corruption, as had been seen in other instances. It would equalise the package of care that everyone could have. It did not require the centralisation of the Fund that would be managed by political appointments.

The DA put forward that there needed to be decentralisation of services. A centralised healthcare service structure was not efficient; it was inefficient. If powers were devolved to provinces, which could devolve powers to regional structures, one could ensure that the package of care and services were closer to the people. A centralised fund would not necessarily trickle down. There were models of universal healthcare that worked and did not require the kinds of changes that the NHI wanted to impose. This would get the country to a point where all South Africans had access to quality healthcare be able to have the kind of dignity that was only afforded to those who had money. This was due to the public health system being run poorly – money would not fix that problem. An overhaul of the system would not fix that problem. That was why this Bill was not addressing the nub of the issue – that was why it was myopic – all that it did was introduce a funding model. It said nothing about how to introduce universal healthcare at ground level in isolated areas.

There were many issues about the reduction of funding of the NHI grant over the years. There had been no movement in how to fund the proposals in the NHI. Treasury was not in agreement with the Committee – this had come up a number of times. She would argue that the DA agreed with Treasury. A R380 billion deficit – more was spent servicing debt in this day and age than was being spent on education and health. That was a reality. One could not legislate for a ‘future hope,’ of the GDP growing. The policy needed to respond to the current economic climate. It was incumbent on the Committee to pass legislation that would be implementable. Otherwise, the whole process was null and void. There was a massive concern about tax – unemployment was on the rise – the tax base was shrinking by the day. It was not fair or right to impose an additional tax South Africans when they were already struggling so much.

A fund of this nature and magnitude should not be appointed by the Minister. There were ministers in this portfolio, as well as Members of the Executive Council (MECs) and mayors across the country who were trusted with public service, who were looting funds during COVID-19. What one wanted to do when legislating was to ensure that accountability mechanisms were built in. Allow Parliament to appoint the Board.

She responded to the question about equality – that if one did not support he NHI, one was ‘anti-poor’ or did ‘not support the idea that South Africans who could not afford medical aid should have quality healthcare.’ She would argue that this was to the contrary. She pleaded that the Committee did not look at where the proposals were coming from – but looked at the process in a dispassionate way. There were ways of equalising access to quality healthcare in the country. The NHI would not get the country there.

The Bill misdiagnosed what had gone wrong in healthcare. What had gone wrong, was not the fact that the rich were getting quality healthcare, because they could afford it. What had gone wrong was that 84 percent of South Africans had been let down by a system that had not catered for them. When fixing that, one did not propose that the 16 percent become the 84 percent. What one put forward was to allow for the 84 percent to enjoy quality healthcare like those who were covered by medical aid.  One needed to bring the country up and not down in a race to the bottom. That was what the DA was pleading.

There were medico-legal claims in the private sector. The DA’s presentation was not done on behalf of the private sector. The Committee had powers to summon the private sector and ask about the medico-legal claims. There was a rise in the cost of medico-legal claims within the Department that was threatening to bankrupt the sector. There were certain things within the Bill which would mean that the medico-legal claims would become rife. It would send the Department further into the red. The sweet spot existed in the collaboration between the public and private sectors. The quality should be the same in both sectors. It seemed as if the Committee did not believe Treasury. Treasury had repeatedly stated over the past two years that the implementation of NHI had not accurately been budgeted for. The current economic climate needed to be considered when legislating.

The regulations would likely be a lot more detailed than the Bill – the Bill was currently open to interpretation and vague about which package of care would be provided. The remaining public entities were classified as schedule 3A and schedule 3C. These entities were extensions of the public entities with the mandate to fulfil a specific economic or social responsibility of government. These entities relied on government funding, as such these entities had the least amount of autonomy. The basis of what had failed in SOEs, would fail in these public entities. The entities would be open to corruption and public looting. There were differences between the way SOEs and Schedule 3A entities were put together but ultimately the weaknesses of both of those entities existed in the Fund – that was the point being made. [Another language spoken 2:05:37]. The DA was proposing that the system be invested in before implementing universal healthcare, to ensure that people did not just have access. [Another language spoken 2:06:16]. A lot of people had been let down by the system. It was not about the DA’s obsession of NHI versus universal healthcare.

The DA did not think that the exclusion of foreigners was consistent with Section 27 of the Constitution - that was not in line with global thinking. She had spoken about the danger of having a politician appoint the Board – because of the size of the Fund. She agreed with the Chairperson – the DA wanted people to be able to access primary healthcare and then move up the rank according to their need of care. However, in the current state of the health system, where someone might not have a quality primary healthcare facility close to them – that provision would be limiting and become a barrier to access. Clarity was needed about the package of care and what would be limited. There were massive issues of over-pricing amongst medical schemes. These problems should be addressed the whole system did not need to be overhauled. The Health March Inquiry was very clear about what government ought to do to bring down the collusion of prices in the private sector. Clarity was needed on the package of care.

Mr Horn answered the question about where the Constitution guaranteed choice. He suggested that Members look at Section 7 of the Constitution – which enshrined the right to freedom. If one looked at the legal definition of ‘freedom,’ it was defined in the negative, such as the absence of constraint in choice, the liberation from restraint or the power of another. This meant that choice was included as a right. If one read the provisions around the private sector in the context of Section 55(a), (m), (r), (t) and (w), it was clear both the options to patients and medical practitioners in private healthcare would be dependent on the benevolence of one person, being the Minister. That was highly problematic. What if the complaints satisfied the definition of a crime – there could not be a situation where, given the tight centralization of decision making of the Bill, crimes were not reported. The other aspect was that an investigatory unit would bring with it massive financial implications for taxpayers. There were already established institutions that were empowered to deal with corruption and such complaints.

It would not be proper for the Committee to pass a bill and then state that maybe the bill was problematic – ‘but there was international convention which would dictate what to do in certain circumstances.’ There seemed to be a difference in opinion about Treasury‘s position on the affordability of the Bill in the current economic climate. He suggested that the Committee consider engaging National Treasury on the tagging and affordability issue. Even if the economy were to return to pre-pandemic levels – the debt levels were still concerning.

Presentation by the African National Congress (ANC)
Ms Febe Potgieter Gqubule, ANC’s Elections General Manager, briefly introduced the presentation and handed over to Dr Gwen Ramokgopa, Former MEC for Health in Gauteng, to present.

Dr Gwen Ramokgopa and Dr Esthras Tlou Confidence Moloko, healthcare practitioner, presented the ANC’s submission on the NHI Bill.

The ANC unequivocally supported the National Health Insurance (NHI) Bill that was before Parliament. Many South Africans across various sectors indicated that it was critical that South Africa’s two-tiered inequitable National Health System be integrated. The status quo of the two-tier system was not an option if the consensus on the Universal Health Coverage was to be realised. Many South Africans expressed hope that the enactment of the NHI Bill would allow the implementation of a funding mechanism that would strengthen the fractured and fragmented health system into one accessible, good quality, efficient and equitable National Health System.

The ANC was committed to good governance at all levels led by a Board that was professional, charged with fiduciary accountability and with zero tolerance to corruption and unnecessary interference. The role of the Minister should be that of leadership as the health policy custodian and to provide oversight over the execution of the mandate of the NHI Fund Board, as it was done for most entities and structures of the National Department of Health. Additional safeguards included subjecting the NHI Fund Board to the oversight scrutiny of the Cabinet, Parliament and any other relevant institution such as the Auditor General.  Most systems and processes that mitigate against corruption were in place.

Three hospital groups, Netcare, Mediclinic and Life Healthcare had a combined market share of 83 percent of the national South African private facilities market in terms of number of beds and 90 percent in terms of total number of admissions. Extreme high market concentration proved bargaining and control of cost difficult. Highly concentrated supply market structures were generally conducive to overt and covert collusive conduct. There were 16 medical scheme administrators in the market. Discovery Health and Medscheme account for 76 percent of the market based on gross contribution income (GCI), which makes the administrator market highly concentrated as well.

Concerning Clause 4(2), the ANC further proposed that the NHI Bill must be explicit about the need for all, especially illegal immigrants, to comply with the provisions of all South African laws especially the South African Immigration Act. Further, to enhance sources of revenue for the fund and to cover immigrants, the role of multilateral bodies such as the UNHCR and the African Renaissance Fund must be alluded to in the Act to ensure the sustainability and affordability of the NHI Fund. This must be added to clause 49 of the Bill.

The ANC recommended that clause 15(3) of the NHI Bill be enhanced to direct that the Board or its representatives and the Minister meet every six months to share information, as the practical expression of the relationship of the Board and the Minister, who was the Executive Authority, and the Board which was the Accounting Authority.

(See the ANC’s presentation for further information)

Discussion
Ms Wilson stated that there was a quote on slide two that stated that ‘government for its part, would honour citizens’ commitment by ensuring that resources were well managed and efficiently deployed.’ According to the Financial and Fiscal Commission (FFS) and the AG’s report that was the single biggest failure in the Department of Health. There was no management, never mind the corruption found by the Special Investigating Unit (SIU). When people went to public facilities, depending on what was closest to them (i.e. clinics or hospitals), what exactly were they paying? Could an indication of the out-of-pocket expenditure be given?

She wanted to deal with the taking of money from the private sector to fund NHI – there was a common English saying that one ‘could not rob Peter to pay Paul.’ If one did that, one or the other would suffer. During the pandemic it was proven, that without the private sector, the public sector would not have coped at all. She was concerned that the ANC was still promoting the fact that ‘robbing Peter to pay Paul’ was an advantage as well as ‘constitutional.’

She was concerned about the downplaying of malnutrition. South Africa would have 1.7 million stunted children in 2025, according to the World Health Organisation (WHO), which was twice as high as the 900 000 children, which was the target. Many deaths amongst children resulted from malnutrition. 27 Percent of children were stunted and would never meet their full growth potential. Most of these children were born underweight on the date of their birth. This was because mothers were not healthy and getting sufficient nutrition to support pregnancies and babies. That was a poverty issue, and the extent of poverty was well-known in the country. In 80 percent of those cases, those mothers did not have reasonable access to healthcare. Mothers had to walk miles to a local clinic and did not have the fuel. When mothers got there, they had to sit there for hours under trying circumstances. The ANC would not change that, if there was no access, there was no access. If this was not addressed quickly, there would be a generation of children who would not meet their full potential and would have a severe economic impact on the country. Malnutrition might have improved – but it was not eradicated. There were significant health claim costs, if half of them were won in court, there would be a bill of R60 billion that would need to be paid out. This did not include what needed to be paid out and what was granted in recent court cases. How would this be funded under NHI – how would the NHI cope? In the current economic climate NHI was simply not affordable.

Ms Clarke asked how government would deal with the systemic corruption and lack of will to end it. Would the NHI not become yet another no-help intended plan and a cash cow for more corruption, considering the country’s loss of R1.5 trillion to corruption between 2014 and 2019. The recent looting of COVID-19 relief funds showed that R1 out of every R2 was stolen, while 62 percent of contracts were found to be irregular. How would the NHI mitigate this systemic behaviour?

It was noted that the current cost of healthcare in South Africa was over R450 billion in public and private healthcare spending. The true universal healthcare costs could amount to that. Original estimations for the cost of the scheme were put at R250 billion a year – however it was now up to National Treasury to determine the true costs as it was unknown. How would the NHI be financed? While the Bill had earmarked payroll and other taxes to be levied, it would be on an already overburdened tax base. Beyond the broad plan, there were no specifics about where the taxes would come from and how big it would be. The question remained what would be covered – did one fund a model that was outcome based? For now, all that was known was that the coverage was to be bureaucratically designed at some point.

A matter was raised when the DA presented, about the GDP growth going forward after the pandemic. About nine percent of the GDP was spent on healthcare in South Africa, which was in line with the global average. South Africa already spent a lot more than comparative emerging markets on healthcare, as a percentage of GDP. South Africans were not getting value for money due to the State’s inefficiency and the major corruption. The GDP spending was on par with countries such as Italy, Iceland and Slovenia – but there were worse outcomes in South Africa because the public sector wasted money and had a severe corruption problem.

In slide 28, there was mention that the Board operated independently and implemented rules of good governance. She asked that the ANC elaborate on what was meant by ‘good governance.’ In the presentation, there was mention that the board members belonged to the institution of boards of South Africa. Did Ms Dudu Myeni belong to the same institution? One saw what happened there with South African Airways. She was a political appointee. One needed to guard against that sort of process going forward. The NHI Bill seemed to be driven by greed rather than evidence-based policy making – how would the ANC respond to such criticisms? Slide 12 of the presentation made a sweeping statement that NHI benefits would be comprehensive and in line with individual needs for healthcare, without risk of financial hardship. She asked that the ANC elaborate on this. What was included and excluded in the comprehensive cover? How could the ANC guarantee that it would not lead to financial hardship?

Ms Hlengwa asked what financial feasibility studies were undertaken to justify the proposal. Why had no such study, with reference to the current economic indicators, been made available to the public to view and consider, given the scale of the proposal? What alternative to the NHI Fund would be considered by the governing party to strengthen universal access to healthcare? Many stakeholders had pointed out critical constitutional concerns about the proposed Bill. Was the Bill constitutionally compliant? Would it infringe on the rights of South Africans?

Ms Ismail noted that the ANC stated that it had attended public hearings and listened to the people. Most party representatives had been present as much as possible. Many people at the hearings highlighted the major lack of service delivery from the public sector. Examples included the shortage of staff, infrastructure issues and long queues. Most people highlighted that the state of infrastructure needed to be attended to before NHI was implemented. There were doctors and healthcare workers that also shared their views at the public hearings. Doctors stated, that while agreeing with universal healthcare coverage, one would not want to practice in a non-efficient healthcare sector as this would not allow them to work under the Hippocratic oath they took. Considering this, did the ANC not think that the shortcomings needed to be addressed, such as the critical skills and capacity required before the implementation of NHI. Many highlighted the issues of corruption in government of State funds. The NHI Bill was looking at billions of Rands. This should be taken into consideration in conjunction with the COVID-19 corruption, SIU investigations and Digital Vibes saga. Would the ANC not recommend parliamentary oversight to improve the accountability and legitimacy of the Board, rather than the Minister appointing the Board, as corruption had even been seen from the former Minister of Health? Had the Department adequately planned for the NHI, taking into consideration that the pilot projects were not an effective measuring tool for the establishment of NHI? Should the feasibility studies not be done?

The OHSC presently could not manage to monitor 20 percent of the Country’s healthcare facilities; these facilities needed to reach certain compliance requirements under NHI. Would this stifle innovation and impact the provision of health services to communities rather than increasing quality health services to the Country? Public facilities were not up to standard and would not be able to operate under NHI. Would this not impact service delivery and equal access to quality health services, which was the intention of the Bill?

Most presenters had highlighted that the referral pathways were labour intensive which could negatively impact timelines and adversely impact the health of patients. Would the ANC agree with this? With referral pathways – she was specifically thinking of persons with rare diseases. Considering that the country was 27 years into democracy, under the present government, and in this period nothing constructive was done to fix the dysfunctional healthcare sector, how did the ANC contemplate that a few years into the implementation of NHI, the country would have an operational health system? How effective would the ANC say the current governing structure was, considering the number of SIU investigations and corruption during the pandemic, where money and services for the people were not spent on the people.

Mr Siwela stated that there were complaints that the Bill was irrational. How did the ANC respond to such allegations? Some organisations complained that the Bill usurped the role and powers of provinces. Had the ANC engaged with provinces on this – what were the provinces positions? The presentation proposed that the relationship between the Minister and the Administration of the Fund needed to be further clarified. What was the firm proposal that the ANC was making on that?

Mr Sokatsha noted that the ANC went and had an extensive consultation process – that showed that what was presented were the ‘views of the masses.’ The ANC asserted that it supported the NHI Bill as a Section 76 Bill – what was the basis of the support? Was the ANC not of the view that the NHI Bill should be tagged as a money bill under the authority of National Treasury and the Ministry of Finance? Slide 23 stated that the ANC indicated their support of the single funding pool and single purchaser of comprehensive healthcare services. What was the view of the ANC on the medical scheme administrators playing an intermediary role, such that was played in the current medical scheme environment?

Ms Gela stated that the ANC was the ‘leader of society,’ the ANC knew that NHI was the ‘right thing to implement in South Africa.’ What level of GDP spending on health, did the ANC believe was a reasonable target to aim for? Governance was an issue that had been raised in a number of presentations. Would a cabinet committee be a better option to appoint the NHI board? The board could then appoint the CEO and other members

Dr Havard asked that the ANC clarify the issue of extra taxation being a myth.

Mr Munyai stated that some presenters complained that the Bill infringed on the human rights of South Africans, such as the right to freedom of choice. It was argued that the Bill would not pass constitutional muster. Slide 17 of the presentation indicated that to address the burden of illegal and undocumented immigrants on the health system, the role of multi-lateral structures, such as the United Nations High Commissioner for Refugees (UNHCR) and the African Renaissance and International Cooperation Fund support funding for healthcare systems. He asked for more clarity on how this could be implemented. The presentation covered the issue of the two-tier system and how it perpetuated the inequality in South Africa. There was an issue raised about ‘wanting to challenge the powers of the Minister.’ In Gauteng the mayor of the DA appointed the board as well as in Cape Town but the board was considered independent. Why was this issue being challenged in the instance of NHI? Constitutional reform was needed to take away the role of the Minister. What was the ANC’s view of there would be no money under NHI – noting that it would be funded from general taxation?

The Chairperson asked for the ANC’s view on the contradiction about National Treasury and Minister of Finance not supporting the implementation of the NHI. Was it possible that the Department and Ministry in government could make such assertions about affordability of health reforms. He noted the suggestion about the Ministers meeting to oversee the running of the Fund. Was this proposal aimed at enhancing governance in the Fund – or did it result from learnings of COVID-19? Some programmes were designed to promote access to testing which had resulted in marginalisation of the poor and disadvantaged - what lessons should be learnt from this?

Dr Moloko stated that any unanswered questions would be responded to in-writing. He noted the question of the Chairperson about the Ministers regularly meeting about the Fund. It was not a proposal of the Ministers meeting to manage the Fund – it was proposed that it was good governance practice that the shareholders regularly met – not for the sake of negotiations but to get briefings about what the Fund was doing, as well as the health of the Fund. Even if the Board was independent and able to carry out its activities, the Ministers needed to be aware of what was happening in the Fund. There were good local practices and international good practices of this nature. This would strengthen the board and oversight role.

During COVID-19 there were a number of good programmes, however there were cases of such programmes disadvantaging the poor. There was a good programme that promoted access to testing by those who could not go to big centres or hospitals. In many instances the testing sites were found in urban areas, specifically shopping malls. Many only tested people on a drive-in basis. The bulk of people who came from townships and squatter camps did not have cars which disadvantaged them. There was a need for universal healthcare to facilitate access by all.

The ANC was of the view that the NHI Bill would pass constitutional muster. One needed to look at equality, right to life and healthcare etc. The Bill made provisions for these aspects of the Constitution. He suggested that the question seemed to suggest that the status quo needed to be left as it was, as it would compromise those that had rights. To address the disparity in the healthcare budget across the two sectors – the NHI would ensure that equity would be met. The laws of the country needed to be applied correctly, where illegal immigrants and foreign nationals were concerned. Everything had to be done in line with the Constitution. Everyone in South Africa was covered in the Bill in terms of emergency services and services for notifiable diseases, likewise their children and asylum seekers, whom were eligible for basic healthcare services. In the same breath – one needed to look at the resources that were available through multi-lateral bodies, such as the UNHCR. Those resources were given to other countries, South Africa needed to be ‘able to access that.’ The Bill passed with flying colours in terms of public consultation, in line with the Constitution.

The current available resources in the private and public sector was the first source of funding. The additional allocations would be made where necessary. There were medical aids, where only a small percentage of the workforce was making contributions. If the NHI Bill stated that contributions needed to be made by all – no one who was in a position to contribute would be exempted from contributing. The contributions would come from employees and employers. That needed to be quantified – it would be seen that the ‘source of funds would be adequate and the NHI would be affordable.’

Governance, constitutionality and the role of provinces was covered in the Bill – thus it was constitutional. When the Bill was prepared for submission to Parliament, it was required that Cabinet be favoured with all the reasons and proof that the policy and the Bill complied with the Constitution.

Dr Ramokgopa clarified that she had not previously stated that there was ‘no malnutrition.’ There was no ‘severe malnutrition,’ such as Kwashiorkor. There was still a way to go in dealing with issues of stunting. It was the democratic government that instituted the fortification of staple foods to ensure that mothers, workers and children got the required nutrition. There had been results, more needed to be done.

In a number of cases the same healthcare services in the public sector, was unaffordable in the private sector. The public sector received a number of patients from the private sector, where benefits ran out. The expenditure in the private sector was not a proxy – it was extensive. With public health measures, such as immunization, vaccinations and antiretrovirals, government had to plan for all South Africans. Government had always been planning for everyone.

In the public sector she had to pay R5000 for admission over three nights – out-of-pocket expenditure was expensive for an ordinary South African. That was why there was a need for healthcare to be free at the point of care. The issue of access was important. It should be noted, that regardless of provincial capacities, national government had invested in the roll-out of a clinic building programme and resourcing it with competent nurses and doctors. There was improvement in some public health services. Institutions, such as the Steve Biko hospital was built during the democratic era, with the support of national government. Khayelitsha hospitals was built etc. This was not adequate, that was why transformation could not slow down. It needed to be fast-tracked. Before she left her position as the MEC for Health, she had begun engagements with some of the private hospitals to utilise their spare capacity to reduce their waiting lists in the public sector. Initiatives were there to collaborate.

Many were shocked and angry by those who were trusted who were proven to be involved in corrupt activities, stealing from the public purse, whether from the public or private sector, whether ANC members or not etc. There should be zero tolerance of corruption. There needed to be strengthening of anti-corruption efforts. The collaborative effort should be welcomed – in the adoption of the anti-corruption strategy at a national level which needed to be expanded across all levels. The rapid expansion of the clinic building programme was due to there being standardised plans. She still looked forward to the former Minister ‘being cleared’ of the allegations. She ‘still could not believe that he could have been involved.’ If he was found guilty, it would be a great disappointment, having ‘served the public with distinction’ and riding the ‘cloud of COVID-19.’

She responded to the issue of not getting value for money. More needed to be done to account for money used in both sectors. Medical aids ‘were not profit making,’ they held contributions of employers and employees in trust. South Africa could be benchmarked with other countries where it had worked – such as the United Kingdom (UK). There was global experience to benchmark against. The United Nations (UN) had included universal health coverage in its Sustainable Development Goals (SDGs). The Bill referred to preventative, promotive, curative and rehabilitative services in terms of ‘comprehensive’ service provision.

There were attempts of financial feasibility studies. A number of studies were done. When signing off the Bill –  the Bill was sanctioned by all of Cabinet – including the Minister of Finance. The President had said in August 2019 that there was ‘enough resources in the country to give every man, every women and every child healthcare, but people refused because they wanted to promote the interest of the few to the detriment of the rest, this would be changed.’ 8 Percent of GDP expenditure was spent on health – this was above the WHO’s recommended expenditure. It was a matter of aligning resources to ensure no one was left behind.

There was a long way to go with compliance, but it would be fast-tracked under NHI through financing. There were those that were cynical and believed ‘nothing constructive had been done.’ The People would speak on that. One needed to avoid party-politicking. The Bill was not irrational – she would ‘not go more into detail.’ It would ‘stand-up to constitutional scrutiny.’ The constitutional court would determine the constitutionality and rationality of the Bill, if it was challenged in line with the constitutional prescripts that South Africans embraced. The powers of provinces were a constitutional matter that needed to be resolved constitutionally. When the World Cup was held – powers were aligned.

There was a tendency to send everything to the Minister of Finance, who had his own primary responsibilities at a macro-economic level in ensuring fiscal management. The ANC agreed that there needed to be checks and balances, including that Parliament should execute its responsibilities. Law enforcement, the AG’s Office and independent agencies needed to execute its functions. The AG’s office had recently been strengthened – that had been identified during COVID-19. There were efforts to reclaim the money lost. Corruption must be defeated. Who else would ensure oversight of resource management? The Committee should consider the appointment of the board by Cabinet. That was an option the ANC was open to. If the capabilities of the Minister of Health were constrained to manage the health sector – it would be a greater risk to the health system and the health of the people.

The ANC was not averse to the medical schemes offering a top-up service to mandatory contributions. The principles that would make the NHI projects successful – were the principles included in the written submission. This included free healthcare at the point of care, a choice of provider in the districts and mandatory contributions to pay, according to ability to pay. No one eligible would be allowed to opt out of NHI. If these were incorporated it would be sustainable. She suggested medical aids could cover surgeries such as cosmetic plastic surgery.

The expenditure of GDP to health was reasonable – it depended on how it was used across sectors. The Board should appoint the CEO in consultation with the Minister, as a safeguard. The board needed to be empowered to hold the CEO accountable.

All public services that the State was responsible for came from tax – the NHI Fund should not be treated differently. This matter was presented, and she was asked to provide evidence of the leadership of government. There was no evidence that the Minister of Finance was against the NHI. This Bill was one that was signed off by the whole of Cabinet. If there was evidence of this – that needed to be listened to, this would enable the country to be more productive and the recovery of the economy. Otherwise ‘it was just a rumour.’

She had been ‘chased away from one of the testing centres in a private hospital’ after she had been called to take her vaccine. She was ‘chased away because she did not have medical aid/insurance.’ She was able to access the same service from another private healthcare facility, which sent her an invite. She went there like everybody else.

The State had a constitutional obligation to provide access to healthcare services. 

She requested that Dr Havard’s question be re-asked.

Dr Havard asked that the ANC clarify the issue of extra taxation being a myth.

Dr Moloko stated that the Bill outlined the sources of funds and the manner in which the issue of extra taxation was being raised was relatively misleading. The sources of funds were from the current available resources. It would be from tax and contributors such as employers.

On the powers of the Ministers, this was done to ensure a properly running structure. The Committee would be requested to interact with the Department of Health and Treasury. Measures needed to be developed that took into account population movements. Measures should be developed by the health sector to address the burden on the health system that was the consequence of international patients using the public health system without assistance from other countries or international health agencies.

To resolve the issues around medical malpractice – clinical expertise needed to be improved for example. This problem affected both sectors. This would be looked into – to see if the work was being done.

At clinics, people were not paying. The district health hospitals sat at the top of the pyramid of the district health system. The human resources going to the community health centres and clinics were usually accounted for by the systems and structures that existed at the level of the district hospital. the issue of the central hospital was stated clearly in the National Health Act – where the hospitals fell under national competence. He responded to the question about ‘taking money from Peter to give to Paul.’ The money being spoken about for the NHI involved ‘no money belonging to Peter nor Paul.’ All the money ‘belonged to South Africans.’ The ANC wanted a unified system where the money belonged to all.

Ms Gqubule made brief closing remarks, highlighting that the NHI Bill was an important milestone.

Closing Remarks
The Chairperson dealt with some Committee matters. He stated that the public hearings on the NHI Bill were concluded. He outlined the meetings that would take place the following week.

The Committee Secretary stated that she had submitted a letter to International Relations about the study tour. The UK was identified. The Committee would travel on 25 March 2022 and return on 2 April 2022. The Committee was awaiting their response.

The Chairperson asked that everyone other than the Members leave the meeting.

The meeting was adjourned.