National Health Insurance (NHI) Bill: public hearings day 4

26 May 2021

Documents:

Meeting Summary

In this virtual meeting, the Committee continued with day 4 of public hearings on the NHI Bill. Four organisations presented oral submissions.

They noted that the objective of the NHI Bill is to achieve universal access to quality health care services through the establishment of a National Health Insurance Fund and to set out the power, functions and governance structures for the pooling of resources and the purchasing of health care goods and services to meet the needs of the population.

While they all supported the Bill, they proposed a number of amendments to improve it.

The National Health Care Professionals Association said that provinces faced many challenges such as budget cuts, non-filling of vacant critical posts, failure of facility improvement teams to carry out requisite maintenance and upgrading of facilities, failure of projects and difficulty implementing the six core standards. Some people were vacillating about the implementation of regulations, rules, laws and policies relating to NHI. South Africa was famous for having good policies but poor implementation. Oversight did not seem to be biting enough to ensure that officials that were deployed to implement government’s programme of action did so in a manner that they should.

It pointed out that the Office of Health Standards Compliance did not have an adequate footprint to do justice to its mandate across all provinces – in terms of accreditation of facilities and the state of preparedness for the implementation of NHI. The process would be made slow if accreditation was put on the shoulder of the OHSC alone. It suggested that partnerships or collaborations with other formations that were like-minded would be imperative for that to be considered. This was a collective responsibility.

Notwithstanding all of this, it believed that NHI should be implemented immediately to ensure that access to quality healthcare services reached everyone.

Members noted that the leadership and governance failings had resulted in an accumulation of enormous medical malpractice liabilities and claims, which was having a huge effect on the balance sheet. Their concern was around implementing NHI immediately versus fixing governance and leadership.

The South African Institute of Environmental Health pointed out that universal health coverage is for all health services in all spheres of government. Accordingly, funding must be made available to local government to provide proper health services including Environmental Health Services/ Medical Health Services. It emphasised that the recruitment of environmental health practitioners should be prioritised together with the recruitment of other health professionals in preparation of the full implementation of the NHI and that the Bill must clearly spell out the role of municipalities.

Members stated that when it came to re-designing legislation toward universal healthcare, they needed to rectify issues that had been overlooked in the past. It was quite important to get a sense of how an entity envisioned a comprehensive package of care that started right at local government all the way through to provincial and national government. It was important to get a sense from a foundational point of view, how the legislation relating to universal healthcare would deal with that.

The South African Association of Hospital and Institutional Pharmacies recommend that a process of upgrading or improving non-compliant facilities be provided for or be put in place so not to further affect peoples’ rights to access to healthcare services. It said that more emphasis should be placed on prevention rather than cure and that all amendments and decisions taken by the NHI board must be officially announced to public, irrespective of how minor the decision may be.

The Committee noted that this was the third presentation from a pharmacy groups and the same issue had been highlighted by all - that there needed to be specific mention of pharmacists and associated medical personnel in the Bill. It was asked specifically where the presenters felt they had been ‘neglected’ in the Bill. It was asked whether the statutory bodies could be captured within the regulations rather than the Bill. It was asked what their response was in terms of the impact of the Bill on profit relating to pharmaceutical services and medicines. Clarity was requested regarding the specific services they provided.

The Pharmaceutical Society of South Africa said that the Bill should not be restrictive in terms of where and by whom health care services should be provided. It recommended that the wording of the Bill should follow an enabling construct which would allow the detail to be prescribed by regulation. This will allow amendment of the regulations from time to time, accommodating technological advances as well as task sharing between healthcare professionals, for the benefit of the population, without the need to revisit the primary legislation.

Clarity was requested regarding the issue of ’unaccredited’ and suggestions were requested in relation to the ‘restrictive’ sections of the Bill. Clarity was sought regarding ‘enabling’ legislation. ‘Scope creep’ was highlighted as a potential issue in terms of the functions of pharmacists that were outlined - a response was requested in that regard. It was asked what role they wanted to play in making pharmaceuticals more affordable once national health insurance was implemented.

Meeting report

Opening Remarks
Chairperson Dhlomo stated that a statement was released by the Minister of Health with regards to some of the questions asked by the Members in the previous sitting. It was not part of the day’s agenda, but he wanted Members to take note of it. It had been communicated to all the Members.

National Health Care Professionals Association (NHCPA) presentation
Dr Benny Malakoane, President, presented, on behalf of the NHCPA.

NHI in context
-It is a health financing system based on resource pooling and social solidarity.
-It is consistent with Freedom Charter, the Constitution, the White paper on health systems, and WHO reforms and IHR.
-Intended to achieve universal coverage where every citizen will have the right to access quality health services, and that access shall not be determined by the socio-economic status of anyone especially the poor.
-It recognises that health is a social investment and a public good and will contribute to better quality of life and improved health outcomes.

Problem Statement
-Fragmentation of funding pools and occupational categorisations between public and private sectors.
-RSA spends 8.5% of GDP on health, and 4.1% is spent on 84% of the population while 4.4% is spent on only 16% of the population –that can afford and are on medical schemes since 2015/16.
-Inevitable out-of-pocket expenses on healthcare as influenced by:
-Long waiting times, co-payments, exhausted medical funds,
-Responsiveness of private providers
-Burden of disease is rising or worsening

Processes are protracted and slow:
-Reorganisation of the health system post assessments of impact in the pilot districts
-Financing mechanisms NHI still in infancy and rhetorical theory
-Primary healthcare re-engineering dis-/unorganised in provinces
-Governance systems not yet in place or fully functional (OHSC, Commission, NHI Fund, accreditations and contracting of providers,
- Provider reimbursement mechanisms not in place
- Information systems not yet adequate or fully in place

Key Challenges:
-There is no independence of the board as it will be appointed by the Minister as stipulated in the white paper.
-Unfortunately following the finalisation on NHI it will be the biggest parastatal in the country and given government track record with parastatals, one has to be really concerned.
-There is very little improvement of public infrastructure at the moment, meaning that we will still see inequality in patients who are allocated to public facilities as their designated service providers.
-The ageing community is getting bigger and always poses as a significant threat for a model such as NHI. They need more health care with paying less taxes.

Recommendations
The NHI Bill must be assented to and the Act implemented now
NHI should be the only recognised fund for healthcare services in South Africa
NHCPA be recognised as a partner and friend of the Portfolio Committee and will lay its resource-base to support;
-Fast-tracking the phased-in implementation of NHI
-The health system reorganisation processes in Districts
-Accreditation of providers and their reimbursement systems

- Healthcare providers are READY
-The strengthening of the four streams of PHC re-engineering
-The strengthening of the health workforce
-Set up an independent special NHI anti-corruption unit
-Start improving public facilities
-Direct fund to infrastructure development for the next 5 years
-Making sure the process is healthcare professionals and community led
-Abolishment of medical aid system and have an insurance that covers only that which NHI cannot provide

(See Presentation)

Discussion
Dr S Thembekwayo (EFF) asked why as a national organisation they were only based in eight of the nine provinces. Which province were they not present in? How could that province’s issues be captured within the NHCPA?

Mr M Sokatsha (ANC) asked how the NHCPA proposed the Board should be appointed. The presentation highlighted a lot of health system challenges, it was also indicated that the NHI needed to be implemented quickly. Was their contention that the reorganisation of the health system should happen in parallel with the NHI Act? With respect to the NHI anti-corruption unit – did they propose that it should be internal or external to the NHI Fund?

Ms E Wilson (DA) noted their report and that they had highlighted a lot of challenges. The real challenge was that budgets had been cut; the cost of employment had seriously affected all the provinces. This had resulted in vacancies not being filled and the facilities were already seriously under-staffed. A visit to the Northern Cape the week before had revealed that, in a province the size of the Northern Cape, which was ‘absolutely massive,’ there were only 2 400 nurses. They had spoken about the attitude of nurses in the ‘ideal clinic scenario.’ When one had nurses who were exhausted because of the times and shifts they worked due to the shortage of personnel – this became a challenge. Over the next period this budget had been cut. Amongst other things that were cut, the infrastructure budget had been cut.

She highlighted the plight of remote rural areas – where there were no mobile clinics that served them. It was all very well to state that they needed to pass the Bill and pass it quickly – but pass it to what degree - there were no facilities. There was a shortage of staff, there was a shortage of facilities, there was a shortage of doctors and yet these were the most critical issues that NHI required. What was their proposal in this regard?

The Committee had requested a meeting with Mr Tito Mboweni, Minister of Finance, to explain that to them. There was no money. South Africa was on a fiscal cliff, health had already collapsed and in areas like the Northern Cape, they had even gone backwards. The regression in their health system, as a result of under-staffing and inadequate facilities, had resulted in a lot of regression, including to the child and infant mortality rate. How did they propose that this could be changed?

Dr K Jacobs (ANC) noted that the presenter spoke about an NHI Commission – he asked that he explain what he had meant by ‘NHI Commission’ and what its role ought to be.

Chairperson Dhlomo echoed the point made by Mr Sokatsha. He asked whether the presenters were aware of the Health Sector Anti-Corruption Forum – or were they suggesting that over and above that Forum, there should be another separate forum to look into corruption? The Health Sector Anti-Corruption Forum was dedicated to looking into any corruption in Health, it was made up of various entities, including the Special Investigating Unit (SIU), Police, National Prosecuting Authority (NPA) etc. They had suggested that the work of the Health Standards Compliance was either too slow or not effective because they wanted them to quickly expose challenges that they had attended to. What was their view on the work done on the Office of Health Standards Compliance (OHSC) – he had not understood from the presentation.

Mr Lutendo Phaswana stated that the NHCPA did have contact with the Department of Health. The Committee might be aware of the Council for Medical Schemes (CMS) inquiry, its inception was a culmination of the number of meetings with the then Minister of Health. They met with the Minister at that particular point in their capacity as representatives of the organisation – on that note he wanted to believe that having gone as far as the Ministry, the Department would know about them at all levels. They have had many other interactions with them. In relation to NHI, the Department may not have interacted with them as intensely as they were now interacting with the Committee. They wanted to be a partner of the Parliamentary Health Committee and the Ministry of Health. If they came together it was because they wanted a better outcome, a better health system that was well supported by healthcare professionals. They remained in contact with the Department.

In terms of the different provinces, the Northern Cape was in the most serious situation. They did have members there – it was not that it was not covered, however they did not have the structure to run things alone. Thus, the Northern Cape had been combined with the Free State because they were closer to one another. In that way they were able to have activities that were interlinked.

Dr Malakoane reiterated that the Free State and Northern Cape were viewed as one, as they did not have as many healthcare professionals who could stand on their own as a province. They were therefore covered country wide.

Mr Josias Naidoo, Vice Chairman, NHCPA, stated that in terms of the Board, the systems and structures that they had in place were a bit concerning. They had seen how quickly things went wrong when the incorrect deployment and incorrect implementation of protocols took place. In terms of determining a Board, they needed to establish a set of guidelines where the public also had a stronger voice in terms of who was tasked with the responsibility of sitting on such a Board. They needed to be aware of people’s backgrounds, they needed to be aware of people who were there in a political role – and the risks of that. It was not necessarily a bad thing to have a political deployment, but they needed to ensure that the deployment benefitted the Board and the efficient running of the organisations.

In terms of the importance of the anti-corruption forum, it was setup specifically to prevent abuse – much of that abuse came from management systems and the collusion between management and the private sector. In terms of needing a unique forum for the NHI system, he was inclined to say that they did need another one. One of the reasons he proposed that they have an independent anti-corruption panel was that the existing Forum had been tasked with rooting out corruption. To some extent it had done that – it had identified fraud and corruption. However, with respect to the COVID-19 pandemic, they realised that they often identified problems well-after the fact - after the money had been eaten away. It was usually too late and all they could do was put in measures to prevent future fraud. Ideally if they were going to look at anti-corruption, they needed to have an independent task team including the NPA and non-governmental organisations. There were various organisations that could play a part in fighting corruption in relation to the NHI. There were things that, they as health professionals, may not see in advance. There were certain things as politicians that they would not see in advance. There were individuals who had specialised training in identifying crimes and monitoring potential crimes and patterns. Those were the people that needed to be sitting on those panels so that they could pre-empt fraud, abuse of funds and protect the Fund before money was taken out. They needed to become a preventative forum rather than a reactionary one.

The OHSC was doing a good job, it was an objective body. It had been able to identify problems and challenges at some of the health facilities. If they did identify problems with public sector facilities, what were the steps they would implement to ensure that the facilities were up to standard? They needed to ensure that the bulk of citizens were able to access healthcare through existing facilities. They needed to make sure they were not haemorrhaging money to upgrade the private sector at exorbitant cost. They could up-skill and capitalise on existing infrastructure, so long as they ensured that they were compliant.

Dr Molokoane stated that in terms of the Board, leadership and governance was at the core of operational management of any institution. In any institution that collapsed, the governance of that institution was compromised. Their suggestion in terms of the appointment of the Board was that there needed to be people who were well-conversant with the sector that they would be operating in and governing. It needed to be people who were qualified in the sector or allied sectors. It should include people who had an understanding of duty of care, who were competent in their trade and would be there to give their service and commitment to the institution they were governing and not to be persuaded by other interests beyond those of the institution.

In terms of the reorganisation of the district health services and whether it should be done in parallel with NHI – they proposed that it should be done in parallel. It should be done in partnership with like-minded organisations. It should become a collective and collaborative responsibility for the National Department of Health. The biggest problem with government was the attitude of embracing the private sector far more easily than like-minded formations – in terms of the roll-out of government programmes. For example, the National Department of Health was more inclined to partner with the private sector when it came to things like the vaccine roll-out. They did not want to see programmes being ‘hijacked’ by the private sector. The biggest problem they experienced was that it was very difficult to access the political leaders – it was virtually impossible. It was easier to meet the Pope than their own leaders who had been tasked with leading the public service delivery programmes. That matter should be addressed.

In terms of NHI anti-corruption, they suggested that it needed to be independent. It should not be ‘window-dressing’ of independence. It needed to be independent in the true sense of the word, where invitations for people to participate would be open, transparent and everyone who qualified was appointed on merit.

There were many challenges that were faced in the provinces such as budget cuts, non-filling of vacant critical posts, failure of facility improvement teams to carry out requisite maintenance and upgrading of facilities, failure of projects and difficulty implementing the six core standards. The six core standards included staff attitude, cleanliness of facilities, reduced waiting times and security for various patients and staff etc. Clearly the questions that were asked by the Committee questioned whether they were serious, given the challenges, in advocating for implementation of NHI. NHI should be implemented to facilitate access to quality healthcare services by all citizens irrespective of their socio-economic status. They were still insistent that NHI should be implemented. That financial risk protection of the vulnerable and poor was imperative in ensuring that access to quality healthcare services reached everyone. The problem that existed was that it was not the mistake of the public that there were budget cuts and vacancies not being filled. It was the fault of governance and leadership. Progress was slow. Some people were vacillating about the implementation of regulations, rules, laws and policies relating to NHI. South Africa was famous for having good policies but poor implementation. Who implements policy? Who implements the regulations and ensures compliance? It was the functionaries that were deployed at key positions who failed to implement requisite policy. Oversight did not seem to be biting enough to ensure that officials that were deployed to implement government’s programme of action did so in a manner that they should. In terms of the intentions of NHI and how it stood to benefit the general public – they insisted that it should be instituted now. They did need to go back to basics first – fix the leadership, the layer of people who were tasked to implement what had been promulgated to be implemented.

Mr Phaswana stated that the problems were there so that they could find solutions. They were singing the same tune in this regard. When they spoke of re-engineering of the primary healthcare system, amongst other things, it should reduce the number of feet in the tertiary hospitals. Primary healthcare should contribute in informing and educating the community and population at large to reduce the numbers going to secondary and tertiary facilities. This would start in primary schools in the foundation phases ensuring that that the healthcare professionals were not based and stationed only in the curative element – the hospitals. They needed to ensure that they were there at the early stage where they could actually teach and educate – so that that there would be very few of those cases developing into unmanageable situations. They needed to look into the system with regard to leadership and governance. Issues of budget could be rearranged if the system was re-engineered and issues relating to primary healthcare were dealt with. Much of the budget was spent on 16 percent of the population, surely if that money was to be redirected and covered everyone – it would allow the budget to increase. It could create and bring in better infrastructure. It could be redirected to employ as many health professionals within facilities. They could then start preventative healthcare – as opposed to the current structure that was curative in its nature. They would always struggle with that particular aspect if they stuck to a curative structure.

Dr Molokoane responded to the question relating to health standards compliance. The Office of Health Standards Compliance did not have an adequate footprint to do justice to its mandate across all provinces – in terms of accreditation of facilities and the state of preparedness for the implementation of NHI. The process would be made slow if accreditation was put on the shoulder of the OHSC alone. He suggested that partnerships or collaborations with other formations that were like-minded would be imperative for that to be considered, which was what they proposed. This could be done to assist with the fast-tracking of the process. In areas where they were able to do assessments – they did a good job – but they needed to be strengthened and their footprint needed to be expanded. They needed to form partnerships with relevant people and formations. This was a collective responsibility.

Ms Wilson stated that the budget cuts had become an excuse in the provinces. Between 2006 and 2016, the medical personnel employed by the state grew by 42 percent. The State now employed 75 percent of medical personnel in the country – that was indicative of the fact that some changes had been made. The failings in delivering quality healthcare in the public sector was the result of widespread unemployment and rampant corruption. This had stripped the public health department of skill and capacity. The presenters had stated that they wanted NHI to be implemented immediately but then they contradicted that by saying that ‘that the lack of governance and leadership needed to be dealt with first.’ She thought what they had said was very relevant. The leadership and governance failings had resulted in an accumulation of enormous medical malpractice liabilities and claims, which was having a huge effect on the balance sheet. Her concern was around the contradiction – of implementing NHI immediately versus fixing governance and leadership. She did not think they could do both at the same time.

Dr Molokoane stated that there should not be fear regarding the implementation of NHI nor when budget cuts were implemented. It may not be an excuse by provinces in terms of the non-implementation of certain things. There could be justification as to why budgets needed to be cut – certain priorities took precedence over others. It was a financial management principle. One could employ someone who was highly decorated – when it came to practical implementation of what was pertinent on the ground, one found some of the best crumbled. That was why support was essential in ensuring that it was given to those individuals, so that failure did not become an option.

They were not contradicting themselves in terms of the implementation of NHI, they were being very clear. Healthcare professionals were there, healthcare formations did exist, government was not supposed to go it alone. Government was supposed to partner properly and involve, not only the private sector. It needed to be a mutual responsibility to implement. The dispossession that was suffered by the poor, was not only there’s alone, it was man-made. It needed collective solutions. Partnerships could be done in terms of implementation. Problems that occurred should not be viewed in isolation. They needed to be viewed in context with a view to finding a solution as opposed to pointing fingers.

Chairperson Dr Dhlomo highlighted that there were no women represented by the Association at the meeting. He would have expected there to be women in some of the top positions of the Association. He requested clarity on this. In terms of the Health Sector Anti-Corruption Forum, it was specifically formed to support the NHI process. He asked that the presenters familiarise themselves with that programme. He stated that they would be listening to the Auditor General’s (AG) report on the coming Friday. The AG would be pointing out some of the irregularities that happened in certain provinces, that the SIU was already looking into. The AG was part of the Health Sector Anti-Corruption Forum. He suggested they raised some of the issues directly with the Department as the Committee would not do so on their behalf. If they had experiences they wanted to share – he suggested they share that with the Department of Health.

Dr Molokoane assured the Chairperson that there were two women in the leadership structure of the Association, the Treasurer General and the Secretary General of the organisation. They were unable to make it to the meeting.

Ms A Gela (ANC) thanked the Chairperson for speaking on their behalf. She was happy with the response in that regard. She asked whether the presenters thought that the NHI would improve funding of the health system as the 8.5 percent of GDP spending in the health sector would be pulled to benefit the entire population.

Dr Molokoane stated that fragmentation was created by private and public healthcare and medical aids. With NHI, the medical aids should essentially be ‘abolished.’ What should happen, was that anyone who would like to supplement access to healthcare beyond what NHI could over, should have free and personal will to engage a medical aid separately. As for public healthcare dispensing, medical aids played no role. That role should be taken over by NHI. The problem was that medical aids were shareholders in everyone’s salaries, they were taking between 12 and 16 percent of individual salaries every month, whether one was sick or not. That on its own did not make financial sense because the profit motive was the one that was driving the existence of medical aid. They advocated that government needed to take charge of healthcare funding through NHI, medical aids should be abolished and the Medical Schemes Act should be amended or repealed to give effect to the NHI scheme.

South African Institute of Environmental Health (SAIEH) presentation
Mr Selva Mudaly, President, presented, on behalf of the SAIEH.

Comments on the NHI Bill
-Everything from pages 2 & 3 of the preamble in the bill refers to health services but does not deal with environmental health / municipal health services. There is reference to quality personal health care services and universal health coverage.
-There must be reference to environmental health / municipal health services.
-Universal health coverage is for all health services in all spheres of government

Definitions in the bill:
-comprehensive health care services – does not include environmental health/ MHS
-The definition of comprehensive health care services must include environmental health/ municipal health services.
-The bill defines health care services, but in (d) refers to municipal health care services. In the health act 61 of 2003, it is clearly spelt out in (d) as municipal health services and is expanded under the definition of municipal health services.
-The writers of the NHI Bill only changed (d) to read differently calling it municipal health care services.
-The definition of health care services in (d) must use the right wording of municipal health services as defined in section (1) of the national health act no. 61 of 2003, or the bill must clearly define what municipal health care services as is the case with (a), (b) and (c).
-The definition of primary health care does not deal with municipal health services/ environmental health services and is vague.
-Clearly spell out what primary health care is. Correct (b) to include all health services
-In chapter 3, functions of the fund, there is no reference to MHS/EHS and local govt. Health services, yet the health act 61 of 2003, section 3(2) calls on all spheres of govt. To ensure the provision of health services.
-Funding must be made available to local government to provide proper health services including EHS/MHS and must not be excluded.
-In section 31 (2), chapter 8, 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 equitable provision and financing of health services.
-Why does this bill leave out local government for funding but yet it is expected to provide health services? In section 32(c), there is health services in municipalities.
-Section 37(1), has omitted local government in the implementation of the NHI
-It must be noted that local government played a critical role during the piloting of the NHI.
-Environmental health practitioners employed by local government constituted the ward-based outreach teams and played a critical role in case investigations and in addressing environmental health conditions impacting on the health of the citizens,
-The number of environmental health practitioners currently employed by national, provincial and local government is far less than the number recommended by who and the norms and standards prescribed in the national environmental health policy (1 environmental health practitioner per 10,000 population) and will not be able to service all wards at full implementation of the NHI.
-The recruitment of environmental health practitioners should be prioritised together with the recruitment of other health professionals in preparation of the full implementation of the NHI.
-The bill must clearly define non-personal health services to be managed by the district health management offices to prevent fragmentation and duplication of non-personal health services.
-All health services must be funded through the NHI, with regards to legislation and the constitution.
-The Bill must clearly spell out the role of municipalities.

(See Presentation)

Discussion
Mr Sokatsha asked what their understanding was of the personal healthcare services, in the context of comprehensive healthcare services.

Dr Jacobs stated that he was trying to understand what the presenter had put forward. He remembered a time when healthcare services were part of the local government mandate. Today they spoke of an ‘unfunded mandate.’ The Committee recently went on an oversight visit in Cape Town and visited a clinic which was run by the City of Cape Town and another run by the provincial government. Where he lived, he knew that it was an unfunded mandate – that local government clinics had moved to the provincial government. That was in terms of personal healthcare. He knew that within their local municipality there was an entire department called the Environmental Health Services. He was trying understand what the presenter thought their involvement should be in terms of personal healthcare services versus non-personal healthcare services. Why did they think that needed to be included in the NHI Bill?

Ms S Gwarube (DA) stated that Dr Jacobs raised an important point that was only touched on in the presentation. In terms of the unfunded mandate that local governments would take on in terms of environmental health and personal health services, she suggested when it came to re-designing legislation toward universal healthcare, they needed to rectify issues that had been overlooked in the past. It was quite important to get a sense of how an entity envisioned a comprehensive package of care that started right at local government all the way through to provincial and national government. Where essentially, they would be able to have an easy continuum of care for users of the healthcare system. They did not want a situation where City clinics had to turn patients toward provincial clinics as a result of offering a different package of services. It was important to get a sense from a foundational point of view, how the legislation relating to universal healthcare would deal with that. How did they envision local governments fitting into the system where they wanted a continuum of care – where people could access services at whatever point of care.

Ms Gela stated that National Health Services (NHS) and Environmental Health Services (EHS) services were more oriented to non-personnel health services – what was their view on those services remaining under NHI.

Chairperson Dhlomo asked that they explain what the difference was between health services and health care services. His other question related to the unfunded mandate – that was asked by the other Members.

Dr Mudaly explained that his presentation was not on ‘funded and unfunded mandates.’ The issue they were trying to raise – was that they could not separate the healthcare services in terms of saying that ‘local government should manage this, national government manage that etc.’ Universal healthcare was one healthcare system for the country. It had to be controlled in those terms. They could not have different systems in the country. In terms of comprehensive healthcare services, it covered all healthcare services in the country. It covered clinics, environmental health, municipal health services, hospitals etc. It was comprehensive healthcare services for the whole Country, but the Bill did not say that – that was their point.

In terms of unfunded mandates, the issue was that it had happened, they needed to go beyond what had happened. They were looking at NHI – this was a funding model. They needed to dramatically move away from what was done in the past. They needed to state what they wanted corrected in the system through NHI – it would not happen in one year – or five – it would take a considerable amount of time. They needed to ensure that the Bill facilitated equity throughout the country in terms of healthcare services. They should not perpetuate what was done before - where there were different levels of services in different areas. They needed to bring about equity – that would come about through the norms and standards. A lot of the municipalities were running clinics and everyone knew it – there was an arrangement with the provincial government to do that. Similarly, they were saying that the funding model for healthcare services should be through the NHI Bill. It should not be left to municipalities, looking for money, to try and run those services. Hence, they were seeing the kind of shortages they had in the country. They needed to be prepared for the kind of diseases that would come – it would get worse as a result of climate change - moving forward.

In terms of NHS and EHS, NHS came about when they made the amendment to the legislation. Municipal services went to local government along with environmental health, with the exception of malaria control and hazardous substances (which were national government services). The NHI Bill needed to bring it all together.

Why did the NHI Bill change the language from the Health Act - the Health Act spoke of health services and the NHI Bill spoke of health care services. The language needed to be the same, otherwise the interpretation was vague. They needed to regularise this to speak to the National Health Act of 2003 and to the Constitution, in terms of health services. They had raised these issues - as similar mistakes were made in the National Health Act 2003 – and they eventually made sure that they could align it in terms of the literature that related to healthcare services. That was very important. That was why they were raising those issues. One could not separate environmental health, or municipal healthcare services from the National Health Bill. If the National Health Insurance Bill went through, they would be perpetuating the inequality where local government would have to start making its own plans to deliver services and the National government would conduct some of the services the way it was. Either there was a duplication or there would be inequity. They needed to ensure that there was equity throughout the Country in terms of those services. The issue around governance and finance were two separate issues – and they should deal with them in terms of law

Chairperson Dhlomo asked whether their leadership structure reflected gender equality and whether any women were represented in leadership positions.

Dr Mudaly replied that they did have women representation and it was also mandated within their Constitution. The Treasury General was a female and three of the executive members were female, from Gauteng, Mpumalanga and North West Province. They also had provincial and national government representatives on their Board, not only local government.

South African Association of Hospital and Institutional Pharmacies (SAAHIP) presentation
Mr Shawn Zeelie, President, SAAHIP, presented, on behalf of SAAHIP.

Comments on the NHI Bill
-We recommend that a process of upgrading or improving non-compliant facilities be provided for or be put in place so not to further affect peoples’ rights to access to healthcare services.
-Clear referral pathways are required. Currently the referral pathways differ per province.
-Define Province’s role of overseeing, gatekeeping, influencing policies and ensuring that implementation and monitoring of adherence to prescripts.
-What specific health care services are being purchased for the elderly / geriatric population in terms of chronic non-communicable disease care and palliative care?
-The elderly should be regarded as a separate target group just as children, refugees and inmates are mentioned specifically.
-Will there be assistance programs for the elderly and disabled to register on to NHI?
-Explain non-compliance of referral pathways in a critical situation e.g. cerebrovascular accident or myocardial infarction – refusal of care or criteria to be set for emergency cases?
-Has an allocation been made specifically for services and medication that may be deemed essential or necessary at a later time i.e. during the implementation phase after the formularies have been designed?

General Comments
-The policy deals with a reactive rather than a proactive approach to South African Healthcare.
-More emphasis should be placed on prevention rather than cure. Look at investing in education programs and initiatives as part of NHI function. Demonstrate this clearly in plan.
-All amendments and decisions taken by the NHI board must be officially announced to public, irrespective of how minor the decision may be.
-Access to financial statements and monitoring of cashflow should be publicly accessible at all times. This must be a transparent system.
-The monitoring and evaluation system should involve the public even if they will play observer roles.

Discussion
Dr Jacobs stated that this was the third presentation the Committee had received from pharmacy groups. They had heard again that particular roles needed to be defined, as pharmacists and as medical personnel in the NHI. Could they tell the Committee what exactly ought to be done for them to be included? They were a part of what was envisaged in the NHI Bill. The Committee understood the role that pharmacists played in terms of providing care to patients. He found it difficult to understand where they felt they were being neglected.

Ms Gela noted that the profit on medicines that pharmacists made in providing pharmaceutical services would be impacted through NHI. What was their response to this?

Dr Jacobs took over as Acting Chairperson.

Mr Zeelie stated that they wanted a clearer definition in the NHI Bill as to what was expected of a pharmacist. Many pharmacists were involved in clinical ward rounds in facilities, they assisted with a number of things relating to patient care – which was not outlined in the Bill. They could help with patient care plans and help with clinical assistance of the patient. By putting in place a number of interventions they could save on costs. For example, by going on daily ward rounds, they could improve on patient care plans and identify missed doses, duration of therapy and engage in multi-disciplinary roles. They could have an added clinical benefit to patient care. They could be of more benefit than just in a pharmacy. The reason they had raised this was because they were not clearly identified in the NHI Bill in terms of their scope of functions.

Dr X Havard (ANC) asked whether they were happy for referral systems, for example, to be put into regulations and not the Act.

Mr Zeelie stated that it was one of the things they wanted to look at – in terms of having a universal referral system because referral systems between provinces currently differed. If a patient presented in a facility in a different province, it came with problems and risks. The formula needed to be aligned across provinces.

Acting Chairperson Jacobs communicated the question of Ms Hlengwa. What did they do, or what specific services did they provide?

He asked a question on behalf of another Member. Promoting their economic interests in terms of profits on medicines that pharmacists made in providing pharmaceutical services, created divergence in terms of the principles of the NHI – what was his response to this?

In terms of the various medical councils, most of them had many boards, with different scopes of practice. The Health Professions Council of South Africa (HPCSA) had thirteen boards, and more than 30 professional categories. Did he think it was possible to have all of these defined within the NHI Bill?

Mr Zeelie stated that he had quite a few roles and functions that he currently fulfilled. The main one was procurement and distribution. He was responsible for procuring medicines for a tertiary hospital. That role included doing clinical ward rounds every day. He dispensed chronic medications to patients. They had a specialised paediatric pharmacy, where the dosage was defined more specifically for paediatrics. He was involved in the oncology unit in terms of chemotherapy.

In terms of promoting economic interest – he was not familiar with this because he worked within the public sector environment. He was happy to go back and get a proper answer and revert back to the Committee in that regard.

In terms of the statutory bodies, they reported to the South African Pharmacy Council (SAPC), they regulated them. They all needed to register with SAPC and submit continued professional development (CPD) points – so as to show they were active in the industry.

Acting Chairperson Jacobs stated that the reason for the first question was to understand what a pharmacist did. From his explanation, one would assume that a pharmacist within the public sector would have those roles to play within the healthcare setting. In terms of the statutory bodies, if as requested by the Association, the Bill needed to capture the roles of all the statutory boards – would that not be difficult. Should they be captured in the Bill itself?

Mr Zeelie stated that the roles and responsibilities of the pharmacist and supporting personnel, which would include pharmacist assistant and technicians, was defined by the Pharmacy Council. There were certain things, for example clinical pharmacy, that that the Pharmacy Council was still looking into – acknowledging them and their roles. There were more functions they could add to NHI than that which was specified in the roles and objectives of the Pharmacy Council.

Pharmaceutical Society of South Africa (PSSA)
Ms Refiloe Mogale, Pharmaceutical Services Manager, and Mr Ivan Kotzé, Executive Director, presented, on behalf of the PSSA.

General Comments on the Bill
Section 1 of the National Health Act (Act 61 of 2003) defines a health care provider as: “a person providing health services in terms of any law, including in terms of the:
(a) Allied Health Professions Act, 1982 (Act No. 63 of 1983); (b) Health Professions Act, 1974 (Act No. 56 of 1974);
(c) Nursing Act, 1978 (Act. No. 50 of 1978);
(d) Pharmacy Act, 1974 (Act. No. 53 of 1974); and
(e) Dental Technicians Act, 1979 (Act. No. 19 of 1979)”

-In the NHI Bill it appears that pharmacists are assumed to be included either under health professions or allied health professions
-In order to be included in the NHI Bill and to participate fully in the NHI system, imperative that pharmacists be specified, recognised and listed separately and independently
-Primary health care plays a pivotal role in the NHI
-Primary Care Drug Therapy (PCDT) pharmacists can play a significant role in this field
-Alleviate the burden on the primary care nursing professionals as well as the general practitioner by diagnosing and treating certain conditions
-The PCDT pharmacist is also easily accessible and often based in under-serviced areas, as recognised in the Presidential Health Compact

-It is the position of the PSSA that the Bill should not be restrictive in terms of where and by whom health care services should be provided. It is recommended that the wording of the Bill should follow an enabling construct which would allow the detail to be prescribed by regulation. This will allow amendment of the regulations from time to time, accommodating technological advances as well as task sharing between healthcare professionals, for the benefit of the population, without the need to revisit the primary legislation.

Specific Comments on the Bill
-Preamble: To achieve universal access to quality health care services in the Republic in accordance with section 27 of the Constitution;
Comment: As the Bill currently reads pharmacists, pharmacies and pharmacy support personnel are not included in the NHI. It would not be possible to achieve the goals set out without pharmacists being part of NHI.

-Section 1 – Definitions: ‘‘comprehensive health care services’’ means health care services that are managed so as to ensure a continuum of health promotion, disease prevention, diagnosis, treatment and management, rehabilitation and palliative care services across the different levels and sites of care within the health system in accordance with the needs of users;
Comment: Pharmacists are well trained, regulated, inspected and equipped to play a role in the continuum of health promotion, disease prevention, diagnosis of minor ailments and treatment for those ailments through pharmaceutical care delivery. In addition to the scope of practice of a pharmacist, Primary Care Drug Therapy (PCDT) pharmacists can diagnose and treat a variety of primary care diseases e.g. tonsillitis as part of their extended scope of practice with a Section 22(A)15 permit.

-Section 2 – Purpose of the Act: 2. The purpose of this Act is to establish and maintain a National Health Insurance Fund in the Republic funded through mandatory prepayment that aims to achieve sustainable and affordable universal access to quality health care services
Comment: The PSSA is of the opinion that certain sections of the Bill go beyond the purpose and scope of the Act in that it prescribes the methods of delivery and by whom health care services should be provided in a restrictive manner. These sections should be amended and the details should be prescribed in Regulations to the Act rather than the Act itself.

-Section 26 – Health Care Benefits Pricing Committee: 26 (3) The Committee must recommend the prices for health services benefits to the Fund.
Comment: The Pharmacy Stakeholders Forum (PSF) is the negotiating body on behalf of pharmacy with the Pricing Committee, in terms of the Medicines and Related Substances Act. Going into UHC and NHI, it will continue to be crucial to include PSF in this advisory committee.

-Section 39 – Accreditation of service providers: 39 (2) In order to be accredited by the Fund, a health care service provider or health establishment, as the case may be, must – be in possession and produce proof of certification by the Office of Health Standards Compliance and proof of registration by a recognised statutory health professional council, as the case may be;
Comment: Pharmacy profession already meets this criteria as all pharmacies are inspected on a regular basis by the SAPC. The pharmacy, pharmacists and pharmacy support personnel are all registered with the SAPC as well Pharmacy licenses are issued by the Director-General: Health and the criteria applied when evaluating licence applications does include the location of the pharmacy, current population and distance from other pharmacies. This process should not be duplicated by the OHSC but rather aligned to avoid unnecessary waste of resources

-Section 57 – Transitional arrangements: 57(4)(h) the initiation of legislative reforms in order to enable the introduction of National Health Insurance, including changes to the – Medicines and Related Substances Act, 1965 (Act No. 101 of 1965); (xi) other relevant Acts
Comment: The Pharmacy Act, 1974 (Act. No. 53 of 1974) should be specifically included in this section as currently there are sections prohibiting multi-disciplinary practices and this needs to change in preparation of NHI

(See Presentation)

Discussion
Mr Sokatsha stated that there were five statutory professional councils, such as the Traditional Health Council, the Pharmacy Council, the Nursing Council, the Allied Professionals Councils, most of them had many boards, with many scopes of practice. HPCSA had 13 boards, and more than 81 professional categories, who were also highly skilled. Did they think it was possible to have these defined in the Bill or would they be happy to have the differentiations in the regulations?

Ms Gela requested clarity regarding the concerns around the concept of ‘unaccredited.’ She asked whether they could explain their concerns further about restrictive sections in the Bill and what they proposed as amendments to those restrictive sections.

Chairperson Dhlomo emphasised what was asked by Mr Sokatsha. He stated that there were quite a lot of institutions, could their processes be streamlined via the Pharmacy Council – would that not be efficient in processing issues? The OHSC was not regulating individual healthcare professionals i.e. a nurse, a doctor or pharmacist. It regulated health systems and governance of those health systems. The OHSC would not replace the functions of the Pharmacy Council, it was coming in to cover very specific functions wanting to improve health systems in the Country.

Ms Thembekwayo asked whether they had any effective sustained influence in the avenues of power in South Africa. Which section in the NHI Bill would they make use of to push for an effective sustained influence in avenues of power in South Africa?

Dr Jacobs communicated the question of Ms Wilson. A lot of discussions and presentations were made regarding alterations to the Act and regulations. How many of those alterations or variations were there in their presentation? Given the lengthy time it took to pass and approve changes, what was the impact of NHI on their sector? Did the alterations to such acts and regulations need to be made before adopting NHI?

Dr Jacobs asked a question relating to the enabling construct. The entity had suggested that the NHI Bill should allow for amendment to regulations from time to time to accommodate technological advances, for example. He thought that they should be mindful that this was a Bill that was currently before Parliament. The Bill, once passed, was put into law. Therefore, the same process would have to be repeated for every change that needed to be made. One could not say within the law that there needed to be ‘changes from time to time.’ He thought he needed to provide clarity on this.

This was the fourth pharmacy group that presented to the Committee. Were they not represented already within the health sector? There was an impression that the pharmacists were not included in the NHI Bill. He requested clarity on whether they agreed with that. They had raised the issue of ‘scope creep’ - the differentiation between the functions of doctors, nurses etc. At what point did one say that one particular health professional was trained to do a particular job, another was trained to do a different job etc? Together they could form part of a multi-disciplinary team. He was concerned that there was an impression created that pharmacists should or could be a primary contact for any patient. As somebody involved in the academic sector – he was concerned about what was being put forward by the groups representing pharmacists. That was his personal view – and they were welcome to respond to that.

Mr Kotzé responded to the question regarding the many boards. He agreed, the Health Professions Council represented an enormous number of different specialised practitioners. Their experience internationally was that pharmacy was recognised as an individual profession. They were currently an individual profession. Their concern with the Bill was that in the first part of it, the Pharmacy Act was listed, but pharmacists were not listed in section 57(4)(f) and (h), despite other professions being listed. Also, the Pharmacy Act was not listed in subsection (8). When their members had read the Bill, they commented that other professions were listed but pharmacy was not. They had over-emphasised that point. In terms of the various statutory councils, there had been an effort some time before to create an umbrella organisation – to which all the statutory councils reported - to coordinate the actions of the various professional boards. He did not know what progress was made in that regard. The Pharmacy Council were in the best position to answer to that.

He responded to the issue around ‘unaccredited.’ They had pointed out that the Bill should not read ‘unaccredited’ but rather ‘accredited’ facilities. It was a technical point that they had raised. In terms of the restrictive sections, in section 57(4)(f), other professions were listed, not pharmacy. In the Bill one would see that specific reference was made to emergency care practitioners and hospitals.

In terms of the OHSC, which was not there to regulate individuals, but to regulate systems. He thanked the Committee for that clarity. The way they had previously read it, was that it would deal with inspection of individual facilities. From the pharmacy side, they had pointed out that it was the only profession where those facilities were currently inspected. For that reason, the comment they made was that there should be recognition of the work done by the Pharmacy Council, it was not necessary for the Office of Health Standards Compliance. But as outlined by the Member, it was there to regulate systems – so he thanked him again for that clarity.

In terms of the influence in the avenues of powers – he had not thought of that – he suggested Ms Mogale could answer this. Obviously, one could only exercise avenues of power through institutions that dealt with a specific issue that they were challenged with.

He got the impression that if there were changes to the wording of the NHI Bill, as it currently stood, the process needed to start again. Their experience with health legislation, with specific reference to the Medicines Act and the Pharmacy Act, was that once an Act had been signed into law – one found that through the operationalisation of the Act, one needed to make provision for various current challenges. He referred to the COVID-19 challenge that they were currently experiencing. There were certain permits that had to be drafted to make provision for pharmacists to provide immunisation services, the pricing of medicine had been challenged because it was not in line with section 22(g) of the Medicines Act. The point he wanted to make was that things happened. Legislation then did not make provision for the issues that developed. If an enabling piece of legislation stated that certain things could be regulated through the regulations – then that was done by the relevant department and they could change the regulations through the process of public comment. In a period of three or four months they would be able to implement an important change. The current Medicines Act made provision for urgent changes – such as an amendment or change which could be implemented by the Minister within a month - if it was in the public’s interest. Thus, they had made the suggestion of enabling legislation in that regard to facilitate urgent changes or developments that may occur in the industry. Legislation that was enabling to deal with specific detail in regulations was an easier way in practice to deal with unexpected changes that might come up in the future.

In terms of the ‘scope creep,’ within the pharmacy profession they experienced this from both sides. They saw doctors dispensing medicine, they then saw the primary healthcare nurses providing the scope of practice of both the pharmacists and medical practitioners. From the pharmacy side they saw an enhancement of the services provided in the pharmacy – as they were the most accessible healthcare provider. The ‘scope creep’ was unique to South Africa – it was the modern trend that was developing internationally. South Africa was a member of the International Pharmaceutical Federation for pharmacists and pharmaceutical sciences – there they saw that the scope of practice of professions, did have an overlap. The challenge was upon the regulatory authorities, the Councils and Boards to talk to one another – to know when and how the scope creep would overlap. The beneficiary from a ‘scope creep’ was the consumer – as it facilitated a one-stop service. The traditional approach – he came from the era where there were very clear roles and functions – was no longer the way that healthcare services were provided.

Ms Mogale agreed with Mr Kotzé in terms of the issues around ‘scope creep.’ In terms of the clinics and care facilities in South Africa, there were only a handful of doctors in those primary healthcare facilities but there were pharmacists available. If pharmacists had a broad scope of functions – the consumer would benefit.

As PSSA they knocked on so many doors, some were open and some were closed. They were celebrating 75 years as PSSA – this meant that they had support from some of the powers. This was why they were able to survive and have input into some of the legislation. They were really trying. They wanted to be recognised – they were also part of the healthcare team; they were not outside of the healthcare team. The South African Pharmacy Council (SAPC) had a different mandate to them – thus it was not as simple to streamline functions. The consumer would benefit. The Pharmacy Council’s mandate was the protection and promotion and maintenance of health and wellbeing of patients and the public. PSSA’s mandate was to protect the members, who were pharmacists. The Pharmacy Council would say the public was in safe hands – pharmacists were able to provide the pharmaceutical care to those consumers. They worked hand-in-hand.

Mr Sokatsha asked what their view was on making pharmaceuticals affordable -what role did they want to play in reducing the cost of medicines under NHI?

Dr Havard asked whether they would support the Bill if the proposed changes were not made. Did PSSA support the Bill in its current format?

Ms Mogale stated that their emphasis was that pharmacists would not be able to offer comprehensive healthcare services – they were in support of the NHI Bill. With all the comments and contributions made, the Bill would be enhanced. During implementation there would not be any ‘dilly dallying’ because they knew that they had a responsibility as pharmacists because they were in the Act. She hoped their comments would be taken into consideration – particularly the role of pharmacists.

Mr Kotzé stated that in terms of their view in making medicines more affordable under NHI, they currently had a parallel pricing system in place – the public sector pricing system. Section 22(g) of the Medicines Act regulated the appointment of the pricing committee – they had the mandate to publish a single exit price for medicine. The dispensing fee that needed to be charged by a pharmacist or a person authorised to dispense. The single exit price was the price that was set by the manufacturer. Manufacturers needed to motivate to the Department of Health. The single exit price had been in operation since the early 2000s. The dispensing fee component came into effect in November 2010. The SAP (spelling uncertain) was the dispensing price for a pharmacist – the acquisition price included the distribution/wholesale fee. The SAP was therefore the cost price of medicine and the dispensing fee was based on a cost basis. There were 23 line items that the Pricing Committee recognised – such as salary, rent etc. Those were calculated for a small efficient pharmacy. Added to that cost basis was a small component on return on investment. That gave a figure. The Pricing Committee was of the opinion a pharmacy needed to be able to dispense 2300 items per month. That was divided into that cost basis number – which delivered the dispensing fee. Since then, the fee had been adjusted on an annual basis. The adjustment of the fee for the current year was less than one percent. From a private sector, community pharmacy perspective, there was nothing to give away. The only way the price of the medicine could be further reduced was to go back into the supply chain to put pressure on the SAP to be lowered. There was a complex relationship between the single exit price in the private sector and the price that was supplied on the tender system. This Bill envisaged that the purchaser of all medicine would be by the State. To a great extent, one could talk about consignment stock that would be in pharmacy – there would be no cost to that. The supply of that product would be on a fee basis which would be similar to the current roll-out of the COVID-19 vaccine in the private sector. There was an agreement with the Department of Health of what they would pay per dose administered in a pharmacy – added to that was the administrative process and procedures. There was a fixed agreement on what that should be. In terms of affordable medicine, their opinion was that as the private sector structure fell away, and medicine was purchased by the State, the State would pay for the services provided – there was a good possibility of a further reduction in the price of medicines.

Closing Remarks
Dr Jacobs made brief closing remarks and noted the upcoming meeting taking place on Friday with the AG.

The meeting was adjourned.