National Health Insurance (NHI) Bill: public hearings day 5

01 June 2021

Documents:

Meeting Summary

Video: Portfolio Committee on Health, 01 June 2021

NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee held public hearings on the National Health Insurance Bill. Four organisations presented oral submissions.

The organisations supported the principle of universal health coverage and made various recommendations to improve the Bill.

The Khayelitsha and Klipfontein Health Forums said that there was insufficient public participation especially with communities that were most affected and impacted by the introduction of national health insurance. The Forums requested clarity from the Committee regarding various issues in the Bill, such as the role of the District Health Management Office and the funding framework.

Academics from the University of Cape Town highlighted that an essential package of health care services for children and adolescents must be prioritised within the NHI baskets of care. Specific concern was raised about children of asylum seekers and illegal immigrants who will not have the formal identity documents needed to register as users and how they will gain access. They also noted with concern that none of the advisory committees have representation from child health specialists or the children’s sector. This raises concerns that children and adolescents’ specific needs are unlikely to be adequately addressed and prioritised.

The South African Psychoanalytic Confederation pointed out that mental health was overlooked in the bill. It said this was an oversight and highlighted that mental health was an integral and essential component of health. It offered to partner with government in bringing this to fruition.

The South African Medical Association (SAMA) said it was supportive of the concept of Universal Health Coverage. However, it did not support NHI as currently constructed. It argued that many of the proposed changes in the Bill have yet to be fully researched for their effectiveness and potential to actually improve service delivery by ensuring that there are sufficient funds and the desired framework to achieve this. It reported that there was deep-seated lack of faith amongst its membership in the ability of the government structures to provide the financial support structures for quality services. In addition, it highlighted that NHI will not address the failings in infrastructure and management in the public sector and that emphasis should be on fixing the public sector to a point where it can begin to appeal to private sector patients.

The Committee asked whether the health system needed to be strengthened prior to the implementation of national health insurance.

The Committee asked how funds can be raised to cover undocumented foreigners that seek to gain access to healthcare services.

Concern was raised that only one percent of the facilities in the country met the norms and standards that would allow them to register as NHI facilities. The budget cuts to primary healthcare, staffing and infrastructure were also highlighted.

Presenters were asked if they supported the two-tier healthcare system, the proposed governance model, why they were concerned about the Minister’s powers, if there was a need for every sector to be represented on the Board and if so, should this be reflected in the bill or elsewhere.

Meeting report

Presentation by the Khayelitsha Health Forum and Klipfontein Health Forum
Mr Mzanywa Ndibongo, Chairperson, Khayelitsha Health Forum, presented on behalf of both entities (He was joined by his colleague who did not present).

Overview
-In principle there is support for the purpose of the NHI Bill that seeks to achieve universal access to quality healthcare services in the Republic in accordance with section 27 of the Constitution.
-The success of the NHI Bill is dependent on a strong Public Healthcare System and the challenges experienced by the Public Healthcare System needs to be addressed and fixed as a matter of priority. Failing this, we will be setting up the NHI to fail.

NHI Public participation process
-Lack of public participation with the communities most affected and impact.
-Has not reached poor communities.
-Clarity needed as to how people with disabilities and special needs will be accommodated in the Bill.
-Was Parliament provided with a public participation report relating to the Green and White Papers and stakeholder engagement?
-Urge that public participation process be protected from political interference and party political squabbles and point scoring.
-Ordinary citizens need to be properly informed and educated about the NHI Bill.

Co-operative governance
-There needs to be greater cooperation between different spheres of government in terms of public participation and education.
-Different levels of government need to work together to provide better services.

General
-No feedback relating to the pilot projects
-Need clarity on health committee’s role in the NHI
-Clarity on the role of the district health management office needs to be provided.
-Composition of the NHI Bill must include representatives of civil society
-Funding of NHI: Clarity is required regarding the details of this.
-Clarity regarding monitoring and evaluation mechanisms

Recommendations
-Request government report on public participation processes
-Report on pilot projects be shared with the public
-Feedback to organisations as to how there submissions shaped the NHI Bill
-Government and Parliament should work closely with community-based structures in the roll-out of public participation processes

(See Presentation)

Discussion
The Chairperson said that if they wanted to see the NHI documents and the Green Paper and White Paper, they should go to the Department’s archive because they were not at that level anymore. That took place a while ago. The Committee attended 36 meetings that were attended by people in various parts of the country. There were some that would take place after these hearings, by the National Council of Provinces (NCOP). That report would be available to the public at the appropriate time. The Committee did hold a meeting in Khayelitsha. The meetings were well advertised in advance, with the municipalities support.

Ms E Wilson (DA) stated that, just like with every other presentation they had heard, the presenters supported the National Health Insurance (NHI) Bill ‘on condition that…’ One of the problems that kept coming up was the establishment of the Board by the Minister – this had been raised in every presentation to the Committee. Every sector wanted representation on the Board. How did they believe that this should be managed? One of the things they had raised was the need for monitoring and evaluation. A lot of the monitoring and evaluation that would take place throughout the NHI process – would obviously fall on the Board because the Board would need to do a lot of monitoring and evaluation with regard to the roll-out. If everyone was not represented on the Board – not everybody would be happy. She asked that the Forum suggest how this should then happen.

The presentation highlighted various responsibilities at different levels of government (i.e municipal and district). Currently, budgets were divided in the health sector and they were given to provinces and various Non-governmental organisations (NGOs). Under the NHI, everything would be centralised. Centralised purchasing would take place. One of their concerns was around the current corruption in the health sector – which was quite hectic. How did the Forum feel about the proposed centralised system? The presenters had asked for a guarantee that the system would not be open to state capture – however anything that was centralised did leave them ‘open to question.’ She requested responses in that regard.

Mr M Sokatsha (ANC) noted the presenters question regarding ‘feedback.’ He requested clarity as to the nature and form of feedback that they were expecting from government following the Green and White papers and the Draft Bill consultations. His second question related to the health committees. Were health committees not defined in the Health Act? Could the Forum suggest how health committees should play a role in District Medical and Health Offices (DMHOs).

Ms A Gela (ANC) asked whether there was a role for the private sector under the NHI. What did they think of section 48 and section 49, in terms of financing of NHI?

Dr K Jacobs (ANC) asked a question in relation to the building up of the healthcare system; should that be a pre-requisite before the NHI was implemented? What were they proposing in terms of building up the public healthcare system? Given that they raised the issue of stakeholder engagements, were the presenters aware that there was a socio-economic impact assessment? It was a public document that provided a report on stakeholder engagement.

The Chairperson asked whether the Khayelitsha Health Forum was aware of section 27 of the Constitution It stated that ‘everyone had a right to access healthcare services including reproductive healthcare, sufficient food and water etc.’ If NHI was based on this fundamental principle of the Constitution – would that not be sufficient? He noted that the Forum wanted specific mention in the Bill about children, elderly and people with disabilities. If the Constitution stated that everyone had a right, it meant everyone. What was the challenge with that? If they were to start listing, they would land up leaving out other people unintentionally.

Mr Ndibongo referred to the Green and White Papers and emphasised that the consultation of stakeholders was not done sufficiently. The reports on the consultation processes should be made available to the public. The consultation process relating to the NHI did not accommodate communities and the closing date for submissions was very tight.

In terms of the Health Minister being able to appoint, those people would be accountable to the Minister. That on its own was not public participation in their view. The community would never have a voice in whatever came out as being a problem in a facility. The problems would land up being swept under the rug. Those people would be accountable to the Minister – and in so doing – they would not be able to expose bad things that might happen in facilities. The community should be represented, and facilities held accountable. The Minister should not appoint the health committees; the Minister could appoint the Board.

The problem with the public hearings was that one only heard about them after the closing date for submissions – people did not have sufficient time to prepare themselves to present. If they had been given more time they would have been able to present a better presentation. Implementation was also likely to pose problems – that was why the public should have a say.

It was important to have the private sector involved in the NHI – there was a lot of work that needed to be done. For service delivery to flow smoothly, it was important to have private sector involvement. In terms of building the public healthcare system – provinces and district municipalities should work hand-in-hand with stakeholders. In their communities, they had health committees that were not recognised by the government – the role of health committees should be clarified. Now they were facing a situation where the Minister was appointing the ‘cleaning committees,’ for instance. There was no public participation on that one – but when there were problems health committees would need to get involved. They needed to build these structures – they did not want issues of blaming one another or shifting blame across levels of government, i.e. district to provincial.

The Health Act mentioned that ‘everyone had a right to health.’ They faced challenges in their communities where people queued for ages to access clinics etc. If one conducted oversight visits – one would see the extent of the situation. People woke up early in the morning to go to the clinics and came back without getting any help. This showed that not everyone had a right to health – they could not get the service that they expected.

Dr Jacobs asked whether the presenter had checked the National Health Act in terms of the appointment of the Health Committees. He suggested that this was delegated to the Members of the Executive Council (MECs)

The Chairperson stated that there were about 3000 clinics in the country. This was something they needed to check as to whether it was delegated to the MECs to appoint clinic committees.

UCT
Ms Lori Lake, Communications and Education Specialist, and Prof Tony Westwood, Department of Paediatrics and Child Health, presented on the topic on ‘where were the children in the NHI?’.

Challenges of poverty and inequality
-Children in South Africa are disproportionately affected by poverty, and more likely than adults to be living in poor households.
-Many children experience multiple deprivations that accumulate over time creating long-lasting developmental setbacks,2 and children in former ‘homeland’ areas and informal settlements continue to experience the highest levels of deprivation
-Nearly 60% of children live below the poverty line. 1 in 5 children live in overcrowded households, 1 in 3 are without water on site, and 1 in 5 are without basic sanitation.
-In addition, 1 in 5 children still travel more than 30 minutes to reach a health care facility. Transport costs and safety concerns lead to life-threatening delays in accessing treatment, and a lack of “positive and caring attitudes”6 undermines uptake of both adolescent health services7 and antenatal care8.
-It is therefore unsurprising that diseases of poverty such as diarrhoea and lower respiratory infections account for 21% and 18% of under-five mortality, or that 50% of child deaths in hospital were associated with malnutrition.

Rights of foreign children
We are pleased that the Bill upholds the constitutional right of all children to basic health care services as provided for in section 28 (1)(c) of the Constitution - including children of asylum seekers or illegal migrants.
-Yet children of asylum seekers and illegal immigrants will not have the formal identity documents needed to register as users. Clarity is therefore needed on how these children will gain access.
-Some children with long term health conditions or complex care needs enjoy a range of additional essential services in the public sector that may fall outside the basic package of care. It is therefore important to clarify if the NHI Fund will cover these benefits for children of asylum seekers and illegal migrants.
-Antenatal and obstetric care are key determinant of child health and survival and are recognised as an essential component of children’s right to health by the UN Committee on the Rights of the Child.
-We therefore call on the State to extend antenatal and obstetric services to asylum seekers and illegal foreigners.

Equitable access to healthcare
-In order to access health goods and services under NHI, people must have proof of registration.
-Registration can only be done at an accredited provider or health establishment.
-Children born to users are regarded as having been registered automatically at birth.
-Children already born will need to be registered by their parents or can register themselves from age 12 onwards.
-An original identity card, birth certificate or refugee identity card will be required for registration.

Three concerns
-Barriers for undocumented children
-Barriers for children living with relatives or on the move
-Barriers for children in poor communities where health facilities are not accredited.

Representation for child and adolescent health
The Bill enjoins the Minister to appoint advisory committees:
-The Benefits Advisory Committee to determine the health care service benefits and types of services that the fund will pay for at each level of care from primary to tertiary hospitals. Its members must have technical expertise in medicine, public health, health economics, epidemiology, and the rights of patients.
-The Health Benefits Pricing Committee, which must recommend the prices of health service benefits. Members must have expertise in actuarial science, medicines, epidemiology, health management, health economics, health financing, labour and rights of patients. A member must represent the Minister. This is the only advisory committee with a defined number of members: "not less than 16 and not more than 24".
-A Stakeholder Advisory Committee, comprising representatives from the statutory health professions councils, "health public entities, organised labour, civil society organisations, associations of health professionals and providers as well as patient advocacy groups "in such a manner as may be prescribed".
-We note with concern that none of these advisory committees have representation from child health specialists or the children’s sector. This raises concerns that children and adolescents specific needs are unlikely to be adequately addressed and prioritised.
-For example, there is little to no consideration of children in the National Core Standards outside of neonatal and paediatric wards, despite the vulnerability of neonates and children in EMS settings, and adolescents when they move from paediatric to adult services.

(See Presentation)

Assoc Prof Louis Reynolds. Department of Paediatrics and Child Health, UCT, presented on the NHI package of care.

Why an essential package of care?
A well-crafted and targeted package of care is an established means of improving health outcomes through:
-Improving access
-Improving health outcomes
-Enhancing equity in health outcomes
-Prioritising interventions
-Providing standardised pathways of quality care that are maximally effective for a target population at a reasonable costs.

Packages of care for mothers and children’s health are particularly importance because:
-Major gains in life-long outcomes can be achieved with relatively simple interventions
-Mothers and children have special healthcare needs that are not always optimally met in systems that mainly serve adults.

An Essential package of care
-Maternal and child health (MCH) specifically represented on the benefits advisory committee by experts in MCH
-Regulation under Section 25(2)

(See Presentation)
Wits University
Prof Haroon Saloojee, Department of Paediatrics and Child Health, Wits University, presented on the re-engineered primary health care (PHC).

Purpose of presentation
-NHI needs a strong district health system driving effective PHC
-Needs of mothers and children highly dependent on PHC
-The primary of PHC and its re-engineering is well articulated in the Bill
-However, the lack of success in the implementation of re-engineered PHC (since 2011) warrants some reflection

What is PHC re-engineering?
-Municipal Ward-based PHC Outreach Teams
-District Clinical Specialist Teams
-Integrated Health Programme
-Contracting of private health practitioners at non-specialist level

Implementation
- 58 000 community health workers nationally
- All 52 districts
-Community health workers mostly appropriated from Non-governmental organisations
-Little data on what was being done
-Anecdotally, highly idiosyncratic
-Still mostly offering HIV and TB care, with scant attention to mothers and children.

Challenges
-Varying degrees of training, qualifications, skills and competencies
-Random distribution with poor coverage
-Inadequate support and supervision
- Poor/no link between the community based services and services offered by fixed health facilities
- Limited or no targets for either coverage or quality to be reached

Integrated School Health programmes
-About 2 000 school nurses for 21 000 schools
-School health services are unevenly provided within and between provinces
- School health services are poorly resourced – low/no budget for additional staff, equipment and transport required.
-Focus almost exclusively on screening (about 40 percent coverage for grade one’s).

Re-envisioning
-The focus of school health and WBOT work should move from achieving coverage to measuring quality and impact
-School health nurse as manager
-Task shifting: screening, peer supporters, educators’ role
-Referral systems – unique patient identifiers.

District Clinical Specialist Teams
-Incomplete teams (83 percent) and vacant posts 940 percent)
-Concerns raised regarding the current reporting line, scope, placement and accountability (clinical and administrative).
-Individual competence of members (clinical governance)
-Teams refer to a lack of operational support, inappropriate tasking/demands and a failure to implement or respond to their recommendations.

Conclusion
-With limited available formal documentation, research or public reflection on the reengineering of PHC strategy it is difficult to gauge where the initiative is going as a whole.
-Similarly, the individual components seem to be evolving spontaneously rather than through continuous systematic review and strategic planning.
-An argument has been presented that new directions need to be carved for the reengineering of PHC strategy. Failure to do so risks loss of the few hard-won successes and a collapse of the initiative.
(See Presentation)

Discussion
Ms Wilson noted the long-term health problems that were highlighted in the presentation. Life-time health problems could result from the current healthcare situation. An unhealthy population was an ‘unproductive population.’ People who were ill, malnourished and suffering were unable to be productive. When they were unable to be productive, they were unable to assist the economy of the country. This would impact South Africa as a country. It was concerning that only one percent of the facilities in the country met the norms and standards that would allow them to register as NHI facilities. That was very scary. It was even more scary that there was a budget-cut in relation to primary healthcare budgets and cost of employment, which resulted in limited staff. One of the cuts related to infrastructure. The presenters had spoken a lot about inaccessibility and how far people had to travel to get healthcare. In a lot of the provinces the Committee had visited, the mobile healthcare units did not go regularly to isolated areas – so people could not rely upon that. They were sitting with a very scary situation.

In light of the above issues, if the NHI was past the following day, knowing that only one percent of facilities met norms and standards, that primary healthcare budgets had been cut and the cost of employees had been cut, knowing that infrastructure budget had been cut – would it work? Or should more be done to improve infrastructure, accessibility, staffing and primary healthcare services first. What would they advise?

Mr Sokatsha asked if maternal and child health services should be included in the implementation plan. Did the presenters specifically want this included in the Bill?
Mr T Munyai (ANC) stated that the matter relating to the budget cut was expressed during the budget review process. The Committee had made a call that they should invite the Minister of Finance to the Committee so as to attend to the issues relating to the budget cut. The problems that had occurred during COVID-19 highlighted the reasons why NHI was needed. One country, one health system. Did the presenters want to continue with the two-tier healthcare system?

He asked whether it would not make better sense that children and adolescents health be articulated in the regulations or implementation plans instead of the Bill. It could be confusing to put it in the Bill. Were there any international best practices that NHI could adopt to mobilise additional funding to cover children for undocumented immigrants or asylum seekers. Did they think the United Nations (UN) should play a role in providing funding for such services – like they did in other contexts.

Ms Gela asked whether the presenters supported the NHI Bill.

Dr Jacobs asked whether they envisaged that the District Medical and Health Office (DMHO) would fit into the primary healthcare re-engineering under NHI. He brought to their attention that the NHI Bill was not silent on the coordination at a local level. Section 36 outlined that the DMHO was charged with coordination of primary healthcare provision – for personal healthcare at a district level in line with policy guidelines. Were they aware that the Department of Health and the Office of Health Standards Compliance (OHSC) were implementing the National Quality Improvement Plan Facilities that met the accreditation requirements outlined in the Bill – were then found fit for purpose. It was for that reason that the NHI would be implemented incrementally. When the British National Health Service (NHS) system was initially implemented, they had no money and the system was not ready – but it was implemented incrementally and today great pride was taken in the NHS.

The Chairperson asked how they proposed that funds should be raised for the potential ‘flooding’ of undocumented immigrants who may want to access antenatal and child healthcare in the country. There were extreme views in the country that asked why one had asylum seekers and foreigners included in the NHI. The South African Human Rights Commission would have to accommodate them. The presenters’ contribution was on the other end in terms of what the NHI was proposing. They were proposing this as a comprehensive child and healthcare service for undocumented and documented immigrants.

He referred to section (c) of the Bill which spoke about all children – were they not comfortable with that - did they feel that some of them were left out of that or did they feel that the services they would get was not comprehensive enough. He asked whether the presenters would be comfortable to see their recommendations in regulations if they could not be accommodated in the Bill. Would they support the Bill in this instance?

Assoc Prof Reynolds responded to the question as to whether the NHI Bill would work if implemented now. He was sad to say that he did not think it would. This was due to a number of reasons. The public health system was declining. The private health system was more or less protected from South Africa’s health crisis. It had not been playing its role in dealing with the burden of disease. The ability of the state to manage large funds was also not guaranteed – as they heard on a daily basis – for example in the Zondo Commission. He was a bit pessimistic about the NHI, although he thought it was the only way to go. It had to be done in a way that mobilised all South Africa’s health resources with one objective – and that was to improve the health of the nation. That included, not only curing individuals, but treating the nation through social solidarity. They needed to realise that it was not a technical exercise, it was a technical and political exercise and there was a long way to go. They had been going in the wrong direction for centuries with respect to health. They had some opportunities to improve the health system but they missed them. The country was so far from where it was supposed to be, in terms of health, that they did not even know how to get there. He did not think the NHI could work right now, he did think that it was the only way to go in terms of providing healthcare based on need rather than means.

Ms Lori Lake stated that what they were saying as a collective was that they were concerned that when there was no explicit representation for child and maternal health that there was a very real risk that the specific needs of children and adolescents would be overlooked. They had seen that in the norms and standards themselves. They knew that it was a real challenge. One needed a paediatric specialist because children’s needs were different to adults. The staffing needs were different and the equipment needs were different. There needed to be someone in each of those committees who was attuned to children’s specific needs and who was actively championing them. They were calling for that to be explicitly stated in the Bill – in terms of the composition of those three committees.

She addressed the question relating to sources of funding for services for undocumented asylum seekers and/or foreign children. They believed that this was something the Committee should be exploring ideally with support and guidance from the UN.

In terms of the concern around undocumented foreigners streaming into the country to access obstetric services, they believed that it was absolutely vital for those children to access care. That right was upheld by the Bill. By extension it should be extended to antenatal and maternal care.

Prof Saloojee addressed the question of prioritising changes at a district level – and the focus on infrastructure services and processes. His view was that the delivery of service needed to take priority. Issues around efficiency were the real difficulty. The money did no need to be spent on building better clinics – it needed to be on getting existing services to function more efficiently. Human resources may be an issue – the issue they had not previously highlighted was that they may have many community health workers – but there was a feeling that the current model was not working.

No child care advocate would believe that the principles of the NHI were fundamentally wrong – the difficulty was the amalgamation of the two systems. What were the ways they could make the two tier system into a one tier system? The issue around extending service to ‘non-South African’ children was an important one. When they had looked at international best practice, there were many models and different countries, including highly resourced countries that were either very stingy in sharing resources or benevolent. In terms of external agencies assisting – such as the UN – his view was that it was up to the Country to decide what were considered ‘basic healthcare services’ that could then be provided to non-South African children. An essential package of care also needed to be defined – which was beyond the basic package. They would then need to decide how much of the essential package could be extended to non-South African children. They did not only want it to include children, but mothers as well.

As a country, they had struggled for the past 20 years, in terms of district systems, being able to support primary healthcare. It was fundamentally about where power and money was. They needed to figure out how to decentralise power from provinces to districts.

Prof Westwood noted that the ‘nitty gritty’ aspects could be included in the regulations and implementation plans. When it came to representation, the closer they could get into the Bill for maternal and child health, as they described, the better it would be reinforced at all levels – from the national to the district level. Children and mothers needed to be in the Bill and regulations to ensure that they were comprehensively provided for and government was held accountable in this regard.

Presentation by the South African Psychoanalytic Confederation (SAPC)
Mr Zamo Mbele, Clinical Psychologist, and Ms Carin-Lee Masters, Psychotherapist, presented to the Committee.
The SAPC fully endorses the need for universal health coverage and seeks to partner with government in bringing this to fruition. Mental health is overlooked in the bill. This is an oversight. According to the WHO (2017), mental health is an integral and essential component of health.

Video clip shown

Importance of mental health
-Studies show that South Africa’s public mental health expenditure represented 5.0% of the total public health budget¹
-Necessary inpatient care represented 86% of mental healthcare expenditure, with nearly half of total expenditure on mental health occurring at the psychiatric hospital-level (tertiary). Almost one-quarter (24%) of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system 18.2% of the total mental health expenditure
-Mental health starts at the beginning of life and is paramount for a healthy society, this can be promoted in primary care stage
-Improved mental health directly reduces physical illness
-A society with optimal mental health will be more economically viable
-Investment in mental health has proved cost effective in the long run
-Most importantly, mental health interventions work best at the preventative, primary care level, where they can have the broadest impact and highest levels of success
- It is imperative that we reduce admissions through preventative care and thus access and funding to primary psychological interventions is essential
-South Africa is a traumatised society that is fractured and in distress, we need to prioritise mental health to heal as a nation and be free; not just politically but in our relations together and inside of ourselves
-Cost-effective public health and inter-sectoral strategies and interventions exist to promote, protect and restore mental health
-Much is in place already that can be used to build from

(See Presentation)

Discussion
Ms Wilson stated that the health of mothers and children was absolutely essential and a key necessity when they spoke of primary healthcare. A sick nation was an unproductive nation. When one said mothers and children, they needed to add adolescents there. A lot of adolescents were also mothers – one would still need to think of them as children because they were still reliant on care from somebody else. They were also seeing the exposure of children to crime, death, abuse, drugs, gangsterism and destruction.

Her concern was that a sick child was harmed for life. So much of this became inter-generational. They often thought of children in terms of inter-generational sickness – as being ‘stunted today, stunted for life and stunted parents produced stunted children.’ Harms of the past had affected mental health of people today and could go on to affect generations to come. They had children who were exposed to sick and distressed parents – one thing was leading to another.

What was not clear in the presentation was whether the entity supported NHI – and where it felt it was missing key concepts with regard to mental health. It was a critically important issue. The mental health and inter-generational outcomes of good mental health were critical. Did the Committee need to add more to the NHI Bill to ensure that this was covered?

Mr Munyai asked how it was possible to realise the aim of the NHI, when almost half of the health spending served only 16 percent of the population - private medical scheme coverage - the two tier system. Did they support the NHI Bill? Did they not think that NHI aimed to resolve issues such as those experienced through the COVID-19 pandemic within the health system?

Ms Gela noted in their submission that they wanted psychoanalysis to be included in the advisory committee. Did they not regard them as part of the integrated health team? Did they think that their participation should be described in regulations?

Dr Jacobs noted what was said about those working in the private sector wanting to work in the public sector. He was sure it would be amazing if everyone could work in the public health sector. They recognised the importance of mental health and the importance of having the number of appropriate professionals to be able to deliver services. How would they ensure a more equitable distribution of healthcare workers and services were made available – when the prices and the wages paid in the private health sector were so much higher than the public sector.

Dr X Havard (ANC) suggested they propose how they would like accreditation to be revised to address the issue of equity. How did they propose that funding is raised to fund undocumented immigrants which may want to access maternal and child health services in South Africa?

The Chairperson stated that mental health was covered in part in the Bill – were they suggesting more than what was mentioned in the Bill? Did they have permission to share the videos that were shown to the Committee?

Mr Mbele stated that they would like to participate more. They appreciated the position of the preamble and they wanted to engage more. They also thought that they had a lot to offer - beyond working groups. They would like to engage more around the issues of mothers and children, foreign nationals and non-nationals not just in working with them – but working with the plight of immigration and migration which was so central to South Africa’s history. Their offerings were not just to patients and people that they worked with – it was to policy and politics. They were able to work with the Committee – not just on matters of NHI – in terms of policy and regulation – but also thinking about the nation overall and thinking about where it was. There was no health without mental health. There was no mental health that was equitable without NHI. To that extent, their mandate absolutely supported NHI. There was no true NHI without a strong appreciation for mental health and mental illness and its pervasiveness. They saw themselves in support of the Bill – the only concern was around the limited mention of mental health.

Ms Coralie Trotter, Clinical Psychologist, SAPC, stated that the problem with the Bill presently was that mental health was integrated into general health. This typically resulted in it being left aside – this happened during the COVID-19 pandemic. Mental health needed to be separated out in some way so that it was not left out in terms of funding and importance. In section 57.4, there was no mention of psychiatrists, psychologists or clinicians – it was small things like this that revealed the gap in the Bill and once it was made law it became difficult to deal with.

They supported universal healthcare. This did not mean that it needed to be a single funding system or that it could not have supplementary tiers – that they could not work collaboratively with each other. There was another question linked to that in terms of resources. They did not have enough resources – they had faced this across the country for years – particularly in terms of mental health. That needed to be ironed out now. The dilemma was that if they got rid of what was working; they would not be able to replace it entirely.

The NHI would not simply sort out all the problems they experienced.
The Chairperson stated that mental health was not taken seriously enough all over the world, not just in South Africa. They needed to be advocating for this in general.

Mr Mbele stated that they could lead the change. They could invest in a ‘radical way’ in the mental health of the people especially when their people for many years were discarded as not having an internal world that needed to be educated or looked after or taken care of. Mental health did not just come into play in clinics and the healthcare environment exclusively – it came into play in schools, homes and working lives. If they decolonized mental health, they would see that it was everywhere – they were hoping that collaboratively they could learn how to see it everywhere.

Presentation by the South African Medical Association (SAMA)
Dr Angelique Coetzee and Dr Mvuyisi Mzukwa, of the SAMA Board of Directors, presented to the Committee.

Challenges of the health system
Public Sector:
-Quality failings in delivery and infrastructure
-Human Resources Shortage AND mal-distribution of these resources
-Acute shortage of management skills
-Poor access to health care – physical, services not available, financial
-Provinces failing to address their own challenges
Private Sector:
-Widespread failures in regulation
-Expensive and financial risk exposure to users
- Quality is essentially unmeasured
-Fraud, waste and abuse
-Fragmented delivery, funding, clinical governance

Position on the NHI proposals
-SAMA is supportive of the concept of Universal Health Coverage
-The proposals in the NHI Bill constitute the most significant changes in the funding of the health system that we have seen since 1994
-We support the step-wise, resource-informed and evidence-based approach to the implementation of any major reforms in the health system.
-Many of the proposed changes in the Bill have yet to be fully researched for their effectiveness and potential to actually improve service delivery by ensuring that there are sufficient funds and the desired framework to achieve this
-There is a deep-seated lack of faith amongst our membership in the ability of the government structures to provide the financial support structures for quality services
-SAMA cannot support the NHI as currently constructed.

Concerns with the NHI Bill in 2019
- Quality of care – not enough emphasis in the Bill on quality, too much emphasis on cost
-Coverage for asylum seekers and illegal foreigners
-Non-Independence of the NHI Fund and the exceptional powers of MOH
-Monopsonistic purchaser – single large fund and no Purchaser/provider split
- Board and Advisory Committees not independent and appointed by the Minister
-NHI Pilot programmes (2012-2016) had demonstrated little useful outcomes
-Uncertainty in many of the key proposals – detail is lacking
-Reimbursement – doctors to deliver quality care at the “lowest possible price”
-Contracting issues – contracting proposals are complex and need trials / piloting before they are included in an Act of Law
-Absence of any structures to address out of hospital specialised care
-Certification, Accreditation and Contracting of healthcare services providers

Concerns about corruption
-A survey conducted within SAMA membership in 2019 revealed significant lack of faith in the government structures to prevent and address corruption issues.
-This was a repeat concern from medical practitioners and one of the main concerns regarding the potential for a single fund channelling significant amounts of funds.
-SAMA re-affirms its White Paper assertions that corruption is eating away our health system and poses a serious threat to the achievement of health outcomes.
-While SAMA endorses the envisaged corruption-fighting Investigating Unit (Clause 20(2)e), it will be ineffective if the corruption develops within the NHI Fund itself, as the Unit will be unable to confront corruption from within.

Coverage of the population
Section 4 – Population Coverage
(2) An asylum seeker or illegal foreigner is only entitled to—
(a) emergency medical services; and
(b) services for notifiable conditions of public health concern.
(3) All children, including children of asylum seekers or illegal migrants, are entitled to basic health care services as provided for in section 28(1)(c) of the Constitution.

-Phrasing of the Bill – does this mean the NHI will only pay for these services and anything else has to be paid by the patient?
-Or does it mean in the new system these patients will not be entitled to anything beyond the above at all.
Medical professionals, by virtue of their training and allegiance to ethical codes, prioritise medically relevant aspects for patients.
-At the point of care e.g. a primary health facility, it is unjustifiable for the medical professional to decline undocumented patients on the basis of them not having identity documentation.
-Additionally, “basic health services” has not been defined for all children

Regulations enabled by the Bill
-Regulated aspects are extensive!
-There will be public consultations for each regulation (Section 55.2.3),with exceptions (Sec 55.4.b)
-Some of the aspects to be Regulated:
-Payment mechanisms for providers
-Fees payable by users
-Optional Contracting In of private providers
-Relationship between public and private establishments
-Clinical info and diagnostic codes to be used
-Accreditation mechanisms
-Functions and powers of the District Health Management
-Relationship between the Fund & the OHSC
-Relationship between the Fund and Med Schemes and Insurance Schemes
-M & E of the Fund

Purchasing of services
Sec 37: Contracting Unit for PHC (CUP):
- “The CUP is the Preferred organisational unit with which the Fund contracts for the provision of PHC services within a specified geographical area…”
- CUP is composed of: a District hospital, Clinics, and/or CHCs and WBOTs, Private providers organised in horizontal networks
-Assists the Fund on its function incl. identifying health needs; identifying accredited providers & issuing certificates, etc.
-CUPs are both the healthcare providers and the contracting unit
-SAMA recommends that the proposed payment mechanisms are adequately piloted before they are included in an Act of Law or any regulation.
Sec 35: Hospitals and emergency care
-The Fund must transfer funds directly to certified, accredited and contracted central, provincial, regional, specialised and district hospitals based on a Global Budget OR Diagnostic-related Groups.
-Emergency medical services provided by accredited and contracted public and private health care services providers must be reimbursed on a case-based fee, with adjustments for severity where necessary.
-Nothing to address out of hospital specialist services.
-Proposals suggest that health practitioners will need to employed by or contracted by hospitals – many of our practitioners have expressed an aversion to these arrangements particularly with the private hospitals groups

Healthcare benefits
-The Sustainable Development Goals 3.8.1, related to UHC is: “Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn, and child health, infectious diseases, non-communicable diseases, and service capacity and access, among the general and the most disadvantaged population).”
-This definition acknowledges that countries provide a wide range of services for health promotion, prevention, treatment, and care, including rehabilitation and palliation.
-Currently, the benefits to be offered by the NHI are unknown and are yet to be determined by the envisioned “Benefits Advisory Committee” as described in Section 25 of the Bill.
-It is thus extremely difficult for health practitioners to support the NHI reforms, not knowing what will be available to patients, or under what conditions.

The role of medical schemes
-Clause 6(o) provides that users have the right: “to purchase health care services that are not covered by the Fund through a complementary voluntary medical insurance scheme registered in terms of the Medical Schemes Act, any other private health insurance scheme or out of pocket payments, as the case may be”.
-SAMA believes that application of this clause should mean that if for example, NHI benefits include hip replacements and hospitals cannot offer the service timeously, patients should have a choice to attend private sector facilities, funded through private insurance.
-SAMA argues that, while the user’s right to use non-NHI service is being respected, a user seeking care from non-NHI providers should not be compelled by an in-comprehensive basic NHI package, or poor quality of the package, including interrupted service and goods supply, especially in the public sector.

(See Presentation)

Discussion
Mr Sokatsha stated that in terms of coverage of asylum seekers and undocumented migrants – how did SAMA propose that additional funding for those groups in the population be mobilised in an environment of financial resource constraint?

Ms Gwarube stated that they needed to acknowledge that there was a difference between the NHI Bill they were dealing with and the concept of universal healthcare. They needed to be careful not to confuse the two. In her view, the governance model was one of the weaker aspects of the legislation. There were various models around the world in terms of how these things were done around state owned enterprises and how boards were appointed. What was SAMA’s view from the health sector – in terms of how to build in good governance models in a way that could get them closer to universal healthcare. All of them were in agreement that universal healthcare was something they needed to work toward.

Dr S Thembekwayo (EFF) noted the presentation said that the Minister had too many powers. She would like to know who was supposed to be included/share the powers that were assigned to the Minister. Based on the recommendation that the proposed payment mechanisms should be adequately piloted before included in the act – what would be an appropriate representative sample and geographical spread that would possibly yield approved valid results?

Ms Wilson noted that a lot of time was spent on certification and accreditation of facilities. However, in the last report only one percent of all facilities and clinics, that were possible ‘contenders’ – actually met the validation and accreditation criteria. This was a huge concern. She asked that more information be provided in this regard. In order for the NHI to become applicable, a lot of other acts, that dictated the regulations and establishment of other sections of the health system would have to be changed in order for them to be relevant in the NHI. She requested that they could indicate some of these and the affect that it would have. Essentially all of those acts would need to be changed first – before the NHI was implemented – she asked that she be corrected if she was wrong in this regard. The failure of the pilot projects – it was hardly surprising that medical professionals were concerned about what had happened. – unless they could share more information in that regard. Her major concern was that, in the last couple of years how health had gone backward. If they went ahead they could not go one step forward and three steps backward. They saw this predominantly in the Northern Cape – where the health system collapsed to such a degree – as a result of the lack of infrastructure, staffing and budgets. Even their infant and child mortality rates had gone backward.

In terms of the establishment of the committee that would decide on the basket of services that NHI would cover and associated the costs – the central procurement of that was quite critical. The powers of the Minister were quite concerning – the monitoring and evaluation would be of the entire NHI project – which would fall predominantly under the Board.

Dr Jacobs stated that in terms of corruption – Did SAMA think that section 21(k) spoke enough about the prevention of corruption? This prescribed that internal audit structures be set up. With regards to the surveys that were done, were they done with the doctors and the public. What percentage of the 12 000 members participated in the survey that related to the emigration of doctors? The patient satisfaction survey conducted by SAMA did not tell one if the statistics of Medical Research Council and StatsSA that showed that 8.4 percent of the public were satisfied with healthcare currently.

Ms Gela asked what SAMA understood by the term ‘portability of services?’ Did they really think health had gone backward given positive improvements of factors like improved life expectancy?

Mr Munyai asked how SAMA responded to some of their members that were opposed to their position. Did SAMA support the current status quo of the two-tier system which favoured the rich and medically aid funded? In 1994, there were some who claimed that in fear of democratic equal society they wanted to leave and go overseas. The survey on patient satisfaction by SAMA did not tally with that of the Medical Research Council. What type of universal healthcare coverage did they support?

The Chairperson stated that he was not aware that SAMA supported the Presidential Health Compact. The single-payer proposal was actually meant to promote cross-subsidisation and would reap efficiency benefits. What other method would SAMA propose in this regard? It concerned him that Ms Coetzee was not in the presentation the week before, but would have wanted Health Professions Council of South Africa (HPCSA) to have presented a different presentation. The medical and dental board – some of them were members of SAMA – why was she challenging other presentations made to the Committee by another entity? She had an opportunity to present today on behalf of SAMA not HPCSA. He requested clarity on this.

Mr Munyai stated that in an elected democracy, where the party that was elected would want to implement its manifesto commitment – he realised there was concern about the powers of the Minister. The Minister had executive power but was accountable to Parliament – this was no different from any other institution. Had they seen any other interference in that regard. Executive power was accountable. This was the structure of this government. Did the presenters have an issue with the Minister performing his functions as outlined by the Constitution.

Dr Coetzee responded to the questions around the people that wanted to emigrate to other countries. It was important to understand that the reason they wanted to emigrate was because they did not trust the current system. Although they would emigrate and work under another NHI system there – that system was likely trusted by the other country and had been in place for many years. This was deemed preferable by them to working under a ‘pilot’ system.

They could not comment on the StatsSA or the Medical Research Council query; that was a patient survey, whereas they had conducted a doctors’ survey. They could only comment on what their doctors were telling them. About 988 members participated out of 12 000 members – this was a high rate in the medical field as doctors were known not to participate. They intended to follow-up the survey. SAMA was in support of universal health coverage. The NHI was a funding model, it was not the universal healthcare model. If there was not enough funding or frameworks in place – one would have difficulty in implementing universal health coverage. Equal access, did not necessarily mean good quality healthcare – it just meant one could go to a clinic – or a doctor. It did not guarantee good evidence-based treatment. They had numerous interactions with their members – in terms of the survey – and getting their opinions relating to NHI.

Dr Mzukwa stated that they all supported the principle of universal health coverage. South Africa had decided to use the NHI as the vehicle. SAMA supported NHI but raised several issues relating to the Bill, as presented in the presentation. In terms of the issue around asylum seekers, it was not a simple question they could answer then. In terms of the discussions that had taken place in the Association, they were concerned whether the Southern African Development Community (SADC) – could come up with a way of funding asylum seekers. Even now, people were coming from other countries to seek healthcare in the country. People were crossing provinces to access healthcare. It was not proper for a doctor to be chasing away an asylum seeker because they were not covered. They were trained to attend to them in terms of their ethics training. Regarding the issue of the Minister’s powers – he suggested they separate the position from the person. They had no issue with the current Minister. They did not want to personalize the Office of the Minister. It needed to be considered objectively. Regarding the appointment of board members, and even some committees of the board, it would be problematic if the board members then chose their strategic committees. There were many issues highlighted in their presentation in that regard.

Dr William Oosthuizen, Legal Advisor, SAMA, noted some hostility in the asking of some of the questions, which was unfortunate given that they were trying to provide insight to better the system for all. Their members just wanted the best for their patients. That was what they were trying to do. In terms of corruption, they supported the investigative unit that would be established. Their concerns related to investigating corruption from within – that there might not be enough independence. They had seen the corruption relating to the Personal Protective Equipment that had taken place. There was also the Zondo Commission – which was ongoing. It seemed that parliamentary oversight was not always enough to combat some of the issues. It was something they took very seriously. Every penny stolen from the population and the health system was a penny that could cost someone their lives. He did not just want this to be dismissed as people just making noise. This was a serious concern and it needed to be taken seriously. There was a severe lack of trust – it did not happen overnight. Many of their members had been the victims of corruption and mismanagement of the systems. He hoped that the Committee would take these concerns seriously and start to think about ways to implement so that they had a universal healthcare system that provided quality healthcare for all of its citizens.

Ms Shelley McGee, Health Policy Analyst, SAMA, addressed the issues raised regarding the certification and accreditation of facilities. It was concerning to them that only a small percentage were accredited – however there was also a lack of emphasis on quality of care in the Bill. They were involved in pillar five of the Presidential Health Compact. That was focused on the quality of services. They had been quite involved with structures within the government and supporting the government to drive around the Bill and implementation thereof. There were efforts being made to improve quality to get facilities up to scratch in terms of accreditation.

SAMA had not conducted patient surveys – they were certainly not comparing them to the Medical Research Council surveys – she apologised if the slides were confusing to members. They did not report any patient information – it was all based on their doctor surveys. In terms of the failure of the pilot project – there were a lot of learnings for them in terms of the pilot projects. It was not that they were a failure – they were not designed to achieve anything specific. The pilots started back in 2012. They did not forge forward with any kind of outcomes in mind – thus it became difficult to measure those outcomes once they came to look at them. In their submission, they suggested that pilots go forward before mechanisms were built into the Bill. The pilots would need to be properly designed with an outcome in mind and clear objectives.

The meeting was adjourned.