The Committee was briefed by Professor Olive Shisana, Head of the High Level Panel (HLP), on the state of the health sector in South Africa, and the challenges faced with the implementation of the National Health Insurance (NHI) scheme.
She said those with the worst access to health care were people in the lowest socio-economic group. Poor people were less likely to access good health care, despite the fact that it was very much needed. They would be found making use of services at primary health care (PHC) facilities and community hospitals, and seldom visited tertiary and academic hospitals, even when those services were available in the area. The poor were faced with several challenges to access health care. The cost of traveling was a barrier, as the health care facility could be far from where they lived. Medical scheme contributions remained unaffordable to them. Another challenge was the low morale of staff and their attitude towards patients.
Prof Shisana gave a detailed presentation on the principles the NHI sought to achieve, the benefits of a National Patient Information System, the role of community health workers, membership of medical aid schemes, and the challenge of providing adequate medical facilities in rural areas.
Members recounted experiences indicating concern at the quality of health care available to poor and rural communities. They asked why courses from emergency medical services (EMS) paramedic personnel had been stopped, as they provided a vital service. They laid the blame for the current “crisis” in the health sector on poor management and leadership. They recognised that the population was growing while financial resources were shrinking, and questioned why there was no control over foreign nationals receiving free medication at local facilities. The NHI had been piloted for nine years, and a Member asked if it would remain a pilot scheme for ever.
High Level Panel (HLP) Recommendations: Health
Professor Olive Shisana, Head: High Level Panel (HLP) said the main thrust of the presentation would be on the implementation of the National Health Insurance (NHI) scheme, taking into consideration factors such as the state of health care of the South African population and access to health care.
South Africa had exceeded its targets for improving the health status of the population. Life expectancy at birth had exceeded the 2014 targets by 2012, while the overall adult mortality rate had also decreased much faster, so there had been fewer deaths and funerals in the country. Under-five mortality, infant and neonatal mortality, had decreased by 10%. These dramatic changes had been ascribed to the government’s programmatic efforts which led to widespread availability of free antiretroviral therapy, free prevention of HIV transmission from mother-to-child programmes, and free immunisation against pneumococcal pneumonia and rotaviral diarrhoea in infants. However, during this time, problems with non-communicable diseases, such as diabetes, hypertension, cardiovascular and cancer had increased.
Health rights were entrenched in the Constitution -- ‘everyone has the right to have access to health care services, including reproductive health care’ – but the HLP had many questions as to why there was inequitable access to health care. Those with the worst access to health care were people in the lowest socio-economic group. Poor people were less likely to access good health care despite the fact that it was very much needed.
Specialist referral services remained less available to the poorest people. The poorest people would be found making use of services at Primary Health Care (PHC) facilities and community hospitals. The poor seldom visited health care at tertiary and academic hospitals, although these services would be available in the area. However, the poor were faced with many challenges, such as accessibility to tertiary and academic hospitals. Although these facilities existed, the poor continued to be unable to access them at the same level as those people who had the resources. The HLP found that more challenges were faced by the poor when their medical aid insurances lapsed, even though they could still make use of the public sector higher level services.
High levels of unequal access to health existed in the lowest socio-economic group in certain provinces compared to people living in the Western Cape or Gauteng, who received better health care. People who lived in the rural areas of the Eastern Cape and Limpopo were faced with the worst access to health care services.
The poor were faced with several challenges to access health care. The cost of traveling was a barrier, as the health care facility could be far from where they lived.Medical scheme contributions remained unaffordable to them. A general practitioner (GP) might be located near to them, but these services remained unaffordable to them.They were then forced to travel past the nearest GP to go long distances to a clinic where they were most likely to receive health care for free.
Another challenge was the low morale of staff and their attitude towards patients. The morale and attitude of health care workers should be noted with serious concern. Staff might be unhappy with their working conditions, which results in a negative impact on services rendered to people. An estimated 16% of the South African population has medical aid.
National Health Insurance (NHI)
Professor Shisana said that the views expressed by people from all walks of life throughout the country’s nine provinces called for the implementation of a National Health Insurance (NHI) scheme. Strong submissions were made at public hearings, particularly from the Congress of South African Trade Unions (Cosatu), who called on the government to implement the NHI as a matter of urgency. Cosatu had expressed the view that it was necessary to ensure health services for poor people.
Although there was no unanimity on the population’s views, the overwhelming majority of South Africans said they wanted a NHI scheme. The written submissions from FirstRand, Econex, the South African Institute of Race Relations and Medi Clinic, and comments made at public meetings, indicated that the implementation of NHI would hold many risks, such as challenges with funding.
These risks and challenges referred to had been articulated in the Government White Paper on the NHI, which was already a policy for the country, and both views had been presented. The written submissions made by several sectors which expressed risks and challenges for the implementation of the NHI, remained the views of a minority. The overwhelming number of submissions from the public gathered from throughout the nine provinces during a road show, were in favour of the implementation of a NHI.
There had been consensus that NHI should seek to achieve the following principles:
- The right to access health care: The NHI would ensure access to health care, as it was considered to be an important service which the State must be able to provide.
- Social Solidarity: The NHI would provide financial risk pooling to enable cross-subsidisation between young and old, rich and poor, as well as the healthy and the sick. This would mean people taking care of each other as South Africans. The solidarity principle would also serve as a guide towards the development of the NHI.
- Equity: The NHI would ensure a fair and just health care system for all. Those who were ill should get services first.
- Health Care As A Public Good: Health care should be seen as a social investment and not as a commodity of trade to be sold for profit.
- Affordability: Health services should be procured at a reasonable cost. Should the cost be prohibitive, this could lead to the NHI not being able to offer health care to the whole country.
- Efficiency: Health care resources should be allocated and utilized in a manner that optimised value for money. The HLP had made it very clear that resources allocated to the NHI should be used appropriately.
- Effectiveness: The health care interventions covered by the NHI would result in desired and expected outcomes in everyday settings. South Africans traveling through the country and in a need of health care, would see that the same treatment one would receive in Dzidane would not be inferior to the treatment received in the Western Cape.
- Appropriateness: Health care services would be delivered at appropriate levels of care through innovative service delivery models and would be tailored to local needs. The health care services should take into account the cultural and social requirements within a particular area.
Professor Shisana said in line with the concerns raised by the HLP, recommendations were made to Parliament to express its support for the introduction of universal health care coverage, underpinned by these eight principles.
National Patient Information System
South Africa needed a unified health system to monitor equitable service provision to ensure that every citizen received the same standard of health care, whether in the public or private sector. Such a system could not materialise without a National Patient Information System. This would merely serve to monitor whether the services provided by the NHI throughout the country would be the same, equitable and accessible to the people.
The National Patient Information System would also work in the interest of Parliament, with information on the following:
- Whether government was indeed eradicating the legacy of apartheid in terms race;
- Access to health care;
- How government was dealing with the gender issue;
- Distribution of aid;
- Whether the patient belonged to a medical aid or not;
- Where the patient lived in a rural or urban area/public or private facility;
- The social and economic status of the patient.
The HPL would like to see the above variables legislated, to assist in finding out whether the government was getting anywhere near to ending the existing inequality in the health sector. The data systems of the public and private sector should be collated and placed on a data base which would enable the patient to access health records throughout the country.
Community Health Care Workers
Professor Shisana said the HLP had expressed concern that South Africa was not moving at a fast enough pace to improve primary health care service delivery, and called on the government to institutionalise the ward-based outreach teams, the community health workers (CHWs). Community based care and health care could be improved with the implementation of the Community Health Programme. International evidence had proved that CHWs had made considerable contributions to improved health outcomes.
The long-term sustainability of a universal health system should be closely linked to the effectiveness of preventive and promotive interventions. This should be seen in the light of the growing burden of morbidity related to non-communicable diseases, such as diabetes and high blood pressure.
The role of community health care workers was to reduce the burden on the health system by visiting and treating people at home with matters they could treat, and training people at the home level to test their blood pressure and sugar levels themselves. The CHWs had proved to be effective and key providers of preventive and promotive health services.
The HLP had made recommendations that Parliament introduce legislation to allow CHWs to be formally employed within the public health system, and that they should be based at all Primary Health Care levels.
At a recent health summit held about two weeks ago, the HLP made two recommendations. It had called for legislation for integrated and comprehensive data on resources and services. It had agreed that South Africa needed one health system to ensure that everyone received the same level of health services from throughout the country. The HLP was not talking about downgrading the current health system, but rather about improving it.
Medical aid schemes had made submissions to the HLP on factors which had led to the raised cost of medical insurance. These included the requirement that each medical aid retain 25% of its annual expenditure in reserves, which they believed caused the bankruptcy of many medical aid schemes, as they were unable to invest the 25%. That situation had to be re-evaluated to establish whether the risks could be more efficiently managed, for capital to be utilized, and the Council of Medical Schemes should consider reducing the fees to consumers.
Reforming health care system to improve quality
A the meeting on 24 August 2018 and the subsequent health summit, where the President and Deputy President made presentations on the health system, the HLP had admitted that the health system remained in a crisis.
To sort out the health system, the following recommendations were made:
- To centralise the allocation of health care resources, as once resources left the national government and went to the provinces, premiers might decide to allocate health money elsewhere.
- Establish public agencies for strategic services, quality assurance and other functions outside the Department of Health (DoH). A quality assurance body, known as the Office of Standard of Compliance, had been formed to ensure the delivery of services, and their quality. A proposal was made for a strategic partnering, which had become a global method along with a national insurance fund. It was also known as strategically purchasing services, a fundamental change from the way in which the health system was currently operating. Such a National Insurance Fund to which the money was directed, would be responsible for allocating the money to a specific service provider on a contractual basis. The service provider would be responsible for delivering the quality services as required.
- To build more clinics and hospitals, especially a new hospital for Gauteng. The HLP noted that during the government’s first five years, the state had managed to build about 700 clinics, which was more health facilities than what had been built now.
Concerns had been raised by the HLP that many doctors and nurses could not find employment due to insufficient budget in the public sector. The HLP recommended that the private sector be allowed to train and employ doctors and nurses along strict training guidelines. The employment of doctors and nurses in the private sector could assist with the alleviation of acute shortages of health care professionals in the country.
Professor Shisana said the lowest socio-economic groups in the poorest provinces continued to make the least use of health services. This could be due to the fact that of inadequate facilities, inadequate human resources and shortages of essential medicines. The HLP had made the following recommendations to Government:
- To build institutional and management infrastructure and skill levels of the public health sector by decentralizing the management authority to the individual public hospitals.
- To centralise the allocation of healthcare resources, by giving the power and authority to the individual hospital or clinic to do repairs where necessary.
- That the Department of Health establish public agencies for strategic purchasing, quality assurance and for other functions.
Membership of medical schemes
The HLP health summit had discussed two recommendations on the whether membership of medical schemes should be voluntary or mandatory.
The first recommendation was that medical schemes should be mandatory for the employed; those who refused would obviously have a problem in terms of accessing medical care. The employer should offer a panel of various medical schemes to employees to choose from. The HLP also discussed that it should be mandatory for employees to belong to a medical scheme to subsidise medical care for the poor.
The HLP also made a suggestion for a two tier system:
- That the employed be compelled to pay for themselves through a medical scheme; and
- That the National Health Insurance cater for the poor.
Based on international evidence, the HLP raised concern that membership of mandatory medical schemes could lead to inequality in health care between the unemployed and the employed population group. The inequality would arise from those who earned more enjoying a better health scheme, while those who earned less would register with a cheaper medical scheme. The unemployed group would not have access to quality medical care.
Professor Shisana said the HLP suggested that clear lessons should be taken from what was happening in other countries such as in Latin America, Germany, South Korea, etc, who started with a system in which only the employed were covered by a medical scheme. These countries had difficulties in changing their health system as people questioned why they should pay for health care for others. The HLP had reminded the health summit that social solidarity could not be implemented under a mandatory medical aid scheme system.
The HLP advised it would be better for South Africans to decide whether they wanted medical aid or should not be forced to have it. The HLP made the following recommendation to Parliament:
- That Parliament address the matter by setting up an Independent task team.
- Such a task team should include all role players in the private and public sectors,
- That the task team should evaluate whether there should be legislation on voluntary or mandatory medical aid.
Maldistribution of health care professionals
Professor Shisana said concerns were raised by the HLP at the Health Summit that many health professionals were employed in the private health sector, whereas they could assist with improving the quality of health care in the public sector. Health professionals were mostly located in urban areas, especially metropolitan areas, whilst there remained a lack of health professionals in rural areas.
A similar situation existed with community pharmacies, which were also mostly located within particular provinces in urban areas, and not as much in rural areas. There were eight times more pharmacies in resourced districts than in under-resourced areas. The HLP also called for the certification of newly qualified health professionals and for the regulation of licences to new pharmacies. The HLP admitted that the call might be viewed as controversial, but it was a necessary method. Based on the above concerns, the HLP proposed amendmends to the Medicines and Related Substances Control Act and the Pharmacy Act, and made the following recommendation to Parliament:
- That Parliament enact legislation which required the National Health Act regulations to be developed and promulgated to introduce a certificate of need for newly certified health professionals.
- That it also enact legislation to regulate the licences of pharmacies to ensure that new pharmacies should be located in areas where needed.
Ms E Wilson (DA) agreed that government has decreased adult mortality and infant under five mortality. There was a growing population in South Africa, but health services have not grown at the same pace, which was a serious concern. The Constitution states that the state must take reasonable legislative and other measures within the available resources to achieve progressive realisation of citizens’ health rights, but the country did not have these “available resources.” It was severely under-resourced. A basic right was that “No-one may be refused emergency medical treatment,” but currently there was one Emergency Medical Services (EMS) professional paramedic per 25 000 South Africans. It was severely challenging. The EMS had started with I, 2, and 3 courses, and the paramedics worked through a whole range of short courses. As they took these courses, they had built up qualifications and gained the expertise to deal with certain situations to become an EMS. There was now a situation where all of these short courses had been stopped, and one could no longer take short courses to qualify. One had to go to universities, special colleges, or the Cape Peninsula University of Technology (CPUT).
In the Free State, 200 students had gone to qualify as EMS and care workers, but the curriculum had been found to be not acceptable, and none of these students could be certified. There were a lot of complaints. Many people had over the years completed lots of short courses and could no longer offer their services as medical care personnel, which they did voluntarily as they cared about their community. They were no longer recognised as a professional, which was a concern for me.
Equity required the NHI to ensure a fair and just health care system for all. However, she had visited a clinic in Limpopo last week where three babies were born over the weekend by a cellphone torch light. There was no electricity, no water, the fetal monitor and sonars were not working; there was not an incubator and the suction machine was not working. One of the babies were born in severe distress because it could not be monitored while being transported from Mokopong to Mkalakwena That baby had died because the staff had not been able to pick up that it had to be born by caesarean section because of the level of distress., and not by normal birth. She was terribly concerned when she hears that members of her community had been subjected to treatment like that in their local clinic.
One had to look at the resources first, because one could not institute a NHI if one did not have adequate resources to do it. One of the issues raised had been to get the private sector professionals to assist in the public sector, particularly in the rural areas. The Department was currently sitting on R56 billion of medical malpractices cases, excluding the legal fees. The Committee visits hospitals on a regular basis, and some of the conditions it uncovers are quite horrific. One could not encourage health professionals to work in the public sector if they have to work under those conditions and expose themselves to potential malpractice cases. The could not work in an area which is under resourced, with no fetal monitor, and where machinery does not get calibrated and does not work.
On the one hand, the health sector is severely under-resourced -- no money for infrastructure, no money for building hospitals, and no money for proper equipment for the health facilities. One the other hand, poverty has increased, and unemployment is at the highest level ever in this country, so one situation was being created, while another situation was collapsing as a result. A lot more had to be done. South Africa cannot progressively improve its health system without progressively improving the resources and infrastructure. She was pleased that the HLP agreed that the health system was in a critical situation and on the verge of collapse.
Ms L James (DA) said she did not think that there was anyone in the Committee who could refuse health care to communities. They were aware that health was in a crisis, and commended the HLP for making very good recommendations. How did the HLP think the NHI could be implemented? Would it remain a pilot forever, especially looking at the challenges? For how long would it remain a pilot, because the NHI was desperately needed by the people? She fully supported the community health worker programme and said that no country could rely on a curative system only, as it was too expensive. There had to be prevention and management as well. She supported the educational interventions, especially in public health facilities, as people did not know how to manage their high blood pressure, how to manage as a diabetic, how to inject themselves and how to take their medication. People really needed education and also monitoring, so there was communication between the people and the facilities. It took some parents a long time to understand that their child was on drugs, as they often thought the child was sick (umfunyani). More education and advice on health was needed so people could manage their wellbeing without going for treatment for petty illnesses.
Dr P Maesela (ANC) commented that an NHI was supposed to cover everybody, regardless. Health was a constitutional right, but if one still wanted to have an elitist grouping somewhere, one could have one’s own medical scheme. Those who have would always victimise those who do not have. If the NHI is compulsory for everybody, one can go where one wants to get treatment and the insurance will pay. Individuals could also always pay extra for an extra consideration -- like having your cake and eating it. He recommended that the emphasis should be placed on communal health centres, instead of regional and tertiary health facilities. These should be well equipped and of high quality so that medical personnel can be trained to deal with specialised situations that cannot be dealt with at the policlinic level. He also urged that training should be carefully related to the country’s needs, to avoid a waste of resources.
Mr A Mahlalela (ANC) said that one of the reasons the use of health services was the lowest amongst the poorest was that health services were inaccessible to most of the poor, and those in rural areas. How would the implementation of the NHI address this matter? The NHI would not change the socio-economic conditions of these people -- they would still remain poor – so the challenges that make it difficult for them to access health care services would still be there. He asked how the NHI would address challenges of the staff morale, which was a big problem. Interventions should be put in place to enable them to do their work, raise their morale and create a conducive environment to provide services to the community. He commented on the issue of affordability in the mandatory medical scheme, saying that the biggest problem was the affordability, and the result was that poor people would not be able to join. Another challenge was that health professionals were unwilling to work in rural areas, so conditions should be improved to draw them to these areas. He questioned whether it should be mandatory for health professionals to work in rural areas, commenting that it was within their rights to decide where they would like to work and stay. He supported the proposal by the HLP to have community health care workers absorbed into the health system, but said he was not sure if this would require legislation so that they could become part of the public service.
Mr S Jafta (AIC) said he also wanted to check what could be done to boost morale and improve the attitude of the staff.
The Chairperson said there were urgent health sector issues which the HLP should have raised in its document. It was a known fact that management and leadership were the key factors in the health environment, and she had failed to pick up what the HLP expected from Parliament, and what the recommendations were which the HLP wanted Parliament to address. Ms Wilson had described the challenges which were happening, and she had just received an sms that two babies had died in a particular province because there was no oxygen. She asked Professor Shisana what she thought Parliament ought to have done, or should be doing. She was of the view that it was not all about resources, but also a lack of leadership. She quoted the HLP’s statement that “the health sector is in dire straits because the population has increased,” and said the health sector had been accused of not providing proper health care to foreigners in the country. Had the matter of foreigners come up during the HLP’s hearings, and what would it suggest for South Africa to improve on the situation?
Ms Wilson referred to the recommendation that the health budget needed to be re-assessed. It had been cut by R9 billion, which had caused a severe impact because sick people could not work and sick children could not learn. When one could not offer health services, it had a major effect on children’s educational progress. She remarked that there were no recommendations on prioritising health, why it should be prioritized, and reasons why budgets should seriously be re-assessed. The point she wanted to raise, which was also mentioned in the Auditor General’s (AG’s) report, was that the biggest struggle was the total lack of leadership, capacity and ability to manage. These were important factors, and that recommendation was not there.
Prof Shisana said the HLP was clearly engaging with health on a multi-sector basis, and not just dealing with health separately. This was why the Presidency had brought together all the government departments that had anything to do with health, whether it was public works, education, public service and administration, or health. The realisation was that one could not deal with health separately without taking into account other factors. The President’s approach now was to bring all the partners together, and therefore there had been a meeting on 24 August with the key stakeholders. At that meeting there had been an agreement that there was a crisis in the health system, so some of the questions being raised were within that context of a multi-sectoral approach.
Replying to Ms Wilson’s concerns on the state of the clinic in Limpopo where a child had died because there was no electricity or water, she said these were issues which could be addressed in the health sector only if one broke it down together with other sectors. The provision of electricity and water was the responsibility of other departments, and that was the real challenge to the health system.
Regarding the NHI outsourcing, Prof Shisana said no facility could become part of the NHI unless it had met the requirements of the Office of Health Standards Compliance (OHSC). This meant that all aspects of management, leadership and infrastructure-related requirements, had to be certified before the facility would be contracted. Facilities would be required to demonstrate that they had enough human resources, infrastructural equipment and trained people, and understood what they were supposed to do to ensure they would deliver quality services on the basis of primary and secondary care levels.
On the question of paramedics and community health care workers, she replied that wrong decisions had been made to recognise only certain professionals as health professionals. She said the health workers -- the doctors and nurses -- viewed paramedics and community health workers as not being qualified enough, and had failed to realise the dangers and detriment to society when they pushed them aside. Commenting on the training and courses which paramedics and community health workers underwent, she admitted there were no clear curricula as to what community health workers and paramedics should be learning and where they should be placed.
The HLP felt it was necessary to have legislation on community health workers in order to deal with them and ensure that the Health Professions Council recognised them. There existed professional jealousy among doctors and nurses which influenced them to protect their own turf, saying that health workers’ education allowed them to do only certain things. To eliminate this situation, the legislation of the Council should be changed to allow other professionals who were helpful to the health system to be recognised.
Replying to the question about malpractices and legal cases against the state, Prof Shisana said the electronic information system on patients would be an option to reduce the number of cases. Such a data system would provide the patient’s complete medical history, and was less likely to go missing compared to files which were taken from one facility to another.
Regarding the implementation of the NHI without resources, she said it would be implemented at a facility which had received its licence and accreditation. This would take place on a progressive basis and there would be no “big bang” approach due to the lack of resources. It would take place facility by facility, and as the budget for health was increased.
Referring to Ms James’s question as to when the NHI would be implemented, Prof Shisana agreed that the Department of Health had been piloting the scheme for nine years, which had not worked out. Reasons for the failure could have been that the Minister had experienced many obstacles and now that the President had taken leadership of the NHI, it was starting to take traction. National Treasury and the HLP had met to look at ways on how to implement a budget for NHI, and Treasury had provided the HLP with a document containing guidelines as to how government would fund the NHI. Once the Bill got adopted in Parliament, hopefully soon, it would allow the NHI to set up a Fund. There would be a quality improvement plan, which had been presented to a meeting of all key stakeholders in August on how the plan would improve health services. The plan was focused on standards to provide quality care according to international standards. It would be implemented at every facility and enable a well-functioned hospital to train a very poor clinic, which was unable to provide quality care. This particular clinic would then be monitored over a period of five years, to assess whether it had become sustainable and if the quality of health care services had improved.
Referring to the status of community health care workers, Prof Shisana said said the HLP recognised the need to improve their skills and to develop an appropriate curriculum. They were busy with processes to train community health care workers in a more structured way with a common curriculum which would allow them to be incorporated into the health system.
Commenting on Mr Mahlalela’s concern on the implementation of the NHI, she said everyone should be clear that the NHI was a national policy. Medical schemes would provide complementary services without duplicating the services provided by the NHI. The HLP agreed that medical schemes should be voluntarily and not mandatory.
She said there were many community health care centres throughout the country which were supposed to provide comprehensive health services, beyond what the clinics were providing. On human resources, she said the Department of Health had a strategy for human resources, but not an operational plan to provide the necessary training.
Responding to the question as to how the NHI would make health care accessible in rural areas where resources were scarce, she said the provision of resources started with Members of Parliament. South Africa spent about 8.5% of the gross domestic product (GPD) on health, and some of this money was paid to some MPs by the government to have health care in the private sector. The NHI wanted to bring back the money which could be used to provide health care to people in rural areas. If people were concerned about equality and equity, then it had to start at Parliament. She called on MPs to demonstrate to the nation how much care they had for the rural and unemployed people. Thereafter, government could approach other spheres and entities like the South African Police Service (SAPS), Eskom, Transnet, etc, to bring money into the NHI. She said there was enough money in the country, but it was not being spent well due to fragmentation.
Prof Shisana attributed low staff morale to the fact the some staff members were owed money by the state for overtime work, or the implementation of salary increases, or that the infrastructure at the health facilities were not in good condition -- such as leaking roofs, and lights which were out of order in the theatre. The NHI would be responsible for ensuring that the certified facility was capable of providing good services and was accredited to provide quality health care.
Commenting on health professionals who refuse to work in rural areas, the HLP suggested that people in rural areas should be trained in health care to serve the people where they lived. The Cuban programme had medical students to Cuba for training and on their return they served their own rural areas.
On the question of too many doctors concentrated in certain areas only, Prof Shisana questioned why licences continued to be issued to doctors who trained in such areas. The NHI would also produce a contract to doctors, stating posts available only in the rural areas. Conditions and infrastructure at rural health care facilities should also be of good standard to make it comfortable for doctors to work there, but it remained a choice for doctors whether to work in rural areas or not.
Medical schemes argued in favour of the high costs, as they reported that more and more people visited doctors for minor illnesses. Prof Shisana commented that medical schemes tried to justify the high costs for reasons they believed in. However, what was obvious was that medical administrators were able to purchase very expensive and luxury vehicles, yet medical schemes were supposed to be non-profitable. The HLP had called for the cost of medical schemes to be reduced, even before the implementation of the NHI.
Regarding leadership and management, she agreed that management needed to undergo changes. The NHI Bill which had been circulated for comment, had outlined a new model for management at hospitals. The Bill had recommended that chief executive officers (CEOs) at hospitals be given the authority, responsibility and autonomy to run their hospitals on the budget provided to them.
On the issue of foreign nationals who received free medication in South Africa, she said it was a known fact that at the end of every month, many foreigners entered South Africa to obtain free antiretroviral drugs. In order to put a stop to this practice, the NHI would introduce an identity system which would be linked to the patient information system, which would then identify whether the patient was South African or not. However, legitimate foreigners and asylum seekers would have access to medication, and tourists should have their own medical insurance.
On the question of the NHI budget, Prof Shisana said there was a need to investigate why the cost of building government clinics was much higher than that of private clinics. In this way, government could easily identify the wastage and it would help to determine a budget for the NHI.
Ms James expressed concern as to how clinics would be certified without having a budget, and to make sure staff would get paid. She also asked for clarity on the position of environmental health practitioners at clinics, as they formed part of prevention and interventions.
Mr Mahlalela asked when the NHI would be implemented. He hoped there would be no procrastination over the implementation.
Responding to Ms James’s concerns as to how clinics would pay their staff without a budget, Prof Shisana it would mean re-prioritising the budget to address the problems health facilities might have, such as shortage of staff, equipment and the infrastructure. Specialists would be deployed to facilitate training and provide expert advice on matters involving patient referrals. She confirmed the need for environmental practitioners, as they were very important. The HLP also had a general plan which brought in an international funding organization with experts from countries who had implemented the NHI, to share their expertise.
She assured Mr Mahlalela that the implementation of NHI would take place very soon.
The Chairperson said the Presidential Health Summit had been the first of its kind to be held in South Africa, which brought together all role players in the health sector. She urged those in the health sector to work together as a family and not in isolation. The issue of health workers “protecting their turf” indicated a mentality that was of no assistance to the development of health care in this country. She would like to ask the Office of Health Standards Compliance who cared for the carers. She noted an incident where health workers at a hospital in Johannesburg had been physically assaulted by visitors who had come to see a patient.
She commended the Office of the Presidency, the Department and all other role players who had ensured action on the NHI. She suggested that the Office of the Presidency and the national Department of Health also address the nation to provide citizens with a clear understanding of the processes leading towards the implementation of the NHI.
The meeting was adjourned.
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