National Health Insurance (NHI) Bill: public hearings day 8

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Health

22 June 2021
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Video: Portfolio Committee on Health, 22 June 2021
Audio: National Health Insurance (NHI) Bill: public hearings day 8 

NHI: Tracking the bill through Parliament


In this virtual meeting, the Committee held public hearings on the NHI Bill. Eight organisations presented oral submissions. All the entities welcomed initiatives to improve access to quality health care services to all South Africans and proposed a number of amendments to the Bill.

The Collaboration for Health Systems Analysis and Innovation outlined the concept of a ‘learning health system’ and emphasised the need for strengthening the health system. Its central concerns about the Bill were the contracting and accreditation of facilities, Fund governance and autonomy and the lack of clarity on implementation. It was emphasised that the Bill proposed a hospi-centric approach to healthcare. It was suggested that principles of primary healthcare needed to be made explicit in the Bill. The level of inequity was highlighted as a significant concern as well as the need in light of this for national health coverage.

Committee members asked if the Bill should unambiguously state that the goal of National Health Insurance (NHI) was to strengthen, build on and complement the current public health sector and by implication leave the private sector alone; if the front-loading concern took into account learnings from other contexts; if additional pilot projects should be carried out. Members noted that precedents on governance and funding would be invaluable to the Committee.

The Alliance of South African Independent Practitioners Association raised some concerns about the Bill, but emphasised support of the principles and commitment to universal healthcare coverage in South Africa. It emphasised that more detail was required about the financial viability of the NHI Fund, referral processes and the Contracting Units for Primary care. There were concerns about the single purchaser model, specifically the monopolistic structure, its governance and lack of detail on administration. It expressed willingness to assist with pilot studies to determine which funding models would be best suited for NHI.

Members asked if clause 48 and 49 of the Bill was not sufficient to ensure the sustainability of the Fund. Clarity was requested on the move from a patient to person-centred approach. It was asked if the detail on the basket of services could be covered in regulations. It was asked if clause 10 of the Bill did not adequately cover the presenters’ concerns about the administration of the Fund. The Committee asked what the Association wanted to see in the implementation plan. It was asked if the Association was comfortable with the current two-tier inequitable health system.

The Self Care Association of South Africa supported universal access to healthcare and the NHI, but not in its current format. Their concerns centred on the implications of the Bill on the pricing of self-care Schedule 0 products, which were presently exempt from medicine pricing regulations. It noted that many benefits would be available under NHI in self-care categories and this would impact the private sector and medical schemes ability to provide such care. Concern about governance structures was highlighted. Its central concern was the Bill’s potential impact on people’s ability to access over the counter medication.

Members emphasised that the Bill did not exclude competition and reference was made to clause 37. They asked how the Association proposed to manage the unregulated over-utilisation of self-medication and if this had the potential to bankrupt the Fund; if small retailers, like spaza shops, should be subject to accreditation, in claiming from the Fund; how those smaller retailers were monitored. Members suggested that the Association’s understanding that the Bill would result in prices being regulated for all medicines was incorrect. Members asked if over the counter drugs should be funded through NHI.

The South African Private Practitioner Forum emphasised that it did not support the Bill in its current format. The Forum’s main concerns were about quality of healthcare, contracting of specialists, treatment protocols, governance, medico-legal litigation, access to healthcare, and corruption. The Forum recommended that clinicians were included on the Benefits Advisory Committee to inform the basket of care services and protocols. It emphasised that outpatient care services needed to be included. The Forum supported the maintenance of a private sector in the health system to contract services for NHI. It suggested that the fraud unit include the functions of mitigation of risks and investigation.

Members questioned why the Forum felt quality was not covered in the Bill when it was stated in clause 55. They asked the Forum’s understanding of clause 38(2)(a); where it saw the Bill failing, in implementation. They asked what specifically concerned the presenters about medico-legal claims. They asked what the biggest barriers to access were. The Committee questioned why low cost and high quality could not occur concurrently. They asked if the Forum was supporting a hospi-centric approach. They asked if ambulatory care was not sufficiently covered in clause 41 of the Bill. The Committee asked what continued medical aid scheme involvement would look like for national health coverage.

The Institute for Race Relations said that a proper socio-economic impact assessment should have been carried out in line with the Constitution. It should have explored different funding options and healthcare frameworks as well as take into account the South African socio-economic context. It noted that the 2019 Report had not explored these options, it was outdated in implementation costs and the status of the economy from the COVID-19 lockdowns. It suggested that the Bill was based on false assumptions in the potential cost. The warnings of the Davis Tax Committee were emphasised, specifically that the implementation of the Bill and the Fund were unsustainable. It highlighted that the Fund would result in increased corruption and the implementation of the Bill, as it stood, would be unconstitutional in that it would not provide access, as suggested, due to insufficient exploration of the implementation and sustainability thereof.

Members highlighted that there was an extensive socio-economic impact assessment done in 2019 which examined the risk. It emphasised that the National Health Service was implemented after the Second World War in strained economic conditions. They asked if the Institute subscribed to the principles outlined in the preamble of the Bill; why SAIRR made reference to the Davis Tax Committee and dismissed the Health Market Inquiry recommendations. They asked if it was aware that the bulk of the funding was already in the system; that the administrative costs were suggested to be under 2% of the overall cost. They asked the Institute’s position on the coverage of foreign nationals under NHI.

The Health Promotion and Development Network highlighted the need for more emphasis on health promotion in the Bill. Additions to the Bill were proposed and concerns about the economic costs were outlined. It suggested that more detail was required on the composition of the Board and suggestions were made on this. It noted that the Bill took a curative approach to health.

Members asked for examples where health promotion and disease prevention were left out of the Bill. They asked if the National Health Commission, advocated in the NHI White Paper, would fulfil the proposed role that it put forward to address the concern. The Committee understood that the Commission would be funded separately, outside of the Fund. They asked if health promotion was not covered by the Bill’s reference to comprehensive healthcare services.

Counselling Psychology of South Africa focused on referred pathways, geographic availability of mental healthcare services and fair payment services. A number of recommendations were made about these concerns. It suggested that counselling psychologists were frontline practitioners and the reliance on referral pathways would result in unnecessary cost. Geographic availability concerns were specifically about access and it was suggested that counselling psychologist in private practice should be contracted to provide mental healthcare within the vicinity where patients lived. It emphasised that patients should have the freedom of choice to elect their practitioner in terms of location, access and credentials of counselling psychologists.

Members requested clarity on the statement ‘meaningful contribution to mental healthcare needs.’ Clarity was requested on the Consumer Protection Act gaining its authority from the Constitution. The registration of children was noted and clarity was requested on what it found to be unclear about this in the Bill. They asked how the redistribution of psychologists could take place. They asked if counselling psychologists considered themselves to exist outside the multi-disciplinary approach. They asked why there were not more counselling psychologists in the public sector. They asked how costs associated with the provision of mental healthcare services be structured. They noted that there was stigma attached to mental health which might prevent patients from seeking psychologists as a first port of call. Questions were asked about the disclosure of diagnosis and the potential impact of non-disclosure on statistics.

The South African Nephrology Society focused on the treatment and care of patients with kidney failure and access concerns within the healthcare system currently. The strengths of the Bill were outlined, particularly in the principles and intent of the Bill. The weaknesses in the Bill were that it did not address the current level of infrastructure and management failure; funding mechanisms were vague; the anticipated cost was not known; nor was there sufficient detail about benefits. Opportunities and threats were outlined about the Bill. The Society noted what it wanted to see in the Bill. It wanted to be recognised as a key stakeholder and expert body on services for patients with kidney disease as well as other sector specific needs.

Members asked why the numbers of patients with kidney disease were higher in the Western Cape and Gauteng and reasons for the disparity in cases across the country; how people could find out about organ donation; why South Africa was behind other countries in the provision of dialysis services. The Committee noted the point about the lack of a regulatory framework. They asked the reasons for organs not being delivered on time. Comparisons were drawn between services in China to that of South Africa.

Meeting report

Collaboration for Health Systems Analysis and Innovation (CHESAI) submission
Dr Leanne Brady, of the Western Cape’s Department of Health’s Emergency Medical Services, and Ms Eleanor Whyle, PhD Candidate studying the socio-political evolution of NHI policy in South Africa at the Health Policy Systems Division at UCT, presented to the Committee.

Introduction
• Our submission was made on behalf of CHESAI (Collaboration for Health Systems Analysis and Innovation) - a collective of public health academics, engaged in teaching, research and policy advocacy. We are health policy and systems researchers from UWC, UCT and SUN
• Although the submission was written pre-Covid-19, it is important to learn the lessons of the pandemic, which highlight the importance of many of the issues we will speak about today.

History of NHI in South Africa
• SA’s journey to equitable universal health care has been long, and various proposals have been put forward over the years
• All of these proposals are informed by the social and political context in which they emerge
• It is appropriate that in determining how to structure the funding of our health system, we consider our national values and ideals
• Many of the comments and proposals put forward in our submission, are informed by a concern with the extent to which the Bill diverges from the principles laid out in the 2017 White Paper.

Learning Health System
• The NHI Fund is only one aspect what is needed to achieve good quality, universal and equitable health care in South Africa.
• Some provisions in the Bill not relating directly to the establishment and governance of the NHI Fund (such as the designation of central hospitals as national government components, and the reimbursement mechanisms for emergency medical services ) are overly prescriptive, and will hinder future efforts to reform other aspects of the system.
• Option 1: Remove extraneous clauses of the Bill to allow more time to develop proposals testing and learning as well as through consultation.
• Option 2: Reduce the level of detail and include provision for learning from experience to generate further proposals.

Health System Strengthening (HSS)
• The implementation of the NHI, and the establishment of a single purchaser (the NHI Fund) will affect health system functioning including quality of care of governance of healthcare facilities
• As such, health systems strengthening should form a part of its technical capacity
• We propose that an entire technical committee be established devoted to HSS
• Sub-committees should be established at provincial and district level to ensure bottom-up feedback and learning.

Contracting and Accreditation
• The public health sector is the backbone of the Health system
• The accreditation and contracting procedures as currently stipulated in the Bill could result in de facto privatisation
We suggest that:
• The Bill state unambiguously that the goal of the NHI is to strengthen, build on and complement the current public health sector
• Provisions be made for when public facilities do not meet accreditation standards
• Accreditation processes take into account quality issues typically seen in the private sector
• The Bill include provisions for ensuring the rights of the country’s health workforce are protected under contracting arrangements.

Governance and Autonomy
• The Fund and its Board members should be ultimately accountable to Parliament, and the powers of the Minister should be reduced to minimise the risk of political co-option
• Ensure a balance of political and administrative actors on the Board, including political appointees, technical experts and civil society representatives
• This would ensure that the Fund long-term strategic planning is not restricted to political cycles
• The Bill should be amended to stipulate that decision-making processes of the Board (including the process of appointing Board members) should be transparent
• We propose that the selection process for the CEO of the Board be open (such as that of the SARS Commissioner).

Governance
Technical committees
• We propose that the process of selection for members of technical committees be transparent
• These committees include civil society representation to ensure a range of interests represented.
Advisory committees
• No details are given about the powers of these Committees
• We suggest that the Benefits Advisory Committee include civil society representatives
• We suggest that the Stakeholder Advisory Committee could be used to add a layer of accountability
• To enable this, its powers should be further defined, and its members stipulated to include representation from civil society and marginalised communities

Stewardship for implementation of the Fund
• The Bill is currently silent on the implementation of the Fund.
• The phasing of NHI does not consider how to develop system capacity through implementation and over time. The Bill seems to take a top-down approach to system design and implementation. This will lock the system into ways of operating which may be revealed to be inappropriate or inefficient or result in negative equity consequences in the long term.
Suggestions:
• It is necessary to clarify some basic principles for implementation of the Fund as well as wider health system reforms arising out of the Bill – for example: support for experimentation, the need for learning and evaluation, and resources for capacity development. These should be explicitly stated in the Bill.

Bill has a curative hospi-centric focus
• Inter-sectoral action is necessary to support health promotion, disease prevention and address the social determinants of health.
• It is as important that these receive adequate financing and are not undermined by the way healthcare is perceived and financed under NHI.
• The Bill contradicts the principles on addressing social determinants of health outlined in the NHI White Paper
• Suggested alternatives: In Table 2 of our written submission for clauses ‘Definitions’ and ‘Preamble’ we suggest some alternatives to reflect the spirit of Alma-Ata, and the principles outlined in the 2017 White Paper.

Principles of primary healthcare need to be highlighted in the Bill
We suggest adding the following to the Preamble under the heading ‘In order to’:
Add to second bullet: “Make progress towards achieving Universal Health Coverage and address the social and economic determinants of health”
Add the following additional clauses:
• “Strengthen primary health care, as proposed in the Alma Ata and Astana Declarations of 1978 and 2018, respectively, as the cornerstone of UHC”;
• “Substantially strengthen the current public health system as the backbone of NHI”

Closing Comments
• Inequalities in health and access to healthcare are, in large part a result of the stark divisions of our health system, in which funding is fragmented, giving rise to an overburdened and under-resourced public sector, and an inefficient and largely unregulated private sector.
• The maldistribution of resources between these two sectors constitutes a catastrophic injustice that risks destabilising the foundations of South African society.
• We believe that equity in health cannot be achieved without equitable distribution of health resources (both public and private) and burden of paying for health care based on the principle of social solidarity.
• This is in line with the principle of social justice, and with the Constitution, which holds access to health care to be a fundamental human right, and not a commodity that can be bought by the rich.
• We fully support the goal of ensuring financial protection from the costs of health care, and recognise and support that cross-subsidisation requires the pooling of revenue across sectors and geographical divides.

Discussion
Mr T Munyai (ANC) asked if it was the view of CHESAI that the Bill should unambiguously state that the goal of National Health Insurance (NHI) was to strengthen, build on and complement the current public health sector and, by implication, leave the private sector alone. On the cost of the inequitable distribution of funding – how did CHESAI expect to mobilise additional resources to allow for redistribution to take place?

Mr M Sokatsha (ANC) noted the submission stated that NHI and the establishment of the single purchaser model would affect health systems functioning, including quality of care and governance of healthcare facilities. Were these statements informed by what was in the Bill or not. Clause 39(4) stated that ‘the contract between the Fund and an accredited health care service provider or health establishment must contain a clear statement of performance expectation and need in respect of the management of patients, the volume and quality of services delivered and access to services.’ Did the Bill not create mechanisms to ensure quality of healthcare? The submission acknowledged the long journey of NHI in South Africa; did CHESAI concern about front-loading not take into account learnings from other contexts, such as the United Kingdom and Japan? Those legislative processes were front-loaded.

Dr K Jacobs (ANC) stated that the Bill defined comprehensive healthcare services – meaning healthcare services that were managed to ensure a continuum of health promotion, disease prevention, diagnosis, treatment, management, rehabilitation and palliative care services across the different levels and sites of care in the health system in accordance with the needs of users. The Bill promoted a primary healthcare approach and clearly stipulated funds to be spent and the financial implications of the Bill. There were community outreach service components. Was that not in line with the NHI White Paper?

Ms E Wilson (DA) stated that NHI pilot projects were run a couple of years before. No data was obtained from those pilot projects as there were no measurables, there was no focus nor objectives. Would CHESAI suggest that pilot projects needed to be carried out again? If so, with what focus and what measurable goals? Would this assist?

Ms X Havard (ANC) referred to the statement on the Bill’s divergence from the White Paper. She asked to which clauses specifically they were referring.

Ms A Gela (ANC) referred to the statement that the Bill did not relate directly to the establishment and governance of the NHI Fund. Clause 2 of the Bill stated that the NHI Fund aimed to achieve sustainable and affordable universal access to quality healthcare services. To achieve this aim, clause 7(f) specified the designation of some hospitals to become central hospitals to ensure provision of healthcare services at the hospital level. She requested clarity on this.

The Chairperson stated that he believed that a primary healthcare approach was embedded in the NHI Bill. He was shocked to hear that the CHESAI interpretation was that it was promoting a hospi-centric approach. He requested clarity as it was experienced with research background and knowledge. It would be important to share its views on the application of similar systems in other countries – particularly on what they were proposing. Precedents on governance and funding would be invaluable. He noted that previous submissions had stated that there was not enough detail in the Bill, and yet this submission had suggested that there was too much detail in the Bill.

CHESAI argued that the NHI phasing did not consider how to develop system capacity through implementation over time – was this evidenced based? Clause 57 was devoted to capacity strengthening – had CHESAI familiarised itself with this. The Committee would be interested to hear its input on specific clauses of the Bill. In its proposal of establishing an implementing unit, did it envisage that the CEO of the NHI Fund – as outlined in clause 20 – would cover and support this view? NHI was viewed by many as correcting the past, both in the private and public sector.

CHESAI response
Dr Leanne Brady replied about the NH implementation unit, the main point the submission had tried to make was that it could not be at the central level. It should not be the mandates only of the CEO of the Fund, instead it should be a unit that actively sought to learn from the bottom. The unit should have resources to allow for research to be done while various models were implemented and tested. It was not known how it would play out. The bottom-up learning that could be supported through an NHI implementation unit was critical and should have a range of actors, researchers and policy makers who could feed into the learnings so that things could be adapted and changed as they went. On international precedent, it absolutely supported this. This was one of the emerging ideas of how to implement health system reforms in a way that corrected some of the wrongs of the past and lead to a more equitable health system.

On reducing the details in the Bill, the point was that if they were overly prescriptive about components, where the answers may not yet be known, it could lock the system into unhelpful frameworks. The point would be to keep things open and flexible so that there was space for creativity and change, as health systems were forever changing. Two years before, when CHESAI wrote its submission, none of them could have anticipated the impact of the COVID-19 pandemic.

On the question on leaving the private sector alone and mobilising its additional resources, she was not a health economist and thus could not speak directly to that point. CHESAI was not suggesting that the private sector should be left to continue as it had been. Correcting the wrongs of the past was about governing the private sector in a more active way. The country spent as much on health as some high-income countries, yet the country’s health outcomes failed in comparison. It was not a question of not having enough resources. It was a question of the distribution of those resources. The Fund was seeking to do that.

On the hospi-centric approach of the Bill, CHESAI did not see primary healthcare, as outlined in the NHI White Paper 2017, translated into the current Bill. It was not only about healthcare services in primary healthcare. It was about active mechanisms of public participation as well as addressing the social determinants of health. Those components had been left out.

On the question about doing additional pilot projects, it needed to be recognised that any health system needed to learn as it went. CHESAI was willing to give additional written input to the Committee on the ways of evaluating those sorts of things, if that would be helpful. Rather than additional pilots, it could be useful to think of ways to evaluate ‘as they went.’ The right questions needed to be asked so that measurement could be done appropriately.

Prof Lucy Gilson stated that CHESAI was not suggesting that focus be given to the public sector and that the private sector be left alone. If that was the impression given, it was not the intention. CHESAI acknowledged the need to address both sectors. International experience suggested that it was important to strengthen the public health system to reach the most marginalised and most vulnerable. Thus, the need to strengthen the public system could not be ignored. The Health Market Inquiry report demonstrated that developments in the private sector had only prompted and fuelled inequity and inefficiency. Thus, it was important that the private sector was addressed, that there was a fund that pulled resources from both sectors to ensure solidarity in the use and redistribution of resources. There was a need to think how to strengthen and develop the public sector in ways that were to the benefit of society at large. CHESAI was concerned about the ways in which the Bill tied in certain design elements, which may cause unintended consequences further down the line and work to undermine the public sector. An example was given in the submission about contracting and accreditation and the potential for the public sector facilities to lose out in that process.

It was not possible in any health system anywhere in the world to see how system development would unfold and plan on a 25-year time horizon. It was always important to consider how to build the desired change through the implementation process. That was where the need to think about learning and capacity development in implementation came in. In Thailand there were very clear investments in advance of implementing universal health coverage and in strengthening analytic functions that would support learning in the health system. This allowed the implementation of universal health coverage proposals to be accompanied by learning processes. Thailand was able to understand what was happening in health facilities, amongst purchasing agents and in the population at large. It was only when change was brought about, that one saw how that change was unfolding. It was important that the learning process be considered. CHESAI was not suggesting that more piloting take place. CHESAI was suggesting that a parallel process take place that focused on learning. On quality improvement, it was widely recognized that it required learning processes that worked cyclically. It was difficult to ensure compliance to quality improvement, one needed to have on-the-ground learning, as well as standards to move toward established goals.

With respect to primary healthcare orientation within the Bill, it was important to step back and consider the health system as a whole. It remained a hospicentric system, even though great effort was made to strengthen the primary healthcare platform and to develop the district health system since 1994. It remained a system that was dominated by higher level hospitals. The primary care platform needed to be strengthened – such as in the case of district hospitals – which were very important in a primary healthcare system. District hospitals had been defunded overtime, which had undermined their place in the primary care network. Beyond primary care, actions needed to be taken within the community health system for encouraging and enabling communities and households to implement the actions that supported their own health and lives. That went outside of facilities. The challenge of any insurance-based mechanism and mechanisms that sought to define packages of care, was that it was quite difficult to include, support and engage communities and households in their own health.

Prof Helen Schneider, Public Health Specialist and Health Systems and Policy Researcher, stated that in considering the role of public and private sectors and what to do about the intractable challenge was to separate the financing and provisioning components of the health system. CHESAI argued that financing revenue needed to be pooled. Mechanisms needed to be found – this was indeed what the NHI Fund sought to do. Current provision of health services for 86% of the population was through the public health system, and it employed 200 000 health workers to provide that care. In considering how to bring together the public and private sectors, the provisioning aspect needed to be considered quite carefully, those were the parts that needed to be approached quite cautiously and incrementally overtime. The point about accreditation and performance standards was critical and needed to be in place. CHESAI would not argue against that. Those should not be seen as a prerequisite. They should be mechanisms that evolved overtime, recognising that quality improvement was as much about indicators and accreditation requirements as about culture change of the system. That needed to happen through systematic bottom up efforts in the system. CHESAI was not proposing that more pilots take place. CHESAI would support bottom-up learning and experimentation that sought to consider alternative governance arrangements, particularly at the district and sub-district levels. Mechanisms of funding flows and financing at the most decentralised levels needed to be considered. The previous pilots did not tackle the more fundamental systems issues. The pilots were more about specific vertical strategies, such as the chronic dispensing or ward based outreach teams.

On the central hospitals, the idea of autonomous central hospitals was not something CHESAI would oppose, but they would caution against separating functions across different levels of the healthcare systems. There was also danger if one centralised one component of the system, that it would become fragmented from the rest of the system. One would then entrench inefficiencies and inequities. One needed to retain some kind of ‘whole system’ perspective, even while promoting greater decentralised decision-making and autonomy.

The language of the Contracting Units for Primary Healthcare (CUPS) was absolutely central to the Bill. The model based on the National Health System (NHS) General Practitioner (GP) model, with public and private providers in one area coming together and setting up CUPS was centred on gate-keeping of the rest of the system. One would have packages of care at that level in order to protect inappropriate utilisation at higher levels. That was one of the fundamental logics of that model. That was different to a notion of comprehensive primary healthcare as outlined by Alma-Ata. This had a much more expansive vision of society; it was premised on the ‘common good’ about the social determinants of health and the link between health and wider social inequities. This included things like public participation and inter-sectoral collaboration centrally that would work to address the determinants of health as a key priority. CHESAI was concerned that the fundamental idea about society was lost in technical understandings of CUPS. It suggested that it was something centred on core-benefit packages and gate-keeping. This was important, however the wider vision should not be lost.

Further discussion
Dr Jacobs stated that for the NHI implementation unit, would CHESAI propose that the unit remained within the Department and not be located in the NHI Fund or did CHESAI propose that a different entity be established – like the case in Thailand? On the NHI White Paper 2017, was it supportive of the establishment of the National Health Commission, which would look at social determinants of health or did CHESAI want to see this in the Bill specifically?

Prof Lucy Gilson replied the important point about the NHI implementation unit was less about where it was located and more about who was brought in to support the unit. In Thailand there was a separate government entity that was a health policy analysis unit. It was linked to the Ministry of Health but existed outside of it. That unit had its own resources and drew on a wider range of research and analysis resources within the country at large. Perhaps what was needed, was a base, if it was in the NHI Fund or the Department of Health, that was networked with a wider range of analytic resources within the country This would allow the wealth of available resources to be drawn on to support the implementation of the NHI.

Alliance of South African Independent Practitioners Association (ASAIPA) submission
Prof Morgan Chetty, IPAF Chairman; KZN DHC Chairman, Dr Unben Pillay, ASAIPA & IPAF CEO, Dr Mabowa Makhomisane, ASAIPA Exco; LIPA Chairman, presented to the Committee. The aspects of the Bill that guide our submission:
• Enabling Legislation
• NHI Fund
• SDGs by 2030
• Access to Healthcare
• Role of Primary Healthcare in implementation of National Health Insurance
• Scope of Family Practitioners

General
• Given the purpose of the Bill and our commitment to be part of Universal Healthcare in South Africa, we need to table the concerns of the healthcare professionals.
• The team will lead us through the array of concerns in a constructive manner to help with the creation of rules or laws that will govern the NHI program in an unambiguous way.

Financial viability of NHI Fund
• Not enough detail is given.

Referral process to secondary and tertiary care
• The family practitioner as the primary care coordinator must be defined.

Single purchaser
Concerns:
• Monopolistic nature
• Governance of this process
• Lack of detail on administration

Payment of healthcare service providers: Clause 41
• Clarity required on payment mechanisms to purchase personal health care services from certified, accredited and contracted service providers, health establishments or suppliers.

Contracting Units for Primary care (CUP): Clause 37
• The Bill does not provide clarity on CUP legal status or governance mechanism.

Emphasis on primary health
• This system will dramatically cut unnecessary health costs for specialist referrals and
duplication of pathology and radiology investigations.

Money investment
• Public Health system immediately gets dramatically improved.

Parallel operation
• Private Health system with voluntary medical aid insurance be run parallel to the Public
Health system until problems with NHI are sorted.

Funding model information
• We are willing to help with pilot studies to determine which NHI funding models are best suited.

Governance
• NHI Board constitution
• Office of Health Product Procurement
• Appeals Tribunal

Discussion
Dr Jacobs noted that the submission stated that there was not enough detail on the financial viability of the NHI Fund. It was recognised in clause 48 and 49 – was that not sufficient to ensure the sustainability of the Fund? He thought those clauses covered it correctly and provided enough information. Clause 48 made provision for the Fund sources of income. In clause 48 the South African Revenue Service would undertake revenue collections for the Fund, including the collection of any supplementary health tax levies if applicable. The Bill stated that National Treasury would, in consultation with the Minister of Finance, the Minister of Health and the Fund, determine the budget and allocation of revenue to the Fund on an annual basis. Clause 49 clearly indicated that the ‘Fund is entitled to money appropriated annually by Parliament in order to achieve the purpose of the Act.’ This included general tax revenue reallocation of medical scheme credits, payroll tax and surcharge on personal income tax ‘introduced through a money bill by the Minister of Finance and earmarked for use by the Fund.’ Did ASAIPA not consider this enough detail to show the financial viability of the NHI Fund.

Mr Sokatsha asked about the re-engineering of the current health system. Was the re-engineering of the health system covered sufficiently by the transitional arrangements in clause 57 which spoke about strengthening the health system on an incremental basis? Did this adequately support ASAIPA's suggestion? On the single purchaser concern, what was ASAIPA view on the objective of the Fund to achieve economies of scale?

Dr S Thembekwayo (EFF) stated that when Dr Chetty presented the introduction, most of the information shared with the Committee was not backed by any written information for referral purposes – it was important when presenting to have slides that were spoken to. She requested clarity on the move from a patient to person-centred approach.

Chairperson Dhlomo requested clarity on ‘incremental re-engineering.’ He asked that ASAIPA expand on why they thought it was a good approach. He noted that ASAIPA had also spoken about the ‘quality development programme,’ that would link to the Office of Health Standards Compliance. He was not challenging what was said by ASAIPA but he requested clarity why they thought they were the primary healthcare leaders in the country. On the basket of services, could this be covered in the regulations? The statement about the lack of detail on the Fund administration – did clause 10 not adequately cover this? What specifically did ASAIPA want to see more of on that? It outlined the functions and the powers of the Fund – all of which were part of the administration of the Fund.

Mr Munyai asked for clarity on its request for information on the viability of the NHI. He asked what ASAIPA wanted to see included in the implementation plan

ASAIPA response
Dr Unben Pillay stated that their biggest concern was specifically to the viability of the NHI and from where the funds would be coming. Clause 48 spoke to different areas from where funding would be sourced – one of the biggest areas would likely be taxation. Their main concern about taxation was that there was a serious unemployment problem in the country. The majority of youth were unemployed and therefore taxation from people who were working might be difficult to bring in. It also mentioned unspecific sources of funding – such as donations – which could not necessarily be measured or anticipated. It also spoke about erroneous payments which might be paid to the Fund, that the Minister may decide not to retain. That level of clarity might only come through in the regulations. Their members were unsure from where the funding would be coming.

The second concern was the monopolistic nature of the NHI Fund – being a single payer system. The concern was that there were areas where it could fail, a monopoly had never been a good thing. One of the clearest examples was the delivery of power through Eskom. The country was experiencing problems in the provision of power for the whole country. The Association suggested the model in Italy, where there was sufficient universal health coverage that was ‘relatively free’ for the entire population. In Italy there was still an element of private healthcare available. People were still able to purchase private healthcare from their own pocket or possibly from their own insurance.

The Association represented approximately 5 000 general practitioners (GPs) in private practice. If one considered the Bill, it spoke about one of the core-participants in NHI being primary healthcare physicians. That was why they believed they played a big role in the NHI implementation.

Dr Mabowa Makhomisane replied that the submission had referred to the payment of administrators. It was similar to the current administrators they had with medical aids, which oversee payment between the service providers and the Fund. The clarity the Association was concerned about was about this process and who the administrator would be. The Association understood the principle of the Fund, the payment process, the claiming process and how the financial remuneration process would occur. The Association wanted clarity on the administration.

The majority of their member GPs were solo practitioners; they had a national footprint across the country. He apologised for the lack of sufficient information in the presentation – the Association had relied on their written submission providing enough detail. The Association was happy to provide additional slides with more detail, if necessary.

Prof Chetty stated that on re-engineering, they were sitting in a situation where to move from where they were to where they wanted to be, would require a reform of the system. Regulation and improvement needed to take place cyclically. Clause 37 did speak to this – the Association was reiterating this and giving their members a kind of comfort – that it was a process that would take place incrementally and not disrupt the way healthcare was being implemented presently. On their members having greater clarity, the Association would have liked to see what the basket of services would consist of as outlined in the Bill – and refined in the regulations. That was the point they had tried to make.

When Dr Margaret Chan was head of the World Health Organisation (WHO) she made a speech before she left appealing to the world that there was a focus on patient-centred care. She stated that there needed to be a paradigm shift. Every South African person should get a basket of care. There should be greater emphasis on preventive and promotive care so that people stayed healthy and well and did not become patients. Focusing on the curative mode of care, as Dr Chan said, was too late. The Association embarked on and endorsed the need to keep people healthy, part of the economy and productive and prevent them from becoming patients. That was where healthcare costs had gone up. There had been a focus on trying to work retrospectively in trying to make people well, when one could have prevented them from getting sick. That was the ethos behind the terminology of moving from patient to person. If one read the Bill, there was a thread in the Bill that said clearly that they needed to be focusing on holistic healthcare, with a focus on preventative and promotive care.

The Association did not want to raise controversy – they wanted clarity. As providers on the ground, they had highlighted areas where they required more information. He agreed that the Bill did cover a lot. The Association was requesting some more detail in some areas.

Dr Makhomisane replied on what it wanted to see in the NHI implementation plan, saying it was important to understand how providers were going to be paid – if it would be a capitation model or a voucher system. To get more buy-in from practitioners, that information would have been important to provide – even though this might be fleshed out in the regulations.

Prof Chetty replied that in the Health Market Inquiry (HMI), a very important point was raised – that the cost of healthcare and the hospi-centric nature and system-based care was due to an asymmetry of information between the patient receiving care and people providing the care. They were moving through the healthcare system without understanding their health problem. Patients needed to understand what was wrong with them, so that they could make informed decisions. That would help to increase the adherence to care, as the country embarked on NHI.

Further discussion
Dr Jacobs asked if he had heard correctly that the NHI Fund should be used as a financing mechanism for health facility infrastructure. He referred to clause 25 of the National Health Act that outlined the "financing of public health establishments". Infrastructure would still be the responsibility of the provinces.

Mr Munyai asked if ASAIPA was happy with the current status quo where there was too much money amongst a small portion of the population, who were funded by medical aid? Was ASAIPA happy with the two-tier system? Did they believe in social solidarity? The principal intention was to ensure that all people have access to healthcare – regardless of their economic status. What was said by Dr Makhomisane was contradictory to what Prof Chetty said in this regard.

Dr Makhomisane replied that there may have been a slight misunderstanding, the Association agreed that the two-tier system that existed presently was not functional or sustainable and did not provide adequate healthcare for all. He was suggesting that there should not be a total delineation of the private sector. If there were people who could afford to pay out of pocket – they could pay for themselves and it should be allowed. The medical aid schemes could fund anything that the Fund did not cover.

Dr Pillay replied that the Association fully supported equitable healthcare. On care that was provided to a few and not to the majority, that was not what GPs supported. Presently most GPs serviced a wide variety of the unfunded population. The Association supported NHI.

Prof Chetty stated that the Association endorsed the fact that healthcare needed to be restructured in South Africa. The Association supported the principles of universal healthcare. Government would be embarking on a transition that would be responsible. The Association was grateful to have had the discussion and shared their concerns with the Committee.

Self-Care Association of South Africa (SCASA) submission
Ms Nicola Brink, SCASA CEO, and Mr John Norman, SCASA President, presented.

• The Self-Care Association of South Africa represents and supports fifty-one member companies involved in the manufacture, sale, and distribution of healthcare products that enable the public to better manage their health and wellbeing
• Our products are widely available in spaza shops, forecourts at petrol stations, pharmacies, other shops, and supermarkets
• SCASA members support universal access to healthcare, which we believe we have in part already achieved in our Schedule 0 self-care products such as Grandpa, Eno, MedLemon, Borstal
• We support NHI but not in the current suggested format.

Informal Independent Retail
• Despite the growth of malls and the continued incursion of supermarket chains into township areas, informal retail continues to exhibit signs of growth against all odds. Growth driven by:
• Rising transport costs – consumers “reverting to local”
• Proximity of the spaza stores to consumers’ homes
• Increased consumer shopping frequency
• Spaza meets the convenience need
• Increasingly competitive pricing, driven by trading-savvy foreign nationals
• Pack sizes and configurations to fit the consumer need e.g. two-pack of paracetamol
• About 2000 Soweto Spazas carry medicinal products (roughly 20% of all stores in Soweto)

Pricing of self-care products
• Schedule 1 and 2 are subject to Single Exit Pricing (SEP)
• Medical devices are not subject to pricing regulation
• Due to market forces, Schedule 0 medicines have been exempted from Medicines Pricing Regulations since its inception. The reasons for this are:
• It ensures access to self-care medicines close to people’s homes and where it is convenient (e.g. when a minibus taxi stops to re-fuel)
• It assists in securing livelihoods for many in non-classic markets (e.g. spaza stores)
• Supply in the state system for some OTC products, for example, paracetamol occurs by means of the tender system.

NHI Bill amendments to S22G of Medicines and Related Substances Control Act
• The NHI Bill proposes in its Schedule that the SEP apply to the NHI
• Currently it applies only to the private sector
• The state sector is governed by tenders as required by Constitution, PFMA (and the envisaged new Procurement Bill)
• An NHI structure will set the prices for all medicines
We do not support a price regulatory system for public procurement of medicines, as:
• Self-care Schedule 0 products are already excluded from the SEP system
• Competitive bidding is a constitutional requirement
• In the case of S0 medicines:
• Market forces work very well in the supply of self-care products
• Many self-care products would be unavailable in NHI and therefore not fall under its control
• In short, a price regulatory regime would severely limit the ability of manufacturers, traders and wholesalers to be responsive to their respective markets.

If the new NHI-proposed SEP is applied to Schedule 0 medicines
• The variety of market conditions which bring these medicines to patients, cannot be accommodated in a “single” price
• Traders may decide to no longer stock these products, as they would not be able to do so profitably, thereby decreasing access to healthcare. Some of the rules for logistics and wholesaling fees would have to apply, which would mean that the logistics would have to be paid off the SEP (as is the case at present), further eroding the profit margin of these traders
• Only a fixed, maximum dispensing fee would have to be levied, and not a mark-up, making the stocking of, for example, a small two-pack paracetamol unviable
• A prohibition on bonuses (e.g. buy one get one free), rebates (a discount of sort) and incentive schemes (e.g. marketing and advertising campaigns) would be similarly detrimental in the Schedule 0 market and its traders.

Benefits available in the NHI
• Many self-care products would be included in the NHI package, and by definition (clause 33) the private sector and medical schemes would be prohibited from providing such care, for example:
• anti-diarrhea products
• de-worming medication
• headache and pain products
• Envisaged centralised procurement system would not be responsive to the needs of population
• Care, more than what would be “medically necessary” should be provided in the NHI, and treatment guidelines must be set by professionals who are registered to work in a particular healthcare field

Governance and other matters
SCASA is concerned about the governance structures of the NHI Fund:
• The CEO having to report to Parliament only once a year
• Technical day-to-day functions e.g. on formularies (medicines lists) and decisions to fund which must be set “in consultation with” the Minister
• We believe it is impossible for the Minister to do so as “in consultation with" means “active engagement”
• Publication of regulations without public consultation is concerning, given the public health importance of such regulations
• The binding nature of “Directives” that can be issued by the NHI Fund as this would be law

Concluding Remarks
• Our most pressing concern is the impact of the Bill on access to OTC products (such as Grandpa and Panado) to markets where there are limited opportunities to access primary and preventative care such as in the most rural of areas, should the pricing reign of the NHI be made applicable to the non NHI market
• Many families purchase products on a need-to basis due to limited disposable income and the nearest clinic is kilometres away in a rural setting
• Finding a means and time to get to this clinic is not financially or practically viable
• What is financially and practically viable is to go to the local spaza store
• If NHI comes into play and Schedule 0 medicines are now subject to NHI (SEP type) pricing, the spaza store may no longer stock the product as it is no longer viable for them
• Self-care products must be accessible in the NHI and remain accessible in the private sector, including the informal and retail sector
• This gives effect to the right of access to healthcare.

Discussion
Dr Jacobs noted SCASA stated that the Bill did not allow for competition. That was not really substantiated in the Bill as clause 37 required competition. Clause 38 stated that ‘the provisions of this clause are subject to public procurement laws and policies of the Republic that give effect to the provisions of clause 217 of the Constitution.’ Clause 38(3) addresses the use of cost effective technologies such as medical devices and the establishment of health technology assessment capability. Was it aware of this clause? The use of the technologies should be effective as well as cost effective.

Mr Sokatsha asked how SCASA proposed that unregulated use or over-utilisation of self-medication should be managed so as not to bankrupt the NHI Fund. What was its proposal on potential risk of self-medication as described by the WHO? This included incorrect self-diagnosis, failure to seek appropriate medical advice, incorrect choice of therapy, failure to recognise appropriate pharmacological risk, severe adverse effects and failure to diagnosis correctly.

Dr Jacobs referred to the essential medicine list and equipment list and asked if SCASA was suggesting that these be included in the NHI products list? Clause 38(4) prescribes that they must be approved before they are included in the National Health Products List as approved by the Benefits Advisory Committee. There was nowhere in the Bill where such products were excluded. How should the small spaza shops be configured to be in a position to claim from the NHI Fund? Should these providers be subject to NHI accreditation to be reimbursed by the NHI Fund?

Chairperson Dhlomo asked to hear how SCASA planned to play a responsible role in as far as supporting the spaza shops. Who was monitoring and checking expiry dates of those products? On the single exit price, how factual was the statement that it would be detrimental to companies? The legislation governing state procurement of medicines already required adherence to a single exit price. The Medicines and Related Substances Act states in section 22G that the transparent pricing system: ‘shall include a single exit price which shall be published as prescribed, and such price shall be the only price at which manufacturers shall sell medicines and scheduled substances to any person, other than the State.’ It went on to state that ‘no pharmacist or person licensed in terms of section 22(c), wholesaler or distributer shall sell a medicine at a price higher than the price contemplated in paragraph (a) above. Only those products that were sold by the State would be subject to a single exit price and therefore it poses no challenges to the private sector. He was just checking how factual the concerns were as raised by SCASA.

SCASA response
Ms Nicola Brink replied to section 22G that the Chairperson had just read. Indeed, all medicines were subject to a single-exit price, however Schedule 0 medicines (Grandpas, Eno, Med-Lemon, Panado etc) had a clause 36 exemption from section 22G and section 18 of that Act. This meant that they were not subject to pricing regulation. This was because of the complexity of the distribution chain. It could not possibly be regulated. Those medicines went through a complex distribution chain and it was impossible to police. Within a pharmacy, regulation was easy. The pharmacy was allowed to put a certain mark-up, the consumer got it at the single exit price. In a Schedule 0 environment due to the complexity of the distribution chain, that model was unviable and literally impossible. That was the reason for granting the exemption.

Mr John Norman replied about the safety of Schedule 0 products. South Africa operated in a highly regulated environment for how medicines were imported, manufactured, packaged and distributed through to the pharmacy. In many cases there were temperature-controlled environments and tracking systems. When schedule 1 and above medications were dispensed from a pharmacy, the integrity of the medicine, including the expiry date, were managed. The professional was trained to dispense that medicine, either against a script or in consultation with the patient. The Association did support the highly regulated environment, and the integrity of the supply chain in bringing the medicines to the patients via pharmacy channels. When it came to Schedule 0 medications, those medicines had existed for a long time. The regulatory authorities determined the Schedule 0 medications. If the integrity was maintained through the supply chain process, the safety determined by authorities would be intact.

Ms Brink replied about spaza shops and helping their consumers make informed decisions. Along the distribution chain there were various representatives – there were strict agreements with those outlets – and they were obliged to ensure that the expiry dates were well within the parameters. The Association educated the wholesaler – such as Macro and Pick ‘n Pay to pass along that message – but that did not always filter right down to the spaza store owner. The Association had launched an over-the-counter (OTC) online directory. It was a mobile-friendly simple portal where a consumer was able to type in a name of a product or an ailment and through that search engine, simplistic information would come up as well as means to contact the South African Health Products Regulatory Authority (SAHPRA) on questions they may have on that particular product. There was a grey area as a spaza store owner may purchase from the wholesaler and where it fell short was what happened to that product if it was in a spaza store and it expired.

Mr Norman emphasised that the country had a highly regulated environment. SAHPRA governed the registration of medicines and determined the requirements that pharmaceutical manufacturers, distributors, pharmacies etc had to comply with.

Ms Brink addressed the question on health technology assessments. The Association made a decision to leave that to their prescription counterparts. The Association acknowledged that some of their self-care products fell into that arena – they made the decision in the submission to stick to access to Schedule 0 medicines. The Association acknowledged the point on clause 38 made by Dr Jacobs. The Association believed that market forces for Schedule 0 medicines were driving competitive provision and should therefore not be included in the mix. The Association acknowledged that a lot of the population was illiterate. That fell within SAHPRA’s ambit. The Association was engaging with SAHPRA on a regular basis to ensure that they met those requirements and mitigated that potential risk, of somebody taking something inappropriate. Schedule 0 medication was considered safe enough by SAHPRA to be sold in open shop and for there to be no need for a medical practitioner to intervene.

Further discussion
Ms Havard said that the statement that the NHI would set prices for all medicines was incorrect. The NHI Bill set parameters for the public procurement of health-related products in clause 38.

Mr Munyai referred to the Medicines Act section 36 exemption. Did SCASA agree that Schedule 0 medications, which were OTC products, should not be funded through the NHI, as NHI should cover the regulated products by SAHPRA?

Ms Brink replied SCASA was not proposing that Schedule 0 products should be funded through the NHI. Schedule 0 products needed to be available in the NHI, such as pain medication and deworming products – these had a relevant place in NHI. The Schedule 0 medications also needed to be available in the private sector without having any restrictions on pricing regulations or controls imposed on them. Access needed to be ensured – thus they proposed that no interference was posed to Schedule 0 medication. The way that SCASA had understood the Bill was that all medications would be subject to pricing control as was currently employed on Schedule 1 medications and above.

The Association’s understanding was that there would be parameters on price even for Schedule 0 medications. The Association was proposing that those parameters were not imposed on Schedule 0 medications to facilitate access to the entire population, both through an NHI mechanism and through the current structures that were working well.

South African Private Practitioner Forum (SAPPF) submission
Dr Simon Strachan, Paediatrician, Dr Conrad Mashiloane, Obstetrician & Gynaecologist, and Dr Mvuyiso Talatala, Psychiatrist presented to the Committee on behalf of SAPPF.

COVID-19 Learnings
• COVID-19 response focused on protecting the health care worker personally and financially
• Per diems & service level agreements with Provinces
• Economic Relief Models for Practices ▪ Unity & Participation Between Groups
• COVID-19 Vaccine Roll-Out
• B4SA / V4HCW
• Careful planning and coordination is needed to optimise the roles of the national and provincial departments and private industry

Objectives of the Bill
• Achieve Universal Access to Quality Health Care Services
• Establish a National Health Insurance Fund and to set out its powers, functions, governance
• Provide a framework for the strategic purchasing of health care services
• Create mechanisms for the equitable, effective and efficient utilisation of the resources
• Meet the Health Needs of the Population
• Preclude or Limit Undesirable, Unethical & Unlawful Practices

SAPFF does not support the current Bill and its main concerns are:
• Quality of Health Care
• Contracting with Specialists and Allied Health Care Professionals (HCPs)
• Treatment Protocols
• Governance
• Medico-legal Litigation
• Access to Health Care
• Corruption

How quality of care is defined - Bill makes reference to different quality standards:
• Necessary quality
• Reasonable quality
• Sufficient quality
• Clause 39(4)
• Accreditation of health care service providers
• Contracts are required to "contain a clear statement of performance expectation" such as volume and quality of services delivered.
• Clause 39(8)(j)
• Clause 39(8)(j) accreditation may be withdrawn if the services delivered are "of a quality not acceptable to the Fund.”

Quality and treatment protocols
• Guidelines & Protocols need to be relevant and evidenced based.
• Cost is but a part of the decision-making process when determining benefits and treatment guidelines.
• All funding decisions about healthcare have clinical implications and thus affect the potential outcome for a patient.

Medico-legal litigation
• Pressure on Service Delivery
• Reducing Access to Ambulatory Care
• Extended Waiting Periods
• Pressure on service delivery means pressure on HCPs which will increase the risk for medico-legal litigation.
• Will HCPs need to pay for their own medico-legal insurance?

Corruption
• Corruption in any sector undermines the delivery of healthcare
• Every rand misappropriated is a rand not spent on delivering healthcare
• A Unit to investigate complaints is insufficient.
• NHI Fund will require an independent fraud unit to perform an ongoing in depth analysis of the pressures and opportunities to commit fraud and monitor these threats and react proactively.
• This Unit should also be responsible for oversight and internal audits of board and committees.

Access
• SAPPF supports the need for access to universal health coverage
• Private Health Care Providers form an integral part of the National Health Asset
• Designing a health care model based on cost may reduce access and thus reduce the currently offered health care services
• Limiting the capacity of the medical schemes (clause 33) further reduces the opportunity to improve access
• Clause 8(2)(b)&(d): expand this to allow for choice to choose a health care service provider

Recommendations
• Involve clinicians in decision-making to discuss quality and access to care: this includes participation in Benefits Advisory Committee to inform baskets of care, guidelines and protocols
• Ensure that contracting for ambulatory specialist services is included
• Broaden governance structure to provide more independent oversight of Fund and health system
• Encourage the participation of a high quality, functional, well funded and well administered private system to contract for services with the NHI
• Allow patients the opportunity to fund their healthcare through medical schemes
• Expand the fraud unit to include the functions of risk mitigation and fraud investigation.

Conclusion
• SAPPF supports the need for universal health coverage
• SAPPF does not support this NHI Bill as it is written
• Our recommendations are offered as constructive points for careful consideration.

Discussion
Mr Munyai stated that SAPPF had stated that the Bill lacked clarity on what was meant by quality. Did SAPPF perhaps miss clause 55 of the Bill? This stated that the Minister may make regulations to provide payments on condition that there had been compliance with quality standard of care or the achievement of the specified levels of performance. This implied that the regulations defining quality would be made, it was not expected to be laid out in the Bill. What was the SAPPF understanding of clause 38(2)(a) on who would monitor performance? Clause 38(6) stated how accredited providers would be monitored at a legislative level. Beyond these two clauses, SAPPF had the expectation that the Bill needed to describe in detail how these clauses would be applied. What was their view on this being contained in the regulations rather than the Bill?

Ms H Ismail (DA) noted that SAPPF had mentioned the public and private sectors – but overall where did it foresee the NHI failing in implementation? SAPPF stated that there was no provision for contracting of ambulatory specialists or allied healthcare workers – she asked that it explain the consequences and concern about that, once the NHI was implemented. Medico-legal litigation was one of SAPPF’s biggest concerns – what were these specifically? NHI was supposed to create a more inclusive healthcare system but its submission stated that it would result in barriers to access. What were the biggest barriers to accessl?

Ms M Hlengwa (IFP) asked – given the high health inequality in the country – what was the SAPPF proposal to broaden the reach of private care to more South Africans to pave the way for a sustainable NHI.

Dr Jacobs referred to quality of care as outlined in the submission. He noted the triangle presented and the reference to it. He was concerned that the assertion seemed to be that quality care was not equal to low cost of care. He was of the view that it had been taken into account in the Bill in clause 11(2)(e). It stated that low cost would not be to the detriment of users of the healthcare system. What lessons had SAPPF gained from the COVID-19 response? He also questioned their proposals and concerns about the role of the Minister.

Ms Havard asked why low cost and quality could not occur concurrently. Had SAPPF omitted some factors such as implementing prevention and health promotion through a primary healthcare approach? Was it looking at a hospi-centric approach – SAPPF represented their members as an organisation consisting predominantly of specialists?

Chairperson Dhlomo asked how many SAPPF members were in the public versus private sector. When he had visited private healthcare institutions and complained about certain things observed there – he was informed by those that ran those institutions that it was not their main responsibility but that of the service provider or specialist. The triangle SAPPF presented suggested that if one increased one aspect, the other decreased. He gave a scenario about quality. The caesarian sections were done largely for the outcome of the baby. Without fail, when one visited public health institutions, the caesarian section rate was about 35%. In the private health institutions he had visited, the caesarian section rate was sitting at over 70% . Those institutions stated that it was not their responsibility, it was the specialist who decided to do the caesarian section. The cost had gone up – but it was not translating to quality. In fact the quality of that women’s life had gone down – it was likely that many of them did not need a caesarian section. This challenged the notion of the triangle. In this case the costs were going up and the quality went down.

He asked about ‘specialist ambulatory care?’ Did the presenter feel that ambulatory care was left out of the Bill? Was this not covered in clause 41 of the Bill, which stated that in the case of specialists, this must be all inclusive. How were they to be left out? How could SAPPF support universal health coverage when they supported a multiple funding system? Did they want the two-tier system to continue? Was this vision not contradictory?

Dr Jacobs asked why SAPPF was supporting medical aid schemes when the Bill had stated that the NHI Fund would pay for comprehensive services supplied by all service providers accredited and contracted by the NHI Fund.

Mr Munyai noted SAPPF concerns about the Minister. What did SAPPF think was the problem with the powers given to the Minister?

Chairperson Dhlomo said that the submission supported the need for a continued medical aid scheme process alongside the Bill. Could SAPPF explain what this would look like. How did SAPPF see this happening?

SAPPF response
Dr Simon Strachan replied to the question on how the Bill would be implemented – SAPPF understood that this would be a phased approach. When they considered cost, access and quality, SAPPF was suggesting that there needed to be clear decision making on ensuring that the triangle was not skewed. SAPPF was not suggesting that healthcare could not be delivered at a lower cost. When one was considering lower cost, one needed to understand that there needed to be an understanding of quality and access. That was the principle. Quality was important if a funding model was being developed – there needed to be an understanding of what needed to be achieved. At the moment, without that information, it was really difficult to have a complete understanding of how implementation would happen. The need for healthcare providers to participate in the process of implementing was paramount. All SAPPF members worked in the private sector. Many of their organisations had both public and private parts sitting in the umbrella organisation but the private sector arms of those organisations formed part of SAPPF.

On ambulatory care, there did seem to be a gap in accreditation and contracting. SAPFF had no issue that it was primary healthcare based. There seemed to be a gap between primary healthcare and what happened between primary healthcare and in-hospital services. When payment was deemed to be all inclusive – SAPPF read this as being all-inclusive in hospital services and the specialist services that took place within the hospital setting. In their day-to-day work they had many referrals from primary healthcare and consultations where the patients did not end up in hospital. It was that aspect that SAPPF believed was missing in the Bill.

Dr Conrad Mashiloane replied that quality was about the input that went into treatment protocols. One needed to ensure there were enough broad clinical specialists and GPs participation in drawing up protocols. The other issue that affected quality was the value chain. The value chain was incomplete. The Bill made reference to primary healthcare and then it mentioned hospital care – there was a lot that took place in between primary and hospital services. The Bill spoke about the contracting unit for primary healthcare which was comprised of a district, hospital, clinic, community healthcare centres, ward-based outreach services and private providers organized within a horizontal network in a specific area. It did not illustrate the whole value-chain of treatment to ensure that NHI delivered on quality.

On other medical aid schemes, if one considered other countries around the world, in healthcare funding, there were many models that ensured that there were as many schemes as possible operating within a system and a framework of managed competition. SAPPF believed that the medical aid schemes needed to coexist in a managed environment. There were shortfalls in the private sector. SAPPF wanted all South Africans to be covered by NHI, but there should be the option for patients to access fund schemes outside of NHI. A single fund would strain the NHI. Japan had over 5 000 schemes operating within the framework of managed competition. It was one of the most efficient and cheap health systems in the industrialised world.

Dr Mvuyiso Talatala replied about the role of the Minister saying their fear was the concentration of powers in the Minister of Health. The country had seen how things could go wrong and corruption could take place. The entire health system was vulnerable to fraud, waste, abuse and corruption. The powers should be dispersed amongst the Minister of Health, Minister of Finance and Parliament. It should be anticipated that there would be corruption around the NHI Fund and therefore a system should be developed that would be able to assist with that. This was proposed as opposed to having a unit investigating after fraud, waste, abuse and corruption take place.

On contracting, if contracting took place with the hospitals, they were keeping the hospi-centric approach. For mental health, this was problematic, the country had failed thus far to move mental health into community healthcare. There had been a push over the years to move specialists like psychologists and psychiatrists to a community level – but the hospi-centric approach would prevent this. At a community level, these specialists could not only provide services, but allow task sharing to take place, where some of the work of specialists could include training of GPs, community healthcare workers and nurses. Specialists were unable to cover all the needs of the community. This had been debated in government - that specialist care needed to move to the community level for task sharing. It was not clear how these specialists could be contracted to the community in the Bill.

Dr Strachan said that SAPPF had presented an opportunity, the private sector had the willingness, they had all spent many years working in the public sector. SAPPF believed that to dismantle or restrict the role of the private sector in trying to improve access was not the right way to go. There was potential to improve access to healthcare within the private sector. It was understood that the implementation of the Bill and regulations would occur over years – why was it not possible to allow the private sector to get itself into regulated health structures that were outcome based and cost efficient. It would then be able to allow people to contract individually with the private sector. There was no reason the private sector could not develop centres of excellence. There was no reason this could not lead to better competition within the private sector so there would be options for the State. SAPPF did not believe that dismantling the private sector was a solution. Further research needed to be done on this.

On medico-legal litigation, it would be different for different disciplines. It was not necessarily about what the problem was – although some things would be more expensive than others – it was about what led to adverse outcomes.

On where NHI was failing in implementation, this was a difficult question to answer as that was looking down the line. Their submission was based on what SAPPF saw as possible concerns and how maintaining the private sector would help. Their central concerns were quality and access.

Dr Mashiloane noted the cost in the private sector and the high caesarian section rate. Those were relevant concerns. SAPFF had made it quite clear that they supported the recommendations of the Health Market Inquiry that enabled them to make practitioners account for their outcomes and the high caesarian section rate. SAPFF had adopted a position of establishing a clinical monitoring and intervention outcomes programme that supported the concerns raised by Chairperson Dhlomo. The BetterOBS programme was established by the South African Society of Obstetricians and Gynaecologists (SASOG). The Society had approached all the private hospitals in South Africa that offered maternity care and wanted the hospitals, mid-wives, specialists and anaesthetists to have regular mortality meetings to monitor outcomes and lower the high caesarian rate burdening the private sector. There were areas for improvements and there were positive approaches being applied in the private sector. Dismantling the private sector providing high quality care concerned SAPPF. It noted the required concerns about costs, accountability and outcomes. Both NHI and the private sector could coexist.

Further discussion
The Chairperson said that it could not be that it just required reconfiguration of the public sector health system. The private healthcare sector was pushing costs up. There could not be a situation where there was such differentiation in the number of caesarian sections in the public versus the private sector. It was not the decision of the private institutions but that of the private specialists who decided to do so to all those women. One strived in the healthcare sector to have a certain caesarian section rate – it was cheaper to deliver naturally, it was not cheap to do caesarian sections. Thus, it was not as if everything was right in the private sector and wrong in the public sector. He was just using the caesarian sections as an example. What was SAPPF doing to repair that? What were the clinical indications to suggest the need for caesarian sections?

Mr Munyai said that the Health Market Inquiry had clearly indicated that the specialists were one of the groups driving costs in the private sector. How did SAPPF want to address the HMI findings?

Dr Jacobs asked if SAPPF actually heard the questions posed by Members. They asked what SAPPF thought its role could be going forward to be drivers of lower costs. Where did SAPPF see its role to assist the population to access good quality healthcare at the lowest cost possible? The Committee had the opportunity to listen to the Council for Medical Schemes (CMS). CMS demonstrated that within the private healthcare sector there was also corruption, abuse and waste. He wondered if SAPPF was absolving itself of the abuse and wrongful acts taking place within the private sector. He did not think that the Bill was trying to destroy private practice. The services were still to be provided by the public and private sectors going forward.

Dr Mashiloane replied that SAPPF and obstetricians in general were concerned about the high caesarian section rate. Specialists worked within a framework that allowed patients to have a choice in how they were treated by specialists or any provider. They also worked within the framework of the National Health Act, which allowed specialists to involve the patient in determining treatment. The National Health Act clearly specified that the doctor needed to offer all possible treatments to the patient, which included the cost. Thus, they offered these choices to patients within the private sector. They worked within the framework of the Health Professions Council of South Africa (HPCSA) that mandated them to discuss all treatment options with patients. This was also in the framework of common law which obligated specialists to give patients autonomy in deciding on the treatments offered to them. A study was conducted by SASOG which looked at the causes of the high caesarian section rate. A lot of it had to do with patient choice. The choice of vaginal delivery was discussed with respect to HIV. The issues were systemic. If one looked around the world, all middle-income countries had the same high caesarian section rate. One had a population where there was a high morbidity rate and a sophisticated healthcare system. Those two factors contributed to the high caesarian section rate. They were working on finding solutions. That was why they supported the Health Market Inquiry. One of the reasons the private sector was criticised was because of the vertical integration into hospital groups, where a lot of specialists were found to be under pressure from the hospitals to drive up admissions and surgical interventions. Thus ambulatory care should be a part of the NHI. SAPPF had noted the concerns and was dealing with them.

Dr Talatala replied about SAPPF’s role in improving access. The biggest problem in South Africa for mental health was hospitalisations both in the public and private sector. SAPPF was there to criticise both the public and private sector – SAPPF was forward-looking toward a better healthcare system. One of the cost drivers of mental healthcare was hospitalisation. The way the current system was designed in South Africa, if one wanted to access a psychiatrist, one had to go to a hospital. Thus, SAPPF suggested that the Bill should ensure that psychiatrists, psychologists and counsellors could be accessed at primary healthcare level – not necessarily to treat the patients but to train the other workers. This would lower the burden on hospitals and reduce costs.

Dr Strachan said the point made about ambulatory care was critical. Even with in-hospital care, in monitoring care and outcomes, reducing length of stay, early discharge and appropriate care, all of these were efforts in the private sector to ensure cost-efficient care. Those mechanisms were already in place in the private sector to ensure care was cost efficient. Ambulatory care was encouraged. Under NHI they would be able to offer services to state patients and contract to private healthcare providers for the care needed. SAPPF realised that the fee-for-service model was not the best model to conduct healthcare remuneration. SAPPF was not denying corruption in the private sector. There was a push toward alternative reimbursement models – SAPPF understood that concept. The debates about the implementation of a universal coverage model should include a well-functioning private sector.

South African Institute of Race Relations (IRR) submission
Dr Anthea Jeffery, IRR Head of Policy Research, presented to the Committee.

No way for public to know about the issues
- Parliament must facilitate involvement in legislative process: see Constitutional Court in New Clicks, Doctors for Life, Land Access cases.
- MPs must engage with some 65 000 written submissions.

Proper Socio Economic Impact Assessment (SEIA) needed to comply with Constitution
- Final SEIA report should accompany every bill that is released for public comment.
- Must cover implementation costs for state, compliance costs for economy and set out likely outcomes, both positive and negative.
- Must assess united consequences, adequacy of controls on discretionary power, risks of corruption, and dangers of excessive costs such as disinvestment or emigration.
- SEIA Report from June 2019 is superficial and outdated and simply assumes NHI will yield promised benefits, fails to consider alternatives or likelihood of adverse outcomes.
- Does not examine what NHI will cost or how these costs can be financed.

NHI Bill based on false assumptions
- South Africa spend 8.5% of Gross Domestic Product (GDP) on healthcare of which 4.1% goes to public sector on which 84% rely; while 4.4% goes to private sector on which 16% rely.
- Taxpayers (529 000 earning > R500 000 pa) pay for bulk of public spending on health for majority, then pay from their after-tax income for their own health needs – not ‘South Africa.’

Inefficiency in public healthcare
- Public healthcare spending as a percentage of GDP, has increased substantially since 2001.
- SA spend 12% of budget, 4.1% of GDP on public health, close to WHO call for 5% of GDP.
- Between 2001 and 2018 the number of GPs in the public sector doubled, specialists up 30%.
- Public health is dysfunctional due to theft of resources, crippling inefficiency, lack of accountability: key problem is poor management.
- Public sector managers too scared of unions to punish poor performance and unlawful conduct.

NHI will spawn large and costly bureaucracy
- NHI Fund plus nine sub units for planning, benefits design, pricing, accreditation, procurement, monitoring, combating fraud etc
- District Health Management Offices (44)
- Contracting Units for Primary Healthcare (44)
- Office of Health Products Procurement (OHPP)
- National Health Information System.

Estimates of NHI Costs
- Dr Mkhize: ‘sum total’ of public and private spending R460bn in 2019 is ‘not enough’ to run NHI and we ‘need more.’
- Other guesstimates: R440bn (Dr Mkhize), R275bn (Dr Shisana) and R230bn (Dr Phaahla).
- Sum shifts yearly depending on budget and health services government can afford (Dr Pillay).
- R460bn starting cost at 4.5% inflation will soon cost more than all PIT (R529bn) paid in 2019
- No mechanism to bring down costs
- Monopsony power (one buyer, many sellers) cannot address core drivers of increasing healthcare costs (i.e ageing population, number of trauma cases, crime, accidents, rising costs of new medicines etc).
- Centralised procurement will often be inefficient and corrupt
- NHI offers no credible financing mechanism – no comprehensive Treasury paper as pledged, 2017 White Paper 4% surcharge on income tax and 1% increase of VAT were implemented.
- No room to impose new taxes.

Warning by Davis Tax Committee
- Investigated how to finance NHI amd issued report in 2017
- It said NHI unlikely to be sustainable without sustained economic growth.
- Such growth not possible with COVID-19, Eskom, expropriation without compensation (EWC), falling FDI, municipal collapse, poor skills etc
- In October 2017 Davis Tax Committee said NHI was no longer affordable.

NHI will bring increased corruption.
- Willie Mathebula (2018) stated that procurement rules were ‘deliberately not followed’ in 50% of tenders worth R800bn per year.
- 2019 SEIA report: high risk of corruption in NHI but no effective countermeasures proposed.
- Health supply chain was particularly vulnerable.
- Health Sector Anti Corruption Forum not enough to end corruption, Hawks and NPA already overburdened, Zondo cases.

NHI Bill Unconstitutional
- Section 27: State must take reasonable measures within its available resources to achieve progressive realisation of the right to healthcare.
- NHI will deprive people of the access they have.
- Involves spending beyond State’s available resources.
- Conflicts with freedom of association, protection, property rights etc.
- NHI Bill provides nothing but a bare framework with too many uncertainties and inconsistencies.
- Not enough guidance to Minister and state entities on how extensive discretion is to be exercised.

Discussion
Dr Jacobs noted that IRR made a good point about the socio-economic impact assessment. However, it was missing the extensive socio-economic impact assessment done in 2019, which examined the risk and concluded that the NHI could be implemented. The NHS in the UK was implemented post World War Two with very little money and they seemed to have had great success. Not so long ago, during the pandemic in Britain, there was a push to ‘save lives, save the NHS.’ It was clear that it was important to the British. The socio-economic impact assessment system (SEIAS) in South Africa had been decided on by Cabinet – that there was a need for such assessments for the implementation of policy and legislation. This was done in 2007. That approval followed a study commissioned by the Presidency and National Treasury in response to concerns about the failure, in some cases, to understand the full cost of regulation and its impact on the economy. The decision was implemented from 1 October 2015. This was now standard practice in South Africa and was done by every single department overseen by an interdepartmental steering committee. Extensive work was done on the socio-economic impact assessment prior to the Bill being signed off by Cabinet before the Bill even came to Parliament.

Did the IRR subscribe to the principles contained in the preamble of the Bill? Was it suggesting that the Health Market Inquiry Report published in September 2019 should be ignored? Why was IRR choosing to believe the Davis Tax Committee recommendations while throwing out the HMI recommendations?

On radiologists leaving South Africa, this seemed to be one of a number of projections that ‘everything would just collapse.’ Was that really what IRR was advocating? Was it aware that the Bill had been assessed by the State Law Advisors who certified the Bill as constitutional?

Mr Munyai noted the IRR concern about the affordability of NHI, was it aware that the bulk of the funding for the NHI was already in the system? Was the system not repurposing the existing resources and augmenting them with additional resources on a gradual basis? The financial implication of the Bill indicated that some costs were budgeted for.

The growth of the country changed over time, it was not static. In the last quarter South Africa’s economy grew by 4.5%. This aligned with the new policies the President announced such as increasing independent suppliers of electricity to a maximum of 100MW which was a great economic stimulus.

The assertion that the NHI Bill did not comply with the Constitution required engagement – which part of the Bill was unconstitutional? Did IRR believe that healthcare as enshrined in the Constitution superseded other aspects of the Constitution. The argument was made that too few people paid tax – what about the rest of the population who paid Value Added Tax (VAT) of 15% for everything they bought? Why limit taxpayers to few, when all South Africans paid tax? The argument that the NHI would spawn an expensive bureaucracy – was IRR aware that the administrative costs of NHI would be less than 2% of the costs of the NHI Fund? Was this not more efficient than the administrative costs of the medical aid schemes which amounted to double digit costs. Further, the Department of Health stated that it would transfer its funds to the NHI Fund – would that not manage the cost? What was the IRR position on the South Korea reforms that took place in the past five years when it found that the multi-payer system was unsustainable and it thus moved to a single-payer system? What lessons could South Africa learn from the South Korea experience? The IRR put forward statements as facts that were merely projections / assumptions that everything would collapse - what was its mandate on this?

Ms Wilson stated that the submission required a lot of consideration. One of the biggest complaints the Committee had received was NHI’s lack of coverage of foreign nationals and the access they would have. That was a huge concern, whatever their status, that they were being limited to the amount of access proposed in the NHI. Every submission so far had raised corruption. That was a very relevant point. There was currently millions of rand in medico-legal claims…[network connection lost].

Ms Havard asked about the Davis Tax Committee report – where did IRR get the information that NHI was not affordable? Where did it get the information on emigration of specialists and explain where those specialists planned to emigrate?

Chairperson Dhlomo echoed Ms Havard’s question as to where specialists would emigrate. The NHI was based largely on the Bill of Rights, in particular section 27. This was the basis for the fact that the Bill was constitutional – the State Law Advisors had agreed with that. Section 27 pressured government to ensure that everybody had access to healthcare. The IRR had quoted the same clause and used it as the basis to state that the Bill was unconstitutional - he would have to be educated on that. He was not moving from the understanding that section 27 was the fundamental basis of the Bill.

Was IRR aware of a programme called the Presidential Health Compact? He supposed it was as mention was made of the Anti-Corruption Health Forum. The IRR raised the public having no knowledge of how the supply of health professionals and facilities could be sustained – let alone increased to accommodate the expanding demand for health services. Clause 2(a)(1) of the Bill addressed that. Health systems funding was mentioned there as part of a transitional arrangement that was needed. The Bill anticipated the challenges of how health systems were provided. A timeline was provided in an incremental approach.

Clause 55 stated that the Minister would regulate the relationship between the Fund and medical schemes registered in terms of the Medical Schemes Act and other private health insurance schemes. One could not provide regulations for something that did not exist. The Bill acknowledged that there would be some medical aids that would play a complementary role. IRR made reference to the Zondo Commission which would be completed in the near future. He requested clarity on the proposal of 5% of GDP covering the majority of the population. This was equivalent to what other countries were spending. He asked what information influenced this proposal. On the NHI being too costly, did IRR believe that the private healthcare sector was not expensive? The private healthcare sector was a major health cost driver. Was its assertion not contradictory? To conduct a male circumcision in a public hospital cost R800 to R1 000, to do it in a private health institution could cost anything up to R6 000. One needed to compare apples with apples. The Health Market Inquiry Report was important to consider.

His understanding was that there was a basket of services that would be provided to all South Africans – he had not seen the list of exclusions. He asked for clarity if IRR had made an example of haemophilia. Was there already specific reference made to haemophilia? There was no detailing in the Bill on what that basket of comprehensive health services would be.

IRR response
Dr Anthea Jeffery replied that the IRR supported universal health coverage. The objective was valuable. Critically, it needed to be questioned if NHI was an effective way of achieving universal health coverage. It may be that people who were out the country were not fully informed if NHI was the best way to achieve universal health coverage. There may be alternatives that were better suited to the context of South Africa. This was what the IRR was arguing.

The IRR was seeking to ensure that the resources in the public sector were better used as 4.1% of GDP was not that far off the WHO’s urging of 5% of GDP. If the economy was expanding more rapidly and it was backed by the right policies it could more easily be reached. Inefficiency, a lack of accountability, medical negligence and corruption restricted the use of that 4.1%. The IRR wanted the existing resources to be more efficiently used by all South Africans, specifically the poorest South Africans who relied on those resources. IRR was suggesting that there were various ways that public health efficiency could be improved. One of the mechanisms would be to have public private partnerships – the private sector within the parameters set by the Department of Health could run clinics and hospitals and do it more efficiently than present.

At the moment, major problems existed in the public health sector compounded by other factors. The politicisation of service provision was one of the factors, as stated by the President. There was also corruption. The appointment of people as a result of loyalty to the party rather than their competence was problematic. It was difficult to hold those people accountable, partly because they were accountable to deployment committees which put them in their positions, rather than to their immediate line managers. Managers were sometimes too afraid of trade unions to exercise proper discipline and to require accountability from staff members. There were resources that could be used better – and needed to be used more effectively.

When it came to the private sector, IRR was not suggesting that things should be left as they were. There were important health cost drivers in the private sector which needed to be addressed. Part of the problem was the way in which medical scheme costs had been pushed up by government through many of the changes that were introduced. In recent years this included the reluctance to allow low cost medical schemes. Open enrolment and community waiting were introduced without, what was initially highlighted as a necessary part of the package, compulsory membership for all formal employees. This in itself, would help to bring down the costs of medical scheme membership by 20 or 25%. It would make it more affordable. If one had low-cost medical schemes this would also make it more affordable. Many of the people that turned to the public service for their primary healthcare would be able to obtain it from private providers if they had the medical scheme membership that covered that or similarly if they had primary health insurance. These were regulatory changes that could help to bring down the cost of medical scheme membership and the cost of accessing private care through health insurance. The primary healthcare products existed – but they were under-pressure. The idea was that primary healthcare products should be taken away in order to make way for the NHI.

Access needed to be improved, especially for the poorest households, to the private sector. There was a great deal of wastage in the public sector. Treasury had highlighted the inflated pricing that happened in many state tenders – more than 50%. Instead of having resources being frittered away in the public service it would be a good idea if some tax revenue which would go to the public service were instead allocated directly to poor households, in the form of tax funded health vouchers – so that they could start meeting their own health needs. Poor households could then take out health insurance and medical scheme membership. That would help reduce the pressure on the public sector because more people would be able to access the private one. A great deal of regulation in all medical schemes around the world had lead to a situation where one did not adequately have a market in healthcare. That needed to be addressed before regulatory reform. In the USA the innovation was to introduce health saving accounts. People were able to save money in their own health savings accounts which they could keep from year to year. It made them more prudent shoppers of healthcare. It gave providers an incentive to lower costs to compete for that money. It was the essence of having competition and the efficiency that lowered costs. If one looked at cosmetic surgery that medical aid schemes did not cover at all – the costs tended to be lower and it was an indication of the whole medical scheme process which had distorted the market. The answer was not to get rid of medical aid schemes but to introduce reforms to balance the government regulations which had driven up costs. She suggested making medical aid scheme membership more accessible to poor households and bringing back the market principle in healthcare as much as possible with the help of medical schemes rather than by excluding them.

She was aware of the June 2019 socio-economic impact assessment report. That report was unsatisfactory, it read more like an advertisement for the NHI rather than the assessment it was meant to be. It was supposed to be an assessment that looked critically at all the different options for meeting the need of universal health coverage. It failed to explore any of these possibilities. It did not explore other reforms that might do better than the NHI. It did not interrogate how much the NHI would cost. It simply reflected the starting cost which was the same amount that was mentioned in the White Paper in 2011, which was in itself a ‘thumb-suck.’ It was outdated. There was no attempt to quantify how much the NHI would cost. There was no attempt to find out where that money could be found, especially in a country that had low growth, high death, high unemployment and a very limited tax base. That report simply concluded that the NHI would be a good thing having brushed away all alternatives and important questions. It stated that NHI would meet the needs as outlined by the government to provide healthcare to all those who needed it.

The reality was that it was much more likely not going to provide healthcare to people when they needed it. There would be long waiting periods, many people would find that they would be unable to get access at all to the medicines, treatment and specialists they would like to see for any number of reasons. There was an assumption that the NHI would be some magic golden bullet that would solve all those problems – in the real world one had to look very carefully what the unintended consequences might be, the unexpected costs and the overall impact on the economy. All these things should be covered in a socio-economic impact assessment – but it was not – the assessment was an NHI advertisement.

That analysis compiled in 2019 was before the COVID-19 pandemic hit. As a result of COVID-19 and the lockdowns, the economy was in a more difficult situation. In 2019 the country was in trouble economically. In 2021 the economy was in crisis. GDP had contracted enormously; unemployment had risen enormously. Unemployment, on the expanded definition, had risen to 75% amongst youth aged 15 to 24 years. These factors needed to be taken into account. It could not be assumed that the financing for the costing would somehow magically appear and that people would therefore get the health services they needed. None of the real problems were being addressed. She subscribed to the principles in the Bill, but it needed to be cost effective and efficient. It could not just provide a promise, that in practice, remained unfulfilled.

She replied that the Davis Tax Committee said that the NHI would not be sustainable without better economic growth. She did not think the Health Market Inquiry was looking at the sustainability of the NHI. It made a number of recommendations that would be helpful to the NHI, such as the introduction of pricing controls and the consolidation of medical schemes. It did not contain a detailed examination, with the help of financial experts, of how much the NHI would cost and how it could be financed – which the David Tax Committee did do. Having done that, the Davis Tax Committee came to the conclusion that it would not be sustainable.

Many radiologists were planning to emigrate – the expertise they offered did tend to be costly. She was simply trying to draw attention to the fact that if many of them emigrated, then radiology would become much more difficult to manage efficiently. If the country would drive healthcare professionals abroad by implementing NHI, which was high on promises and short on delivery – then it needed to be re-thought. Universal health coverage needed to be done in a more cost effective, efficient and sustainable way.

She was concerned about the affordability of the NHI. Medical scheme contributions were paid on a voluntary basis by people who got value through them as a result. No doubt not as much value as they should as medical scheme costs had been pushed up through government regulations and needed to be reduced via regulatory reform. It could not be assumed that the same amount of money could be extracted from the narrow tax base without prompting greater problems of non-compliance or emigration. The South African Revenue Service was already noting that there were fewer taxpayers and that the pool of taxpayers was diminishing. If policies were introduced that had the effect of driving out the middle class – it would be even more difficult to fund healthcare or the many other services which the poor look to the government to provide.

Reference was made to the GDP growth rate that was expected to be 4.5% this year. That was due to the country coming off a very low base, the economy contracted by 7% in 2020, that meant that it had a low base, any growth on top of that looked much better than the norm. The norm suggested that GDP growth would come down again to 1.5% of GDP. Treasury projections were usually far too optimistic. If one looked at the previous ten years, Treasury had generally overstated by at least twice what the actual growth had been. The Eskom constraint also made it very difficult to grow more than 1%. The increase of self-generation to 100MW – as announced by the President – was certainly not enough to solve the Eskom problem. As long as the Eskom problem remained, the electricity constraint was one reason why it would be difficult for the economy to grow more than 1%. There were a number of other reasons why it would be difficult to grow at a higher rate. Expropriation without compensation was one of the key factors that would deter investment and make it harder for the country to grow or expand employment. Former President Thabo Mbeki had recently warned of just that.

On the constitutionality of the Bill, Dr Jeffery replied that her doctorate was in law and she had a different view from the State Law Advisors. The State Law Advisors very often certified Bills that were believed to be constitutional but later were found not to be. The problem came from ignoring all the relevant adjectives in section 27. One had to look at not only the intention of the NHI to provide free health services to everybody but what the reality was likely to be. One had to ask if it was a reasonable measure for the government to take. If the measure taken by government would drive many taxpayers and health practitioners away as well as reduce the amount of care people currently received, then it was not a reasonable way of meeting the goal of universal health coverage. One had to consider what resources the government had available. These had shrunk as a result of the lockdowns. The country had very low growth – about half of that of its emerging market peers. The country had limited resources. Debt had been going up sharply from 26% of GDP in 2008 – it was now at 80% of GDP. It might be higher than that if government failed to trim the public service wage bill and cut expenses in other ways. International rating agencies all believed that South Africa’s debt-to-GDP ratio would actually increase further and reach 100% of GDP. The country would battle to meet all its obligations.

The available resources were limited and that needed to be taken into account. Therefore, setting up a system that was premised on having resources beyond that which was available was unconstitutional. There was also a need in section 27 of the progressive realisation to the right to health access - it should be getting better not worse. Through the NHI it would be made worse. Resources would be driven away in the form of health professionals. Many of the government’s public clinics and hospitals, which did not comply with basic norms and standards, would not qualify for certification and accreditation by the NHI. Unless the basic norms and standards were dropped, they would not be part of the system. That too would reduce the amount of healthcare available. They were looking at a system that would not achieve a progressive increase in health but rather a reduction in healthcare.

Dr Jeffery replied that she was drawing attention to the tragedy that South Africa had such a low tax base. There were 22 million people registered for tax, it would be wonderful if all 22 million earned enough to be assessed for tax and to contribute to tax. Low growth, lack of investment and unemployment meant that overall there were many people who did not contribute to the tax pool. This meant that those that did contribute to the tax pool were all the more important – the burden rested on their shoulders. Other countries implementing universal health coverage and trying anything similar to the NHI had a bigger economy with much more growth, higher employment, a much bigger tax pool and more people contributing to the tax pool. That made an enormous difference. The tax burden was too high – one of the highest in the world.

There was not enough information to know if the administrative costs would be 2%. Wage costs in the public service had been rising rapidly. Administrative costs might be higher in the private sector – but that was funded privately via out of pocket income. If there were more medical schemes – if it was not the government’s policy to consolidate them and get rid of them – then the more competition would help to bring down the administrative costs of the private schemes. The key was to promote efficiency and competition and impetus to lower costs through competition.

The UK recently went from a single payer to multi-payer system. This had increased efficiency and competition. It was an important point that foreign nationals were highlighted, but it was peripheral to the larger question if the NHI would meet the needs of South Africans – and that point needed to be concentrated on. Reference made to the high number of medico-legal claims. This pointed to a high amount of medical negligence in the public sector. Obviously, that needed to be taken care of and she had suggested ways of doing that. There was simply a risk of emigration in light of corruption and comprehensive state control. It needed to be taken into consideration. She was aware of the Presidential Health Compact, in essence it was an undertaking to prepare for the NHI. The weaknesses should be identified for the NHI – so as to start thinking of better ways of achieving universal health coverage by improving the public service.

Dr Jeffery replied that hemophilia had been used as an example – it was not indicated if this would be covered in the basket of services – but that was the sort of thing that might not be covered by NHI because it affected relatively few people. It was suggested that private medical schemes would be pushed out through government regulations.

Health Promotion and Development Network submission
Dr Ishaaq Datay, Specialist Physician & UCT Lecuturer, and Ms Aadielah Diedricks, Southern African Alcohol Policy Alliance (SAAPA) Coordinator, presented to the Committee.

Health promotion in the NHI Bill is mentioned as part of contracting units
- It is our contention that given the way that these contracting units are set up, their composition, their myriad functions and the demands that will be placed on them to provide curative services – that it will be extremely unlikely to allow for the necessary attention to be paid to the promotion of health and prevention of illness and to establishing comprehensive and ongoing promotive services. This will place NHI at risk for permanently being a curative service rather than a service that is both curative and preventative.
- Many of the objectives of health promotion cannot be achieved at a district but only at a national level (e.g. taxes on tobacco).

Composition of the Board
- Government Departments including Agricultures, Forestry and Fisheries, Basic Education, Communications, Co-operative Governance and Traditional Affairs, Economic Development, Energy, Environmental Affairs, Finance, Health etc. (i.e. all departments).
- Representatives of civil society and non-governmental organisations
- Academics and researchers

General
- Strengthen the evidence for health promotion activities, conduct research and support knowledge dissemination through grants, evaluation research and knowledge translation.
- Support sporting and cultural organisations and community mobilisation that directly or indirectly promotes health and social capital
- Support capacity building in health promoting activities.

Proposed addition to the Bill
- Propose including a clause before Chapter 8 on National Health and Development Foundation:
"A National Health and Development Foundation is hereby established with an annual grant of 2% of the total NHI Fund. The percentage of this to be spent on administration shall be prescribed".

Economic Cost
- Good population health is essential for economic and social development
- Loss to SA’s GDP 2006-2015 from diabetes, stroke, coronary heart disease R26bn
- Tobacco cost alone 2016 R42.3bn – 0.97% GDP
- Economic cost due to productivity loss from ill health in SA, largely from non-communicable diseases (NCDs) 6.7% GDP in 2015.
- Unhealthy people place an unnecessary burden on health services
- Moderate obesity is associated with 11% increase in healthcare costs and severe obesity 23%.

Conclusion
- Health promotion is an untapped resource to deal with social determinants of health
- Health promotion missing link for the most effective NHI
- Local and international examples of health promotion in action
- Unused health promotion funding sources potentially available
- Opportunity exists now to create a national health promotion foundation to lead the way to make real societal differences.

Discussion
Ms Gela asked that the Network provide examples of where health promotion and disease prevention at the personal level were excluded from funding under NHI. Would the Network consider that clause 36 of the Bill addressed its concerns?

Mr Munyai stated that the comprehensive health services definition included health promotion; it was mentioned in the Bill. Could the Network respond to that?

Dr Thembekwayo stated that the objective of the NHI Bill was to provide universal access to quality healthcare for all South Africans. In accordance with what was said by the Network, why did health promotion need to be funded by NHI?

Dr Jacobs asked if the Network thought that the National Health Commission advocated in the NHI White Paper would fulfil its proposed role of a national health promotion foundation. The understanding of the Portfolio Committee was that National Health Commission would be funded separately outside of the Fund. He asked if the Network was aware of this.

Network response
Dr Sue Goldstein, South African Medical Research Council (SAMRC) Deputy Director, replied to the questions about the NHI addressing healthcare at a personal level. This was not the issue, the NHI addressed health education at a personal level, it did preventive medicine such as vaccinations and immunisations. When one considered the commercial determinants of health, where people were getting obese as a result of too much sugar and eating highly processed foods, this could not be attacked at an individual personal level – neither could it be at a comprehensive health services district level. The only way to engage on this was through a multi-sectoral process at a national level. In Australia, when the Health Promotion Foundation first came into being and tobacco advertising was banned, it was questioned who would sponsor sports and the like. The Foundation sponsored sport instead.

Ms Jane Simmonds, SAMRC Research and Programme Manager, highlighted what COVID-19 had taught them what was possible about health promotion. Government had instituted health promoting behaviour to address COVID-19. It was a multi-sectoral arena such as sanitation, transport, education and different departments in government had worked together to stop people getting COVID-19. It was a health promotion issue, it was preventing illness by putting in place methodologies to keep people safe. COVID-19 had shown that it was difficult to provide sanitation to people. One might say that one needed to wash one's hands – but there was no water. That was something that a health promotion development foundation would do. It would be able to intersect different sectors.

Dr Ishaaq Datay replied that there were health promoters but what they mainly did was health education – the entire ambit of health promotion needed to be enacted, which included policy change and community development. It was very difficult to enact – one needed a dedicated body that was thinking that through and facilitating it.

Further discussion
Chairperson Dhlomo stated that there was an understanding that comprehensive healthcare services, which was what the Bill spoke to, was inclusive of health promotion and prevention. Did the Network think it was not covered? What was their view about the Bill suggesting that a health foundation or national health commission would be established?

Ms Diedricks replied that whilst Network recognised that health promotion was mentioned in the Bill, it was inadequate. It invited people into the health service when they were sick – it was not looking at what needed to be done to prevent people from seeking out that. The intention of the Foundation was to reduce the demand on the service, so that practitioners could provide quality care for those that entered the service. The Thai Health Model had shown that by engaging communities, academia, research and different sectors and departments, there was a better chance of creating an environment in which people could make healthier choices. That needed to be facilitated by some policy changes.

At the moment, for example, vegetables in South Africa were exported. It was expensive for people to buy them. There were challenges with alcohol. They needed to be looking at policy on availability, marketing, promotion and pricing of alcohol. South Africa currently had the cheapest beer available in the world. How was the pricing and availability of those products changed so that people chose not to have it – so there were fewer health consequences from consumption. That was how they envisaged health promotion. There were different pillars that needed to be brought into play when they considered preventing illness and promoting health.

Dr Goldstein stated that the National Health Commission had been envisaged in a similar way to the South African National Aids Council (SANAC). If one looked back at the first ten years of SANAC, it was an impotent body. It did not have funding and could not do anything besides volunteer. A lot of money went into making people come to meetings by government with very little impact. Eventually, after many years, SANAC was able to become an organisation and start commissioning and doing work. It was not clear from where the National Health Commission would get money. If it did get funding – how much money would be able to be used for funding of sports and advertising campaigns that were counter to the massive advertising campaigns by, for example, Coca Cola. Health promotion was not included in non-personal health services.

Ms Simmonds emphasised the difference between a health message, which was health education and health promotion. Health promotion happened at a structural level, it happened at a policy and institutional level not at a health poster or flier level. Those were health messages, which were important but were not able to bring about change in behaviour or healthy choices without health promotion support at a structural level. An independent foundation would be able to do this. It would look at what structural changes needed to be made.

Dr Datay said that he worked on the ground and saw the avalanche of people coming through. He also considered how he could work upstream to stop the avalanche of pathology coming through. There were solutions but limited support. There was a lot of money in curative services. Lip service was given to health promotion in policy. The Network was appealing to the Committee for it to become more than just lip service. For it to become a guiding mechanism. Money should be ring-fenced for that.

Counselling Psychology of South Africa (CPSA) submission
Mr Michael Webber, CPSA President, presented to the Committee.

Referral Pathways
- The NHI Bill makes provision for referral pathways. If referral pathways are not followed the NHI will not fund the services.
- However, psychologists are not medical specialists or a medical “add-on” service.
- The functions of psychologists are clearly stipulated in the Health Professions Act.
- Section 37 of this Act clearly specifies that psychologists are competent to diagnose and treat mental and behavioural disorders independently of medical practitioners and do not require patients to be referred to them by medical practitioners or nursing staff.
- They are thus deemed to be frontline healthcare practitioners and do not operate under the supervision of medical practitioners.
- This is further reinforced by Regulations Defining the Scope of the Profession of Psychology (R.993 of 16 September 2008) that reserves the diagnosis and treatment of mental and behavioural disorders for psychologists registered with the HPCSA.

Recommendation:
- It is recommended that the provision of mental healthcare services is specifically provided for in the NHI and that mental healthcare users be permitted to approach psychologists, including counselling psychologists in the first instance without the need to follow a complex and bureaucratic referral pathway to access mental healthcare services.
- In this way access to mental healthcare services will be opened up and enhanced rather than restricted as provided for in the Bill.

Geographic Availability of Mental Healthcare Services:
- Mental healthcare services provided by psychologists within the state sector are currently grossly under resourced and only available at large clinics or hospitals.
- Due to service constraints, patients in small villages and towns throughout the country do not have close access to mental healthcare services, but are required to travel considerable distances to large clinics or hospitals to access mental healthcare services provided by psychologists.
- This is a constraint that appears to be perpetuated in the NHI Bill. In this model patients are required to travel to healthcare services rather than healthcare services be extended to people where they are situated.
- This will have the net effect of limiting access to services rather than promoting universal healthcare.
- The centralization and control of access to services are not the most effective manner of providing mental healthcare services.

Recommendation:
- It is our recommendation that the NHI Bill should be amended to provide that not only may patients approach psychologists directly for diagnosis and treatment of mental and behavioural disorders but that the system should allow them to approach psychologists within their vicinity.
- It is therefore imperative that psychologists in private practice in towns and villages across the country should be contracted to provide mental healthcare services to communities without the need to be linked or practicing within a clinic or hospital setting.

Payment for Services:
- It has been our experience that the payment model used for payment of private healthcare services to deal with the patient numbers during the pandemic has provided a useful model that could be used by the NHI to reimburse practitioners, and more specifically psychologists where they practice.
- Patients unable to be accommodated in the state healthcare system were referred to private hospitals with an authorisation number issued by the Department of Health.
- Payment for services was then effected through existing medical scheme payment channels using the current practice code numbering system (PCNS). In this way hospitals and healthcare practitioners were paid via medical scheme administration systems which then claimed that money back from the Department of Health.
- In this way the existing channels of an efficient administration of payments could be used by the NHI Fund to channel payments to practitioners in the private sector contracted to provide services to NHI users.
- In this way the existing system does not need to be disrupted but rather improved upon.

Recommendation:
- Apply the existing payment channels using the existing practice code numbering system and medical aid payment channels which function efficiently.
- Practitioners rendering services on behalf of the NHI would submit their claims for payment through electronic channels to the NHI via existing medical scheme administration systems.

Fair Payment for Services:
- A significant concern of CPSA membership, and which has resulted in some negativity towards the practical application of the NHI, is the remuneration of psychologists participating in the NHI.
- In the absence of a clear-cut payment model that is not covered in the NHI Bill there is considerable uncertainty around how practitioners in private practice would be paid and what the quantum of the payment would be. In the light of this uncertainty absurd figures as low as R200 per consultation are being bandied about. Psychologists employed in the public sector are paid about R1 025 316 per annum (Dept of Employment and Labour 2020) whilst a chief psychologist is paid about R1 487 664 per annum (Free State Psychiatric Complex 2020). In addition to salaries, state employees are provided with free office, telephone, computer, internet connection, administrative support, stationery and filing, paid sick leave, annual leave, etc.
- Private practitioners whose earning capacity is quite similar are required to provide their own paid office accommodation, administrative support, internet, computer, telephone, indemnity insurance, public liability insurance and short-term insurance out of their earnings. They have to purchase sick leave by way of sick and disability income protection policies. There is no annual leave so practitioners are required to make provision for savings should they wish to take time off from their practice. Further, if psychologists in private practice reach the income threshold of R1m per annum, they have to register for VAT and pay 15% of their income in VAT.

Recommendation:
- It is our recommendation that a fair and integral system of remuneration for psychologists that will contract to the NHI be calculated and made explicit to clear up the uncertainty that currently exists to reassure psychologists and attract them to contract with the NHI.

Discussion
Ms Hlengwa asked what was meant by ‘making a meaningful contribution to mental health care needs.’ What in terms of assistance, was not fair or, was it not fair in terms of mental healthcare?

Ms Gela noted that CPSA said that the Consumer Protection Act gained its authority from the Constitution, she requested clarity on that. The Constitution simply listed consumer protection as a concurrent power between provincial and national government. Was there a section of the Constitution that gave it authority? She also asked for clarity about its concern about registration of child in clause 5(2). The Bill required that the child was registered by one person without duplication. Whilst raising the scarcity of psychologists, how did CPSA suggest that psychologists be distributed so that no one was left behind. How could the resource be redistributed to benefit the entire population?

Dr Jacobs said that CPSA stated that psychologists were not mentioned in the list of professionals in the Bill. Indeed, not all professionals were individually listed. However, the Preamble to the Bill stated that ‘Article 12 of the United Nations Covenant on Economic, Social and Cultural Rights 1966 provides for the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ to achieve the progressive realisation of the right to access to healthcare. This implied that psychologists were included. The Committee hoped that this was the understanding of CPSA.

Concern was raised about clause 33, which allowed medical schemes to cover complementary services not reimbursable by the Fund. Clause 33 aimed to prevent a parallel system for those who rejected the NHI. CPSA had highlighted the role that psychologists ought to play. There was an important role for all health professionals in the Bill. Did CPSA regard psychologists as being outside of the multi-disciplinary approach? In that case, where did the psychologists fit into the various levels of care? Did it regard them as professionals that could be accessed at primary, secondary and tertiary levels of care? Why did it position them outside of a multi-disciplinary team? Did CPSA suggest that the reimbursement strategies be detailed in the Bill or in the regulations?

Mr Munyai asked why psychologists were not migrating to the public sector, since CPSA said the public sector was 'so superior’ in healthcare systems – if its statistics were correct.

Ms Havard stated that given that there were few taxpayers to contribute to NHI, had the presenter included the tax contribution by everyone in the country who paid VAT? How did CPSA propose that costs associated with provision of mental healthcare services should be structured? The Health Market Inquiry had identified mental health as one of the key cost drivers.

Chairperson Dhlomo stated that CPSA saw no problem with a patient starting directly with a psychologist. There was stigma attached to mental health. Why did they think that psychologists would be the first primary contact as opposed to a nurse? There were not enough psychologists to be placed in every clinic; it was not practically possible. How many of CPSA members were in the public sector? How would it negatively impact the livelihoods of professionals? The National Health Act would be amended at some point as a result of the implementation of NHI.

Responses
Mr Michael Webber replied that a meaningful contribution could be made by advocating and lobbying amongst their members to get involved with the NHI. There was a lot of ambivalence in the private sector presently, this was mainly due to uncertainty. CPSA encouraged its membership to get involved in the NHI to make a meaningful contribution in the provision of services to people who currently did not have access to those services. Fair access meant an acceptable level of service. CPSA positioned itself as being for the NHI.

He offered to find the clause on consumer protection submitted at the end of 2019 and send that to the Committee. South Africans were entitled to high standards. The current NHI was based on a medical model; there was no reference made to mental healthcare. It was focused on medical disorders and illnesses. Mental healthcare operated on a different model.

The private sector in their minds did not reject the NHI. In places like the UK, there was still a private sector that provided the same services. Having a private sector did not mean that the NHI was being rejected. CPSA did not see themselves working outside the multi-disciplinary approach. In the private sector, patients often approached psychologists in the first instance, not via the medical sector. CPSA was not opposed to the multi-disciplinary approach but they saw this happening far more at secondary and tertiary healthcare levels, where there were teams of psychiatrists and doctors working within that context. At a primary healthcare level, this was more of a relationship between GPs and psychologists. Patients often approached psychologists in the first instance – that was where he would disagree with the Chairperson. Most GPs in South Africa only underwent about three weeks of psychology training in their seven years of training. Whereas psychologists undertook six years full-time training just in mental healthcare. Most nursing staff did not have the level of training to recognise some mental healthcare disorders, which a psychologist would. That was why psychologists were suggesting that the referral pathway should allow people to be able to go directly to the psychologist. Counselling psychologists were an integral part of the system. However, they were also capable of working independently with certain patients, and this was corroborated in legislation and guidelines.

Many psychologists wanted to work in the public healthcare sector, however there were no posts. There was a bias that certain government departments, such as the Departments of Correctional Services and Labour would happily employ counselling psychologists, the Department of Health did not. The Department of Health had almost an exclusive bias toward clinical psychologists. All its advertised posts were for clinical psychologists.

If one considered the statistics, depression was the leading cause of workplace incapacity worldwide. Depression was taking more people out of the workplace and hampering productivity than cancer, diabetes or pneumonia. Mental health should be afforded the same status as medical healthcare. As they were not financial experts, he did not want to comment on the funding and tax base questions. Their concern lay with increasing the number of counselling psychologists in the public sector. CPSA was more concerned about the allocation of funds – in terms of universal access. Many of the private medical schemes refused to pay for counselling psychologists in their benefits – this was one of the reasons that CPSA was formed initially. CPSA membership was 90% in the private sector, and the rest were in the Department of Education, the Department of Employment and Labour, as well as Correctional Services.

On the Consumer Protection Act, this was part of their initial submission in 2019. The Bill could not waive or dilute people’s rights in the Consumer Protection Act, as it was constitutionally required law. However, clause 3(3) stated that the Bill's provisions prevail. if it contradicts the provisions of another Act. Clause 5(5) referred to a registration system that would include biometrics and other information on users. People made many shameful and humiliating disclosures to psychologists – and its concern was how that information would be used within the NHI. Payment in the NHI Fund would be subject to the disclosure of certain types of personal and health information. CPSA wondered how that mandatory disclosure would gel with the Protection of Personal Information Act which outlawed certain disclosures. NHI should not dilute any rights that consumers may have in those two Acts.

The registration of children was unclear to CPSA. In clause 5(2), it stated that one of the child’s parents must do that and register the child to the Fund – it raised the question of how the child would then be linked to the other parent. The regrettable fact was that the divorce rate in South Africa was terrible. Parents had joint custody, one parent would register the child but how would the child be linked to other parent, especially where they lived in different provinces. How would the child draw on benefits in a different area? This could also be the case for grandparents who may have to register a child in their care. In the Children’s Act, children over the age of 12 years were entitled to consent to medical treatment without the knowledge or consent of the parent, guardian or caregiver. Would this be allowed under NHI? Would children have a right to access healthcare without being linked to a parent in line with the Children’s Act?

Further discussion
Dr Jacobs asked about reimbursement strategies. Should it be detailed in the Bill or in the regulations? Was CPSA suggesting that the diagnosis should not be disclosed? Would this not skew the burden of disease statistics – in terms of non-disclosure.

Mr Michael Webber replied that the code would inevitably need to be disclosed. Patients that were seen in the private sector had to consent to the disclosure of their diagnosis to claim funding from a medical aid. The Medical Schemes Act and regulations specifically provided that certain information had to be included in accounts – such as the practice number, date of service, place of service and an ICD-10 code. It was inherent in the national health system that they made use of these codes. Some of these codes might be covered by the NHI, and some might not. Their concern was on how much more information would be required i.e. the need to declare what the diagnosis was based on – that was a situation that was already being encountered with medical aids. The medical aids were now wanting to know symptoms – which was muddled territory. In the case of trauma patients was it really any business of medical aids that the patient was raped or sexually molested? He did not believe that it should be required by medical aids. If one considered the constitutional right to privacy – this should prevent such disclosure.

On the reimbursement model, he did not have a clear idea of where that should be, their concern was that it was not clear anywhere presently. No one knew what the reimbursement model would look like, how private sector practitioners would be incorporated in the system and how remuneration would be calculated. It did need to be made explicit somewhere. He offered to respond in writing to additional questions that Members might have.

South African Nephrology Society (SANS) submission
Dr Shoyab Wadee, Nephrologist, and Prof Razeen Davids, Head of Nephrology at Stellenbosch University, presented to the Committee.

Treating Kidney Failure: Kidney replacement therapy (KRT):
- Dialysis
- Transplantation
- KRT is expensive, so limited access
- Palliative / supportive care

SA Dialysis and Transplant Registry
- Established in 1977
- Last data 1994
- Two decades without data

Access
- commit to improving KRT access
- shortage of nephrologists
- shortage of training posts
- make data submission mandatory
- registry needs better funding

Strengths of NHI Bill
- Recognises the need to change the current system
- Aims to equalise disparities
- Intends to promote universal health coverage
- Progressive realisation of this constitutional right
- Inclusivity of stakeholders
- Phased initiation
- Utilisation of both public and private sector resources for the benefit of the patients

Weaknesses of NHI Bill
- The Bill does not address the current level of infrastructure and management failure in the state
- Funding mechanisms are vague, and critical for implementation
- Benefits are lacking detail and CRUCIAL
- The anticipated cost is not known

NHI Threats
- Reduced interest in training in nephrology
- Inadequate remuneration
- Poor working conditions due to inability to offer life-saving therapy
- Both may discourage nephrology as specialty choice
- Transition period
- Thousands of patients currently on dialysis in private sector will die if planning is poor
- Loss of medical aid cover without NHI funding will result in inevitable deaths within days or weeks
- Will take our country renal services backwards

NHI Opportunities
- Improved integration and planning at all levels of kidney care
- Screening
- Prevention
- Management
- Timely referral to nephrologists
- Better dialysis initiation
- Allow universal access to renal care services including dialysis and transplantation.
- Using consolidated purchasing power to negotiate down costs.
- Improved organ procurement for transplantation
- Adequate basket of benefits and protocols developed with SANS.

What we would like to see
- Fundraising to allow a progressive increase in services
- SANS recognized as key stakeholder and expert body in planning and implementation of services for patients with kidney disease.
- Fair remuneration for nephrologists
- Increased training posts for nephrologists, dialysis nurses and technologists
- Improved referral systems to access nephrology services
- Correct the historical gap in access to dialysis services
- More dialysis infrastructure and staffing
- Develop plan based on hope offered by future technologies and partnerships rather than past failures.
- Universal dialysis for all.

Discussion
Ms Hlengwa noted case numbers were higher in the Western Cape and Gauteng – was this linked to inadequate detection of kidney disease in other provinces? How was the problem of inadequate detection distributed across provinces? On donors, how did people learn about organ donation – was there awareness of this important function? What was its advice about private hospitals – for dialysis?

Ms Gela referred to the slide showing dialysis levels for countries – it showed that South Africa was lagging behind – why were countries such as Japan ahead? Was South Africa able to access these technologies and what was the SANS recommended strategy?

Dr Jacobs appreciated that SANS had asked for specific items such as more training platforms and an increased number of nephrologists over time. The lack of a regulatory framework was mentioned. This was an interesting point and something the Committee could look at in the draft regulations. He asked for clarity on the disparity in case numbers across the country. He noted the point on multi-disciplinary care for people with renal disease.

Ms Wilson noted that SANS said organ donations which were key to saving lives were slow and there was incapacity in reaping organs. What were the reasons for not being able to deliver compatible organs on time? Emergency Medical Services (EMS) were under huge strain – she requested clarity on the status of Intensive Care Unit (ICU) and theatres for organ donation. She requested SANS repeat the backlog figures.

The Chairperson referred to the slide that showed opportunities to improve nephrology services. They spoke of screening and prevention – did they play a role in health promotion and prevention? He asked if they were medical doctors who had become specialist physicians and then added on some years focusing on kidney disease. In the event that haemo-dialysis was not available how valuable was the peritoneal dialysis? Could it sustain one for long?

When he had visited China there were dialysis machines even in the district hospitals. Some of them were lying empty because there were no patients coming in for that. One could get them at a district level and not a hospital level. Was SANS familiar with the Presidential Health Compact? Was nephrology services under resourced in the public health sector? Would they suggest that the Benefits Advisory Committee look into ring-fencing funding for renal services? Would they support this to be further articulated in the regulations? Did they have a view on reimbursements under NHI? Did they suggest that there should be a centralised system so that those in outlying areas were not disadvantaged?

SANS response
Dr Shoyab Wadee replied that the Western Cape, KZN and Gauteng presented higher figures because there might not be sufficient infrastructure in outlying areas. This was specifically in the public sector.

Prof Razeen Davids echoed this. Prevalence levels differed across countries and it was not because the burden of disease was different in those areas. The incidence of kidney failure was relatively similar from one area to the next. The big differences were seen in access to and provision of treatment. There was presently insufficient capacity to treat everybody. There should be 30 000 patients on dialysis which was three times the actual number treated. It was an expensive undertaking but they needed to make a commitment so that they gradually moved closer to that.

On availability of peritoneal dialysis, it was widely available in all areas of South Africa, in fact South Africa did most of the peritoneal dialysis on the continent especially in the public sector where it was used for kidney failure.

Nephrologists started off as doctors who specialised for four years in either internal medicine or paediatrics and then trained for another two years in nephrology to become adult or paediatric nephrologists.

Dr Wadee stated that there were two types of donors, living donors who donated one of their kidneys to a family member or friend. This was an effective way of donating a kidney and getting off dialysis. People generally did well with a living donor transplant. In many sectors of society people were unfortunately unable to donate for a variety of reasons. Secondly, there were donors who were ‘brain dead’ or ‘non-heart beating’ donors – there were not a lot of these types of donors in South Africa. These cases were where there was severe brain damage and permission needed to be granted by the family to take the patient off life support – and one needed to wait until the heart stopped to harvest. In those instances the quality of the organs was poorer – one needed efficient mechanisms and those had not been developed in ICU nor theatres. One needed good ICU care to reach a stage where a patient was brain dead but still alive in every other way so that the organs were usable. This also relied on good emergency care.

There were changes to organ donation policy that could be implemented, such as opt-in and opt-out systems. Opt-in required permission from family members for transplants. In countries like Spain they had an opt-out system where it was published widely that unless someone refused, every individual would be a potential donor. This increases awareness. In practice most of the countries with opt-out system would still get permission from the family. In South Africa there was the Organ Donor Foundation which was a non-profit organization that advocated for organ donations – SANS worked alongside them.

On why the public sector was lagging behind in dialysis, there would be slots for dialysis in many towns, that is 100 slots would be funded for different types of dialysis. Unfortunately the number of slots had not increased in many of these places over the years. Many patients died while waiting on the waiting list. The resources of the private and public sectors should be seen as a single resource and should be funded by NHI. There was very little strategic planning on dialysis services in the country. SANS was willing to engage with the Department of Health in how to plan for this.

Prof Nicola Wearne, UCT Nephrologist, emphasised that peritoneal dialysis allowed for an adequate quality of life. It allowed rural patients better access to care. It was not without its own challenges. More sisters needed to be trained to be able to accommodate those patients. Doctors were needed and they needed to be comfortable with it. It was a good stepping stone and had a good mortality benefit in the first couple of years. They knew from studies that it should be part of an integrated care approach that involved haemo-dialysis.

Dr Vakhtang Rekhviashvili, Nephrologist, stated that the regulations were a great hope for the field in standardising care delivered to the patient at every level. There was no knowledge of how many units operated in South Africa and if there were nephrologists or vascular surgeons attached. Most of those units were private and were keeping the standards in check. Licensing was absolutely crucial – which was on hold and they had not been updated on where and how it was progressing.

Dr Wadee referred to the Soobramoney case where the Addington Hospital in KZN was sued to access dialysis. The Constitutional Court ruled that the Department of Health and the Hospital may reasonably withhold dialysis based on the available resources. Unfortunately, this meant that they could withhold this life-sustaining therapy. The balance was between the right to life and the right to healthcare and the availability of resources. If there were limited resources, it gave the Department of Health the right to limit the right to access it. One of the problems was that the Constitutional Court stated that this should not be carte blanche or an excuse to prevent progressive realisation of the right to healthcare. There should be a progressive increase in the ability to provide care to people. Unfortunately, that had not happened. The number of patients on dialysis had increased a lot since then. The survival rate had increased in the five year survival rate – particularly in the private sector. Nephrologists did not play a day to day role in screening and prevention. Nephrologists would be involved in refining the care pathways and screening and prevention pathways for patients with chronic kidney disease and cardiovascular disease.

The meeting was adjourned.

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