The Portfolio Committee of Health has continued to hear presentations from various healthcare and civil society representatives on the proposed National Health Insurance Bill which provides the funding framework for nationalising healthcare in South Africa. While there has been some outright opposition to the Bill, the majority of presentations have supported Universal Healthcare and outlined areas that need to be addressed, strengthened or reviewed to ensure timely implementation of the Bill ensuring an optimum continuum of care. the SAMED NHI Committee continue to engage with stakeholders and legislature as the hearings unfold. We have summarised some of the discussions and recommendations below:

Bonitas

  • Advocated for a more flexible role for private medical schemes
  • Emphasised the important role which private sector could play in assisting the government in the rollout of Health Insurance to successfully deliver universal health coverage.
  • Pressure on state resources and infrastructure
  • Language used in the Bill
    • Impacts legal certainty and the rule of law
    • Ambiguous and has anomalies
  • Raised constitutional concern around limiting people’s choice of healthcare service
    • Freedom and security of person in section 12 (s12)
    • Healthcare, food, water, and social security in s27
    • Human dignity in s10
    • Life in s11
    • Freedom of trade, occupation, and professions in s22
  • Corporate governance of the NHI Fund
    • Governance structure lacks accountability
    • Fiduciary duties and accountabilities should be defined
    • Minister has unwarranted powers
    • Criteria needed for appointment of advisory committee
  • Flow of funding from the NHI Fund to service providers
    • Apart from section 49(2)(a) there is no clarity in terms for how NHI will be funded
    • No information on how funds will be managed, financial planning or budgets
  • Maintenance of the purchaser/provider split throughout the NHI system
  • Milestone-driven instead of date-driven. Piloting and taking certain aspects of the NHI based on a framework to expand the coverage of the NHI.
  • Acknowledged the need for reform in the private healthcare sector to bring the cost down for more people to be able to enjoy its services. Health Market Inquiry has made many good recommendations in this regard.

Discovery Health

  • Emphasised its support for the National Insurance Bill and importance of collaborative work between NHI and private medical schemes to deliver universal health coverage
  • Portfolio Committee wanted more details of Discovery’s Vitality programme and the health expenditure saving it accrued as a result of the encouragement for its members to live a healthier lifestyle
  • Provided examples of global health insurance models:
    • parallel funding model
    • dominant public funding model
    • blended funding model
  • Recommended a blended funding model and pointed out that no country legislatively restricts the scope of services that private healthcare could cover.
  • Issue of governance; expressed worry over the governance issue among the country’s several institutions
  • Plead with government to consider the recommendations of the Health Market Inquiry
  • 12% of the population in the UK chooses private medical insurance alongside the coverage of the NHS. Although the NHS provided an extensive range of healthcare services, it does not legislate in any way what the private sector may offer. A demand and supply environment exists, which allows the private sector to provide services where consumers choose to purchase those services privately.

MedScheme

  • Focused primarily on the alternative reimbursement model to help bring the cost of medical scheme premiums down
  • Emphasised the role that the private healthcare market could play in the rollout of Health Insurance
  • Two key aspects that had been highlighted were the alternative reimbursement model (ARM) and the quality and outcomes reporting system:
    • The singularity of the fund
    • Role of provinces
    • Role of the private sector
    • Funding sources
    • Applicability of the bill and complaints and appeals processes
    • Governance issue
    • Its concern on the duplication of functions
  • The NHI has a lot to learn from the private sector, and government should not risk breaking what is already working in the private sector before it gets its own NHI smooth running on track.

Mediclinic

  • Bill was potentially unconstitutional:
    • Its proposed procurement model was not compliant with constitutional standards
    • It did not provide reasonable certainty about the nature and scope of the NHI scheme
    • It might breach the right of access to healthcare services
      • There were inadequate financial resources and human resources for the effective implementation of NHI
      • The Bill offered virtually no role (or no viable role) to private hospitals
      • The Bill eroded private medical cover, especially by limiting it to “complementary cover,” a phrase whose meaning was not clear
    • Mediclinic recommended
      • Stagger implementation based on costing and human resources estimates
      • Ensure a comprehensive and sustainable role for private providers
      • Remove the limitations on medical scheme cover
      • Clarify various issues, including the nature and scope of services available under and outside the NHI scheme
      • Provide for a fair and transparent methodology for reviewing the scope of services covered by NHI
      • Amend the procurement model, with decision-making entrusted to an independent body
      • Establish an independent body to determine reimbursement models and tariffs
    • NHS model is a hybrid financing model, and patients had freedom of choice.

HASA

  • Proposed various amendments, especially to governance framework.
  • To avoid unintended consequences, government should reconsider the timing of the roll-out of NHI and of the various amendments the Bill effected to other acts.
  • NHI should be implemented not on a time-based approach but on a milestone-based approach.
  • Government should also consider shifting to a multi-funder NHI, to mitigate against the risks of a single-fund system
  • Bill was narrow: it focused on financing mechanisms and neglected other obstacles to healthcare access, especially the structural shortage of healthcare workers.
  • Recommendations
    • Stipulate that quality and sustainability should be considered when the NHI Fund procures healthcare services
    • Clearly set out the conditions, timing and guarantee of reimbursement to service providers
    • Stipulate that the Benefits Pricing Committee should be independent and incorporate various additional areas of expertise
    • Consider shifting to an integrated multi-funder NHI and removing the restrictions on additional funding after contributing to NHI, especially to mitigate against the systemic and financial risk of a single-fund system
    • Replace the dates in clause 57 with clear and measurable milestones, in dimensions including the expansion of priority services and population coverage
    • Refrain from immediately effecting the legislative amendments in clause 58 and the schedule, but rather effect such amendments following public participation once the NHI Fund was practically established
    • The NHI Fund should not be exempt from the Competition Act
    • The board should be appointed by Parliament, following consultation with the Minister
    • The Stakeholder Advisory Committee should include business
    • The delegation of ministerial powers should not apply to the appointment of structures and committees
  • As far as possible, the fund should purchase services – primary healthcare services, emergency services, and hospital services – from both private and public providers.
  • Private hospitals believed that they would be able to compete well on an “equal playing field” with public hospitals. The high costs had structural causes – such as high taxes – whose removal would increase the competitiveness of private hospitals

The Western Cape Department of Health

  • Agreed with HASA that NHI, as proposed in the Bill, was a narrow financing mechanism and did not consider the other key building blocks of the healthcare system
    • Did not mention the social determinants of health problems, instead of focusing only on direct service delivery.
  • Bill drastically and inappropriately reduced the powers of the provinces
    • Significantly reduced the scope of the provincial governments’ work and powers in the healthcare system, and left the provinces’ responsibilities unclear
  • The Department advocated for a single healthcare system with multiple entry-points, and for a strong role for the provinces in NHI, including as contracting units
  • Centralised procurement carried the risk of corruption and which, as other submissions also noted, vested considerable powers in the national Minister
    • Established a centralised Office of Health Products Procurement within the NHI Fund, which would require significant administrative capability
    • Made the NHI Fund a single strategic purchaser, with attendant risks such as corruption
  • Would fragment the health system, especially through the role envisaged for national bodies in provincial facilities
  • Reallocated conditional grants and redirected the provincial equitable share
  • WCDoH proposed that:
    • The NHI Fund and NDoH should work with the provinces, as “co-stewards” of the health system
    • Provincial departments should continue to govern the central hospitals
    • Procurement should be decentralised, with the provinces also serving as strategic purchasers
    • Provinces should become the contracting units of the NHI Fund, receiving funds, coordinating services, and managing contracts with a mix of public and private providers
    • A centralised procurement process should not be attempted until the NHI Fund had appropriate and sufficient staff, systems, and processes
    • The lines of accountability in the National Health Act and Public Finance Management Act should be retained
    • The current funding arrangements (provincial equitable shares and conditional grants) should remain in place, with the NHI Fund topped up by tax subsidies in the initial phase
    • Appropriate checks and balances, including parliamentary oversight, should be applied to the board and chief executive officer, and to their appointment; and
    • The social determinants of health should be explicitly prioritised
  • Further important principles:
    • Public and private resources should be pooled
    • “Customisation” should be allowed in individual provinces, based on differing capacities and performance track records
    • Collaboration between the provinces should be strengthened
    • The National Treasury should be asked to assess the affordability and financial management of the NHI model
  • WCDoH had identified four pillars of or “action areas” towards universal health coverage:
    • service delivery
    • governance capability (including the relationship between the public and private sectors)
    • workforce capability
    • learning capability

Life Healthcare

  • NHI should be administered through a single-fund, multi-payer system, which would reduce operational risk and encourage efficiency
  • Objectives of NHI would not be met until the health system had been capacitated, especially in human resources and infrastructure, so NHI should be implemented through a milestone-based approach
  • Required public-private collaboration, especially because the use of existing private-sector capacity could help accelerate implementation
  • Life also had the following recommendations for the implementation of NHI:
    • Implementation should proceed on a milestone-based approach
    • The public and private sectors should collaborate
    • The use of existing private sector capacity could help accelerate implementation
  • Three key deliverables required to meet the objectives of NHI:
    • Human resources: both management skills and healthcare professionals
    • Infrastructure: sufficient facilities of appropriate standards
    • Capital: sufficient capital with appropriate reimbursement models
  • Four areas in which the public and private sectors could productively collaborate during the transition to NHI:
    • Education and training
    • Hospital management services
    • Elements of supply chain management (especially procurement of imaging equipment and pharmacy)
    • Provision of spare capacity through service-level agreements

The Competition Commission

  • Disagreed with the proposed exemption from the Competition Act as stipulated in the NHI Bill and submitted that the exemption should be dropped.
  • The blanket exemption would have a negative impact on the provision of universal health care services as envisioned by the NHI and could lead to collusion amongst private health care suppliers.
  • Competition Act provided for adequate mechanism to protect NHI Fund activities
  • The CC submitted that the blanket exemption should be dropped because it was inappropriate and exposed the NHI to unnecessary risks. In the interim, the mechanism in the Competition Act would apply

The Democratic Nursing Organisation

  • Highlighted the need to clarify a number of definitions in the Bill
    • ‘national health insurance’
    • ‘complementary health benefit services.’
  • Issues of corruption were raised and concerns about the coverage of asylum seekers and illegal foreigners in the Bill.
  • The need for representation of nurses within the governance and oversight functions was emphasised.
  • The current situation around the shortage of employment opportunities, despite the need for nursing staff, was highlighted.

GEMS

  • Supported the NHI addressing the barriers to access, resulting from the current two-tier healthcare system.
  • It proposed a universal health coverage for the entire population could be achieved through a health system founded on social solidarity, which allows for pooling of resources, income cross-subsidies whereby everyone contributes to funding the health system based on their ability-to-pay, and risk cross-subsidies whereby everyone benefits from health services according to need for care.
  • The NHI was the vehicle that could be used to achieve universal health coverage (UHC) in South Africa.
  • Countries that achieved UHC using a similar model included the United Kingdom. GEMS believed effective-risk pooling was a means to reduce gaps in health disparities amongst South Africans.

COSATU

  • Supported the purpose and application of the Bill which sought to ensure equitable and fair distribution and use of health care services.
  • It suggested that the purpose of the Bill be strengthened to include Primary Health Care which was the foundation of National Health Insurance and at the centre of its financial sustainability and success of health outcomes.
  • COSATU supported the proposed referral pathways.
  • The establishment of the Board was supported, and the union put forward that there should be representation from organised labour and other key stakeholders on the Board.

The South African Committee of Medical Deans

  • Supportive of a single healthcare system and the undoing of the inequitable two-tier health system
  • Concerned about the disconnect between the White Paper and the NHI Bill
  • The pilot projects did not produce the results that everyone expected – these were not written up in an evidence-based way
    • The pilot projects predominantly focused on district healthcare systems and to a small extent the contracting of private providers, but only in terms of individual practitioners
    • Recommended the piloting could be extended into hospital-based spaces and other areas that had not been covered in the previous pilot projects
  • Wanted to see the purchaser and funding mechanisms separated, to ensure good governance
    • There were benefits in purchasing that could be negotiated at a global scale – but there was concern about it being tied up in a single purchaser model.
  • Public health entities needed to be strengthened and there was a need for clarity about the management and funding models
  • Clarity was requested about the interim measures in the implementation of NHI
  • It was suggested that universities needed control of the training platform

NEHAWU

  • Supported the implementation of National Health Insurance, as it sought to ‘transform historical injustices and inequalities caused by the apartheid state.’
  • Highlighted how government subsidies were used to benefit medical aid members
  • The unaffordable private healthcare system was outlined, with particular reference to the medical schemes
  • There was a shortage of healthcare workers in the Country, this had become evident during the COVID-19 pandemic
  • The Union supported the public administering of the Fund, the future role of provinces and tertiary institutions being provided with autonomous powers
  • It was suggested that political support was needed to overcome the challenges in the healthcare system, particularly in restructuring financing of healthcare and the roles of both sectors

The Democratic Alliance

  • Supported equal access to universal healthcare but did not support the bill as it would not meet its intended objectives and was not compliant with key constitutional principles or rights
  • The manner in which the Bill sought to achieve equal access was regressive
  • The Bill misdiagnosed what had gone wrong in healthcare
    • What had gone wrong, was not the fact that the rich were getting quality healthcare, because they could afford it. What had gone wrong was that 84 percent of South Africans had been let down by a system that had not catered for them
    • When fixing that, one did not propose that the 16 percent become the 84 percent
    • What one put forward was to allow for the 84 percent to enjoy quality healthcare like those who were covered by medical aid
    • One needed to bring the country up and not down in a race to the bottom
  • Public healthcare institutions had suffered from a culture of corruption and incompetence which had led to poor management, underfunding, understaffing, a loss of skilled staff and deteriorating infrastructure
  • The Bill should be tagged as a money bill, given the massive financial consequences it would have
  • Concerns about the referral pathways were raised, particularly where it would result in unnecessary costs and delays, such as where a pregnant woman would be required to see a General Practitioner before a gynaecologist or obstetrician
  • Highlighted that the Bill discriminated against asylum seekers and foreign nationals
  • Section 27 of the Constitution stated that ‘everyone’ had the right to access healthcare, and it did not expressly exclude persons with the status of asylum seekers

The ANC

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