Update on SAMED’s and other stakeholders’ engagements with Parliament on NHI

The SAMED NHI Committee has been keeping an eye on oral submissions to Parliament by various stakeholders regarding their views on the NHI Bill, as we finalise our own presentation and await the slot allocated to SAMED to engage with the Portfolio Committee on Health.

Please ensure that your organisation has registered for the SAMED NHI Forum (11-12h30, Friday 18 June) for a preview of the SAMED presentation and an opportunity to ensure that we address the key issues that affect our members and industry, and those that are likely to shape the market as well the healthcare system and health outcomes for years to come.

Here is a snapshot of some of the positions taken by other organisations that have presented at Parliament in the last few weeks.

• Board of Healthcare Funders (BHF) identified constitutional issues in the Bill that might impede the implementation of NHI. It proposed that the Bill be strengthened in several aspects, including the language used, corporate governance of the NHI Fund, flow of funding from the Fund to providers, the role of provincial and local government in the delivery of services and maintenance of the purchaser/provider split throughout the health system.
• Health Professions Council of South Africa (HPCSA) took a pro-centralisation view suggesting that NHI should be the only funding mechanism for health services in the country and that some R90bn in medical schemes’ reserves should be transferred to the NHI Fund as well as that the Fund should be funded through taxing all employed South Africans. NHI should be about funding and contracting while service provision is left to other public and private entities.
• National Health Care Professionals Association (NHCPA) is concerned by governance structures and the Minister’s powers to appoint the board and also the slow improvement of public health infrastructure, with a recommendation for direct funding over the next five years for infrastructure development. Despite its concerns, it believes that the NHI Bill must be assented to and the Act implemented now, with the NHI as the sole funder for healthcare services in South Africa.
• National Health Laboratory Services (NHLS) recommended that the Fund contracts with the NHLS as a designated service provider for all pathology services. NHLS has the platform to ramp up laboratory tests to meet the increased needs for healthcare that would come with increased access to services. It thinks that the Bill should contain principles and not every detail, and that the legislation should be enabling. Necessary amendments would be more difficult to make to the Bill than the regulations – a matter that was also raised by the Pharmaceutical Society of SA (PSSA).
• Public Health Association of South Africa (PHASA) said that the Bill as currently formulated is essentially a standalone, independent piece of legislation, largely unrelated to much else in the national health system. It would be much improved if the financing mechanism underpinning the provision of NHI was explicitly linked to the health system, specifically in reference to the National Health Act.
• South African Association of Hospital and Institutional Pharmacies (SAAHIP) recommends a process of upgrading non-compliant facilities, placing greater emphasis on prevention rather than cure and that all amendments and decisions taken by the NHI board must be officially announced to the public, irrespective of how minor the decision may be.
• SA Human Rights Commission (SAHRC) said that the success of NHI will depend on, among others, good governance, proposing clarification of the powers and function of the Chairperson, Deputy Chairperson and members of the board. SAHRC is concerned about the appointment process of the board, its independence and reporting lines in light of the proposed governance structure which affords concentrated power to the Minister.
• SA Medical Association (SAMA) said that thousands of doctors may emigrate if the NHI is adopted in its current form and warned about the fear of corruption and “uncertainty and anxiety” that the Bill was causing among the medical profession. SAMA does not support the governance structures in the Bill and believes the Minister has too much power. If the Fund was accountable to the Department of Health and vice versa would come closer to a true purchaser-provider split as originally envisioned by NHI policy. It is concerned with excessive focus on cost and the lack of emphasis on quality of care as well as the absence of structures to address out-of-hospital specialised care. SAMA added that the development surrounding Minister Zweli Mkhize has far-reaching consequences for health provision in the country, and casts a cloud on plans to roll out NHI.
• SA Medical Research Council (SAMRC) raised the matter of the envisaged accreditation process which could render many currently operational public sector facilities ineligible to be contracted by the Fund. This carries the risk of socialising the funding of healthcare but privatising the provision of healthcare in the country.
• SA Nursing Council (SANC) recommended that the definition of health-related products in the Bill is replaced with health products as this is the internationally accepted WHO definition. SAPC also recommended the use of the WHO definition for “promoting affordable and fair pricing and effective financing” as it is in line with international benchmarking and to ensure that the health products procured address not only cost but also quality and effectiveness.
• 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 the 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.
• Free Market Foundation (FMF) were frank about the State’s inefficiencies with managing public funding and the tragic state of State-Owned Entities (SOEs). They referred to the last Auditor-General report and stated that there was woeful health misspend that needed to be addressed. There was room for improvement in both the public and private sector but this was not reason enough to presume nationalising the management of healthcare in the hands of the state would solve all the current healthcare problems,
• Business Unity South Africa (BUSA) supported the implementation of national health insurance but proposed that a multi-funder dispensation be permitted in providing a minimum package of healthcare services for all South Africans. BUSA stated that both high income (Germany, Netherlands, Switzerland) and middle income (Chile, Mexico) countries, have multi-fund partnerships between the public and private sectors. SA is well-suited to a multi-fund NHI, given its existing systems and capacity. No countries with large “single fund” approaches have legislative restrictions on private cover. Optimal investment and innovation in the health sector is the product of vision, skill, competition, policy and regulatory certainty and a diversity of views. NHI as a single fund will not promote such an outcome. Phases should be defined by milestones achieved rather than dates and a progressive realisation of cover should target the most vulnerable with an incremental approach to tax-based funding within the construct of our national social protection floor.
• Health Funders Association (HFA) emphasised that medical schemes were a vital vehicle for social solidarity in accessing healthcare. There were a number of consequences that would result from restricting medical schemes, including increasing the burden on the public sector, reducing cover sustainability and exacerbating the issue of a shortage in healthcare providers.
• The American Chamber of Commerce South Africa (AMCHAM) outlined American investment in the South African healthcare sector and highlighted that the unclear funding mechanism for the NHI would impact the sustainability of the proposed system. It proposed that the Bill should opt for a milestone approach, with a detailed implementation plan. Risks of centralised funding were pointed out, specifically as it could lead to provincial misalignment if not managed appropriately. There needed to be robust governance and transparency in the system, both in the private and public healthcare sectors.
• Black Pharmaceutical Industry Association (BPIA) raised concerns around the inclusion of small black-owned pharmaceutical companies as this was already an industry challenge and encourage the Committee to ensure that a B-BBEE certificate is a consideration for SAHPRA licensing.
• FW de Klerk Foundation highlighted Canada’s Supreme Court judgement which found that prohibiting private medical insurance in the face of long wait times violated human rights and freedoms. The submission emphasised the impact of NHI on individual rights to freedom of association and asylum seekers and concerns around the Minister’s powers under NHI.
• Helen Suzman Foundation supported universal health coverage but suggested that it could only be implemented if the existing system was functional. It highlighted the essential problem with NHI, as set out in the Bill, was that it was a funding and payment mechanism that would be superimposed on two badly functioning healthcare sectors. The Bill did not adequately explain how NHI would transform these sectors and address the problems.