August 20, 2019

Concerns mount over speedy Cabinet passing of the National Health Insurance Bill

The July announcement that Cabinet has endorsed the controversial National Health Insurance (NHI) Bill, which sets it well on its way along the legislative pipeline with the possibility of it being passed into law by July next year, has been greeted with reminders by civil society that the urgent priority remains to fix the public health service.

The NHI Bill, which proposes a national fund to facilitate better access to universal essential healthcare services for all, would have to be premised on an improved public health service. The announcement by the new Minister of Health in his budget speech takes into account that improvements need to be made to existing management, staffing and general infrastructure in the public service as the basis for a successful NHI system.

It is generally agreed by most stakeholders, including the minister himself, that while further delays in setting up the NHI fund are not desirable, at the same time the NHI Bill is not ready for debate in parliament until there are clear signs that the basics are in place and greater certainty that the public health service in South Africa is in a position to provide universal quality healthcare services to all South Africans, irrespective of socio-economic background.

Various stakeholders have warned that the NHI will not succeed if the current mismanagement of public healthcare facilities persists, and the shortage of doctors and other health professionals is not addressed.

Speaking at a press briefing before the debate on the health budget, the new Minister of Health, Zweli Mkhize, acknowledged, “It will be impossible to convince the public about the virtues of the NHI if it is built over a dilapidated and decaying infrastructure”.

However, the speedy move by Cabinet took many by surprise. It was followed days later by Mkhize announcing in his budget speech that the time for talking was over. He had already presented Parliament with the national health department’s latest annual performance plan, which indicated that the final NHI Act could come into effect before March 2020.

Most stakeholders agree that while further delays in setting up the NHI fund are not desirable, the NHI Bill is not ready for debate in parliament.

Progress on the Bill lagged under former Minister of Health, Dr Aaron Motsoaledi, and it has been suggested this may be a reason that he was shifted to the Home Affairs ministry. In this context it is understandable that new Minister Mkhize would be keen to prove himself.

But stakeholders in the health sector have raised concern that the bill that is heading for parliament may not reflect the last round of public hearings that were conducted last year. It is not known when it is due to be tabled before parliament, but that will provide another opportunity for further public consultation.

The latest comments from civil society group the People’s Health Movement South Africa (PHM-SA), the South African chapter of the global People’s Health Movement (PHM), which is a network of grassroots activists, civil society and academics from about 80 locations mostly in the developing world, commented that the NHI Fund must be implemented urgently. At the same time it recognises that introducing the NHI without addressing the challenges in the public health service is pointless.

PHM-SA argues that that the two go together. While the priority is to improve management, infrastructure and services in public health this should not delay setting up the NHI fund as a single, mainly tax-based funding mechanism The two are inter-related and inter-dependent.

A member noted: “We want to see the Department responding to the groundswell that says the NHI will not work unless the public health system is fixed. Their response needs to show that while they introduce the NHI they will also fix the public health system. If they don’t, the NHI is doomed.”

From the start, PHM SA has thrown its full support behind the introduction of a NHI. Its founding principles resonate with the NHI Bill, which is committed to “equity, social solidarity, health care as a human right and public good, and the provision of effective, universally accessible, comprehensive, high quality care in an affordable and efficient manner”.

PHM recognises that South Africa needs a single progressive NHI Fund, but warns: “the Bill contains several deficiencies and anomalies which need to be rectified if the human right to health is to be achieved for all the people who live in South Africa”.

The group confirmed that they had heard nothing in advance of Cabinet’s decision and were surprised to find themselves outside of the consultation process at this critical state. This especially after being part of former minister Motsoaledi’s ongoing, albeit protracted, consultation process.

A strong supporter of the NHI, a source from PHM-SA expressed the hope that “the unfolding parliamentary process allows for substantial revisions and clarifications – and time to really invest in strengthening the public sector,” which is broadly seen as an essential precondition for a successful NHI.

“PHM is greatly concerned that if the public health sector is not strengthened urgently and private sector facilities are accredited to receive NHI funding, the already wide gap in health service provision between public and private, especially in rural areas, could be aggravated.”

It says so far public consultation on the NHI Bill has been “constrained” by a lack of access to information, which they describe as “a constitutional imperative when appraising new legislation. Facilitating and expanding discussion on the NHI Bill would only be effective if the discussions are informed by adequate information” on the various proposals presented in the NHI.

It is known that many technical background reports have been produced which informed choices made in the NHI Bill, but few of these reports have been made available to the public, says the PHM-SA. These reports, as well as reports on NHI pilot studies, which are known to have largely been a failure, must be made publicly available, the group insists.

In the most recent public submission by PHM-SA it states: “Going forward, we believe that a specific mechanism and process of ongoing stakeholder involvement, engagement and interaction needs to be instituted, to assist with popularising, defending and implementing the NHI. As with the land appropriation consultative process, an active process of public engagement is not only required but is mandatory in terms of our Constitutional commitment to participatory democracy.”

In light of this comment, made late last year, there is definitely something ironic in the way Cabinet has proceeded, leaving an array of public stakeholders behind, and unaware if the concerns they have raised have been incorporated into the Bill approved by Cabinet or not.

When last engaged, the PHM-SA pointed out a number of issues that it believed needs to be addressed:

  • The centralised NHI Fund threatens to be another state enterprise that could be open to corruption. It will have extensive purchasing power and authority to invest or borrow funds, without a clear oversight authority and apparently answerable only to the Minister. South Africa has learned to its great cost about the dangers that could result from such an institution.
  • In the last version of the legislation to be subjected to public scrutiny there was concern about the composition of the NHI Board, with eligibility for membership of the board specifically excluding public sector health providers and persons with “personal or professional interests in the health sector.” Would this exclusion be in the best interests of effective oversight?
  • There remains lack of clarity about the sources of income for the fund. Will tax mechanisms be used and how will transparency be guaranteed and procurement processes protected from influence from private sector sources?
  • According to the last version of the bill, the Benefits Advisory Committee and Benefits Pricing Committees would have no civil society or labour representation.
  • The Bill that was last considered publicly did not, in the view of PHM-SA, make sufficient provision for preventative health care or for strengthening the public sector, especially in primary health care, which is seen as the backbone of the NHI. There was also little attention paid to the obstacles facing rural health care.
  • The present wording suggests that undocumented migrants and refugees will be discriminated against by not being included in the NHI.

Whether or not matters such as these have been addressed in the Bill as passed by Cabinet remains unknown.

Moira Levy

Additional Info

  • Author: Moira Levy

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Notes from the House is an independent online publication that tracks and monitors Parliament’s role in fulfilling its constitutional responsibilities to improve the lives of South African citizens. Published by Moira Levy with the support of the Claude Leon Foundation.

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