Advocacy groups are among those questioning the planned National Health Insurance’s oversight body, flagging Sections 42 to 44 of the Act, which designates a centralised investigative unit as the sole authority for managing all complaints.
This has become a contentious issue in the court challenges against the NHI, with detractors arguing that this will undermine transparency, compromise the independence of investigations, and erode public trust in the system, writes Yoliswa Sobuwa for Health-e News.
Currently, patients can submit complaints, either verbally or in writing, directly at the health facility concerned.
Professor Hassan Mahomed, a public health specialist with the Western Cape Department of Health and Stellenbosch University, says Sections 42 to 44 of the NHI Act provide for the establishment of the Fund’s own internal complaints investigation unit and appeals process, raising concerns that this may function separately from the Office of the Health Ombud.
“The Ombud is part of the Office of Health Standards Compliance (OHSC), which is intended to operate independently of both the Department of Health and the NHI Fund, as established by the National Health Amendment Act of 2013,” he said.
But it is unclear whether a complainant can seek redress through both channels, either simultaneously or in succession. Legally, these structures appear independent of each other, and in theory, the Ombud should be empowered to act independently, particularly in cases where complaints are directed at the NHI Fund itself, he added.
With health facilities usually being resource-constrained, it is difficult to give patient complaints the necessary attention.
“A fundamental issue is the asymmetric power dynamic between vulnerable patients and a powerful health system bureaucracy, so most dissatisfied patients do not report their complaints. It is primarily empowered individuals, or those with particularly serious complaints, who persist in pursuing a resolution,” Mahomed pointed out.
People can also lodge complaints through the Health Ombudsman, who is meant to act independently and help protect patients.
But the Ombud’s office is also facing severe resource constraints, with staff based in former store rooms without windows, fresh air, or natural light.
The Health Ombud’s 2023/2024 annual report reads: “The call centre operates in an open space that is prone to noise disruptions, which compromises confidentiality when interviewing complainants. Assessors and investigators also work in an open-plan area, making it difficult to concentrate due to frequent distractions.”
Another avenue is the HPCSA, which handles complaints against healthcare professionals registered with them.
Under the NHI, however, all complaints will be handled solely by the NHI Fund.
Health Ombud Professor Taole Mokoena said his office would collaborate with the NHI Complaints Management unit to avoid duplication, as the office was currently responsible for referring matters related to corruption, fraud, or unprofessional conduct to the appropriate statutory bodies.
The Ombud’s role will expand beyond public facilities to include all healthcare providers contracted by the state. Currently, the Health Ombud primarily deals with failures in the public sector.
“The office will have the authority to investigate complaints related to the NHI Fund, healthcare service providers, establishments, and suppliers,” Mokoena said.
But additional resources will be crucial to manage the increased demands.
Oversight and quality assurance
Dr Nicholas Crisp, Deputy Director-General for the NHI, said if it becomes apparent that a provider was not delivering quality care, “the NHI Fund may initiate an investigation to improve services or, if necessary, terminate the provider’s contract”.
The NHI would be held accountable for how it handles and resolves complaints from patients or healthcare users, he added.
“When a complaint is made, it will be referred to the relevant healthcare provider, the Office of Health Standards Compliance, or the Health Ombud, depending on the issue.
“However, the Fund will keep a record of all complaints to identify any recurring problems with specific providers.”
See more from MedicalBrief archives:
NHI violates doctors’ and patients’ rights – SAMA constitutional challenge
SAHRC to probe hundreds of complaints about public hospitals
Public Protector rules hospitals in 4 provinces fail Constitutional standards
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NHI Bill ‘won’t be a silver bullet’ in saving public healthcare in SA