Health Dept and Treasury battle behind the scenes over NHI Bill

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Presidential adviser Dr Olive Shisana and Minister of Health Dr Aaron Motsoaledi appear to have side-lined senior Health Department and Treasury officials in preparing a new version of the National Health Insurance Bill for submission to CabinetSpotlight reports that it was only after a four-page letter sent by the acting director-general of Treasury that the Presidency again meaningfully involved Treasury in the Bill process.

The report says according to the damning Treasury letter various provisions in the Bill that had previously been agreed between government departments had been changed without consultation or agreed-upon changes were not implemented. Treasury also alleged that comments from the public have not been taken into account. “The Bill has been very substantively changed since the version approved by the previous Minister of Finance, and these new changes have been made without consultation with the Minister of Finance,” the Treasury letter read. “Many of these changes are potentially very problematic and require more work and thorough discussion with the Minister of Finance.” Treasury also said that the Bill is “unfriendly” to refugees, asylum seekers with “even children not entitled to hospital care unless in an emergency” and that “there may be human rights issues with this”.

The report says Cabinet spokesperson Phumla Williams could not confirm whether a new version of the Bill had been or will be submitted.

South Africa has for some time been grappling with the introduction of a universal healthcare system, referred to as National Health Insurance. The report says NHI is likely to become a hotly contested election issue with some analysts arguing that the looming ballot is behind the haste to push this bill through.

The Treasury letter was signed by Ismail Momoniat, the acting director-general of Treasury, and was addressed not to Minister of Health Dr Aaron Motsoaledi or his director-general Dr Precious Matsoso, but to Dr Olive Shisana, the Presidency’s adviser on NHI. According to the report, various sources have suggested that Shisana is the driving force behind attempts to push through the Bill in its current form. The report says Shisana declined to answer questions sent to her. It is also understood that senior officials in the Health Department have not been consulted on the latest round of changes to the Bill and that the new version was sent directly to Motsoaledi for its passage through Cabinet. The Health Department also declined to answer a set of questions.

“Based on the submissions we have seen, our impression is that the revised Bill largely ignores or does not accept many of the submissions received,” read an annexure to the Treasury letter. This view is supported by the fact that Shisana’s latest version of the Bill is dated a mere 14 days after a number of organisations and groups made substantive submissions on the version of the bill published for public comment.

The Treasury letter stated that it is unable to support the Bill in the form due to be submitted to Cabinet and that the Bill should be revised and resubmitted to Cabinet. It argued that a “more measured, gradual and practical approach is required to the shifting of major functions between spheres”.

“NHI is very, very important, but I don’t understand the rush. Ironically if the questions raised by Treasury aren’t answered then NHI will end up being delayed indefinitely,” said Mark Heywood, executive director of Section27 is quoted in the report as saying. “The new Bill being advanced by Olive Shisana and the minister will create a fund that is vulnerable to massive corruption and capture.”

“It’s sad that this is happening now,” said Heywood. “The overwhelming message of the recent Health Summit called by the president, that Shisana is meant to work for, was that we first need to focus on fixing that health system. Instead Shisana is ignoring not only the written submissions made by many organisations but also the 600 people who attended the Health Summit.

The report says the letter and its annexure specify a number of “major problem areas” and legal concerns with the current version of the NHI Bill. One of the key issues is that the Bill will remove many aspects of the health function and health budget from provinces – fundamentally changing the current arrangement by which provinces are responsible for the running of their healthcare systems. “As it stands the Bill introduces massive uncertainty into the intergovernmental financing system and the location of health functions”, reads the letter.

Treasury also cautioned that it is important that a legal opinion be secured on the shifting of provincial functions to reduce the risk of delay through further constitutional challenges.

The report says the Treasury letter also highlights an amended provision stating that the role of medical schemes will only be complementary to the fund (medical schemes will thus not be allowed to offer services already offered through NHI). According to Treasury such a provision is “highly premature given that it will take years for the Fund to be meaningfully offering services equivalent to those existing 8.8m current medical scheme users access from the private sector”. It goes on to say that this move is “unnecessary at this point and will be perceived as extremely threatening to existing medical scheme users and tax payers, to the entire private health sector and will undermine investment.” They warn that this section of the Bill “will almost certainly bog the bill down in endless legal challenges”.

The report says other concerns raised by Treasury include: that some of the proposed governance arrangements in the current version of the bill are “unclear or contradictory”; that “the Bill attempts to supersede all other legislation including the Public Finance Management Act and Division of Revenue Act”; and that the financial implications of the bill have not been costed.

The report says Treasury’s concerns with the NHI Bill are in some respects similar to concerns previously raised by some civil society organisations. Section27 and the Treatment Action Campaign said in their submission on the NHI Bill: “We are in agreement that the current two-tiered health system is inequitable and that there is a need to change health funding. We are further in agreement that the right of everyone to access to health care services means that everyone should be able to access quality services on the basis of need, rather than on the basis of ability to pay. This agreement is unequivocal.”

However, the organisations made it clear that this agreement does not require agreement with the way in which the change to the health system and the establishment of the NHI Fund has been laid out in the NHI Bill and associated documents.

“Disagreement with the NHI proposals does not, in our case, equate to anti-poor sentiment or satisfaction with the status quo. Instead, the purpose behind our criticism is that we are concerned to ensure the health system reforms that are required are in fact implementable and sustainable.”

Treasury is quoted as saying in the letter that if its proposed changes are being taken seriously as stated, then the bill should be revised and resubmitted to Cabinet with a copy sent to Treasury urgently “so we do not repeat issues that have already been addressed”. “There needs to be a series of technical and political discussions between Health, Treasury, Presidency and State Law Adviser teams to resolve problematic areas or to revert to previous agreements,” it says.


Pam Saxby for Legalbrief Policy Watch says that the Treasury has, meanwhile, issued a statement dismissing the allegations. It said the Treasury letter to which the article referred was apparently part of “vibrant and ongoing engagements” aimed at “ensuring policy coherence”. “We have made substantial progress on key areas and have reached agreement on most of the major issues,” the statement continued, noting that “many” concerns raised by Treasury have been “substantively addressed”.

This is nevertheless bearing in mind that the “large and complex” NHI insurance programme envisaged “must be adequately funded and successfully implemented” – and any associated “risks” kept to a minimum.

Against that backdrop (and noting that President Cyril Ramaphosa is now providing the necessary leadership) improvements to the “quality” of existing public sector healthcare services and challenges encountered during NHI preparations are “being addressed concurrently”. The draft NHI Bill released in June for comment is being fine-tuned and will be published “soon” in anticipation of being tabled in Parliament.

Saxby writes that while it is not clear when the Presidency took “stewardship” of the “NHI process”, according to Deputy President David Mabuza the move was made with the aim of “ensuring” that “affordable quality health care” becomes universally accessible within a “reasonable” time-frame.

Addressing delegates at last month’s presidential health summit in Ekurhuleni, Gauteng, the deputy president conceded that, among other things, “a change in the management culture of hospitals” is needed – “underpinned by consultation between staff, managers and labour over decisions that affect the work environment”. Related to this, “gross” human resource capacity ‘inequalities’ between public and private healthcare sectors “need to be faced head-on and resolved speedily”.

Saxby writes that noting disparities between private and public healthcare funding – as well as a budget allocation bias favouring provincial facilities in “rich … urban areas” – Mabuza alluded to a change in priorities informed by a ‘re-costing’ exercise and ‘the burden of disease per district’. He nevertheless conceded that ‘there are challenges associated with the management of … financial resources … (across) the public sector. ‘

“Corruption is an enemy of our people,” the deputy president said, urging delegates to “fight this with everything at … (their) disposal”. In this regard, he emphasised the importance of “value for money” in public procurement, improved supply chain management and proactive infrastructure maintenance.

Daily Maverick report
Legalbrief Policy Watch report
Government statement

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