Fairness is at the heart of the NHI Bill, and most criticism is unfounded, says Dr Kenneth Jacobs, outgoing chairperson of the National Assembly’s Portfolio Committee on Health who played a pivotal role in deliberations on the NHI.
Spotlight’s Biénne Huisman writes that witnessing the signing of the Bill was the culmination of Jacob's own work dating back 15 years, having started working on public health projects relating to universal health coverage and the NHI in 2009 as a consultant to the National Department of Health.
He entered Parliament as an ANC MP in 2019, and two years later was elected chairperson of the Portfolio Committee on Health after predecessor Dr Sibongiseni Dhlomo became the Deputy Health Minister.
A large part of his job was to hold the country’s executive and the National Department of Health to account on citizens’ behalf. He also played a pivotal role in overseeing public deliberations around the Bill, which included 338 891 written submissions and presentations by 133 organisations.
“Never in its history has the committee had such an engagement by the public,” Jacobs said.
‘Disheartening’ criticism
The issue of the NHI has been deeply divisive, with a major criticism being that while many people and organisations made submissions to the committee chaired by Jacobs, the final Bill did not change substantially from what it was before public hearings.
Business Leadership South Africa CEO Busi Mavuso had said government rushed populist policy through Parliament – an electioneering ploy – as the significant public input into the Bill and its socio-economic ramifications had not been considered.
Jacobs voiced frustration, saying such criticism was “disheartening” and came from South Africans who are “in better financial positions”.
How was so much information – from the public submissions – collated?
“Well, first it’s driven by the chairperson (him)… We appointed a team through parliamentary processes, who looked at the submissions, and interpreted them using computerised systems. It’s thematic – what are the themes, really? These are developed into reports; the reports on all the public hearings, those reports are all available.”
So many people “who want to write and say all these negative things, they …should go and access these documents and see what the submissions were”.
‘It’s attractive to make people insecure’
Also of concern for many South Africans is the potential for corruption. Here criticism ranges from a simple distrust in government to run such massive funds, to more nuanced criticisms of aspects that critics say increase the corruption risk, like the Minister of Health’s expansive powers and accountability to Cabinet rather than to Parliament.
In an interview after the signing of the Bill, DA Chief Whip – who is also a Health Portfolio Committee member – Siviwe Gwarube, said: “The NHI will not address the underlying issues in our healthcare system; it is financially unfeasible, an election gimmick, and will burden South Africans with increased taxes. The potential for corruption is staggering, and the flawed parliamentary process further erodes public trust…”
When asked about fears that money might disappear from centralised NHI coffers – to be governed by a board appointed by the Minister of Health – and accountability to prevent such, Jacobs said: “I think people are putting the cart before the horse. You must remember this will be an entity (with tender procedures), and who is supposed to appoint them (board members) in any case?
“Somebody has to have the responsibility. Why can’t that be the Minister, for example? But remember, it will be a transparent process, the same as the appointment, I think, of how we do the appointment of judges.”
Jacobs said checks would be provided by the country’s forensic investigation agency, the Special Investigating Unit (SIU). “And there are many ways to put checks and balances into place. We talk (in the Bill) about the interventions which can be made, or investigations that can be made by the SIU and other law enforcement agencies.”
Shortly after taking over as Health Committee chairperson, Jacobs had told Spotlight that rooting out corruption in the health sector was a priority. He had also stressed the importance of safety nets for whistle-blowers, of establishing systems to enforce accountability.
Yet around the time of his appointment in 2021, whistle-blower Babita Deokaran was murdered for exposing irregular tenders worth R1bn issued at Tembisa Hospital.
On these particular earlier priorities, Jacobs responded: “I have no answer … I don’t think I want to talk about corruption now…”
Then he added: “Of course corruption is important. Losses to the fiscal are important; people doing wrong is important. People need to be brought to book, be held accountable for doing wrong…”
Later, when the issue of corruption arose again, he said it had actually decreased in South Africa: “I think we’ve advanced quite a bit from when it was more rife. I think nowadays you hardly hear about these things and it’s because unprecedented intensive programmes were put in place to address these issues … I think what they (critics) are doing is fear-mongering, telling people you need to be frightened… I’m saying it again, those who tell others to feel frightened are in a better financial position. So it’s attractive to make people insecure.”
Money for NHI?
Another common argument against NHI is that it is not affordable. The government’s spending on health has declined in real terms for much of the past decade and the economy is struggling.
On crippling budget cuts in the sector as it stands, and the NHI’s affordability, Jacobs said South Africa had insufficient central funds because of unemployment, and that the country needed more jobs and more workers to increase its tax-base.
“We need to understand why there’s a budget problem,” he said. “So where is government supposed to get money from? Who is supposed to contribute? Those who are employed. And look at our employment rate – is it government’s responsibility? No, the emphasis is wrong. It is businesses’ responsibility.
“When people have employment they can contribute to the coffers… I’m going to keep saying, the narrative is in the wrong place. We need to say to South Africans: ‘don’t all of us have a responsibility?’ Those who have the economy in their hands and those who don’t have the economy in their hands… all of the responsibility to drive our country forward.”
Jacobs expressed empathy for his clinician colleagues. “As a medical doctor, I have absolute respect for my colleagues… I understand the conditions under which our medical and health personnel have to function. And I don’t think that NHI will be a negative thing for them.”
‘Why should people profit from the ill health of others?’
On the future of medical aid schemes, Jacobs called this “a profit-driven system by people in business”.
“Is it right that there are people who profit from the lives of people, and the health of people? I don’t think that is correct.” (Note: medical schemes are non-profit entities while medical scheme administrators are for-profit.)
“What is wrong with having one single system, where everybody has access to the same healthcare? Why do we need to keep exclusionary rights for some people, based on them having a better income than others? That’s the bottom line on the answer of medical aid. Whether medical aid will stop functioning or not… that’s not the question to ask. The question is why should there be people who profit from the ill health of others?”
‘From policy to practice’
Jacobs hopes to return to public health consulting work for the National Department of Health.
“I have a project which is very dear to me. I want to start an institute for health governance called ‘from policy to practice’. It’s on health governance, universal health coverage… and will be instrumental in influencing dialogue. So I want to stay active in the sector, but not be restricted as a Member of Parliament. . .not feeling that there’s some sort of conflict.”
Originally from Gqeberha, Jacobs holds a Bachelor of Medicine and Bachelor of Surgery degree from Stellenbosch University where he also obtained a Master of Medicine degree in family medicine. He later notched up a Master of Science degree in sports medicine from the University of Pretoria.
In earlier years, he served as a physician to the Stormers and Springbok rugby teams.
See more from MedicalBrief archives:
AG flags shoddy financial controls in Health Departments
Opposition parties reject NHI Bill in current form
Rush to push through NHI Bill before ANC conference – but key questions still unanswered