The fiercely contested National Health Insurance (NHI) Bill will be rushed before the cabinet next week, despite the fact that Health director-general Precious Matsoso says she was completely sidelined from the revision of the Bill.
The Bill is the first piece of enabling legislation for sweeping health sector reforms being planned by the government in order to realise its ambitions of providing universal health coverage.
The Bill was released for public comment on 21 June, and then revised by a small team led by presidential adviser Olive Shisana, after submissions closed on 21 September. The report says their work on the Bill ran into strong opposition from senior Treasury officials, who in early November raised concerns about a host of measures in the Bill, ranging from new proposals that sharply diminished the role of medical schemes, to a lack of adequate consultation on its proposed changes, to the role of provincial health departments.
The report says the extent to which these issues have been resolved is unclear, as neither the Treasury, the presidency nor the department of health have provided any indication of the content of the revised Bill, which was presented to a cabinet committee on Tuesday morning.
Civil society organisations called on the Cabinet to send the NHI Bill back to the Health Department for a more thorough consultation process, the report says. “This version, prepared so soon after the submission deadline, cannot have taken into account the likely hundreds of submissions made by interested parties across the country,” said a joint statement by the Treatment Action Campaign, Section 27, the Rural Health Advocacy Project, the People’s Health Movement, and Lawyers for Human Rights.
South Africa’s biggest trade union federation, Cosatu, said their call should be rejected as it was a “blatant effort to slow down the implementation of the NHI policy for the poor and working class that are in desperate need of quality health services”.
The Presidency and Health Minister Aaron Motsoaledi seem intent on pushing the Bill through Parliament before next year’s election despite major unanswered questions.
Health-e News quotes the Health Department as saying that the revised Bill was presented to Cabinet’s social cluster sub-committee (27 November) before going to Cabinet.
However, the report says, the department failed to answer a number of other questions including why it was pushing the Bill through the legislative pipeline so fast. The Bill has not been discussed in the National Health Council established by the National Health Act to advise the Minister of Health on policy and on proposed health legislation.
Acting director general Ismail Momoniat wrote a letter to Shisana last week saying that Treasury could not support the latest version of the Bill as it had been “very substantively amended in October”, removing various agreements reached between the Ministers of Finance and Health. Treasury was particularly concerned about amendments to the powers of provinces to deliver healthcare, inadequate costing of functions and the relegation of medical schemes to a complementary role which was “premature” and opened the Bill to legal challenges.
However, the report says after the letter was leaked to the media, Treasury issued a statement describing it as “part of the vibrant and ongoing engagement to ensure policy coherence”. “We have made substantial progress on key areas and have reached agreement on most of the major issues,” added Treasury. “Many of the issues raised by Treasury have been substantively addressed. We are confident that we will soon publish this important Bill for tabling in Parliament.” But Treasury stressed that “the NHI must be adequately funded and successfully implemented while reducing the risks involved in the implementation of such a large and complex programme”.
Civil society organisations claim that the draft Bill was prepared even before a Presidential Summit that was supposedly called to consult various parties about the NHI. “Public comments on the NHI over the past decade do not appear to have been taken into account, either between the Green and White Papers and the Bill or after the draft Bill was published for public comment,” the civil society joint statement said. “This makes a mockery of public consultation as required by the Constitution and opens the Bill up to future attack and delay on these grounds.”
The organisations also argue that the current Bill “risks damage to the functional elements of the health system – public and private” and that “government needs to focus on fixing the crises in private and public health rather than on hastily passing legislation that, in its current state, takes the country in the wrong direction”.
The report says while the Health Department failed to respond to the civil society statement, last week Treasury said that “the implementation of the NHI and improvements in the quality of the health system go hand in hand and are therefore being addressed concurrently.”
Health director-general Precious Matsoso says she has been completely side-lined by Shisana and Motsoaledi in revising the controversial Bill. Business Day reports that in a hard-hitting interview, Matsoso said the last time she had seen a copy of the draft bill was when it was released for public comment in June. "I have not been involved at all in Olive’s Bill. The process has been driven through structures I am not involved in," she said. Matsoso said policy development should be conducted in an open and transparent manner, but this had not been the case since Shisana’s involvement. "I don’t know who has been consulted on the Bill. I’ve never seen policy developed in this way. It is an unhappy state of affairs," she said.
Shisana said in the report that the Presidency had liaised with Motsoaledi, who had delegated two officials to work on the NHI Bill based on their technical skills – deputy director-general for NHI Anban Pillay and Motsoaledi’s adviser, Aquina Thulare.
"The role of the presidency is to facilitate where there are difficulties," Shisana said.
The report says in an unusual turn of events, Yogan Pillay, who was acting director-general while Matsoso was out the country, signed off on the revised NHI Bill on Thursday morning. It is understood the minister has previously instructed Matsoso to return to the country to sign off important documents, such as the department’s annual report. But in this case, he did not do so. Pillay said the minister was expected to sign the Bill on Thursday, and it would be submitted to the cabinet secretary later in the day in order to be put on the agenda for next week’s cabinet sub-committee meeting.
Wits University professor Alex van den Heever said in the report that it was "highly improper" for an acting director-general to sign off on draft legislation. "They haven’t properly reviewed the submissions (or_ taken into account serious flaws. It is too substantive to be rushed in an irregular way. "To by-pass the director-general is suggestive of a deliberate strategy to subvert normal process. You don’t do it for good reason."
The report says the Treasury’s letter raised a series of red flags with Shisana, including the fact that the revised B ill reversed a number of issues previously agreed to by the ministers of finance and health, such as allowing medical schemes to continue to operate during a transition phase.
A joint statement issued by Health, the Treasury and the Presidency last Friday said many of the Treasury’s concerns had been addressed, but provided no detail.
The report says Pillay declined to comment on the Bill’s contents. "If I had any reservations, I would not have signed it," he said.
[link url="https://www.businesslive.co.za/bd/national/health/2018-11-27-contested-nhi-bill-on-its-way-to-cabinet-presidency-confirms/"]Business Day report[/link]
[link url="https://www.health-e.org.za/2018/11/27/nhi-bill-being-pushed-for-elections/"]Health-e News[/link]
[link url="https://www.businesslive.co.za/bd/national/health/2018-11-23-health-dg-kept-in-the-dark-on-revisions-to-nhi-bill/"]Business Day report[/link]