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HomeA FocusSAMA's warnings on NHI Bill met with hostility

SAMA's warnings on NHI Bill met with hostility

The SA Medical Association told parliamentarians  that thousands of local doctors may emigrate if the NHI is adopted in its current form, reports MedicalBriefIt criticised the Bill for lacking essential detail and warned about the “uncertainty and anxiety” it was causing in the medical profession.

SAMA warned that in its current form, SAMA's 12,000 members did not support the NHI, a SAMA poll of members had found. Around 78% of respondents did not believe the NHI proposals would improve healthcare services in the country.

SAMA had included a question about emigration when it polled its members about the NHI proposals. A total of 38% said they wanted to emigrate, 39% said they would not and 17% were unsure. Fear of corruption is flagged as a major concern by doctors, as well as a lack of emphasis on quality of care.

“There is a deeply-rooted lack of confidence among our members in the capacity of government structures to provide financial support structures for quality service,” SAMA's Dr Angela Coetzee is quoted as saying, in a report in Die Burger. “We remain concern that the NHI is viewed as a simple and seemingly magical solution for a complicated problem.”

Although SAMA supported Universal Health Coverage (UHC) in principle and the coverage of the whole population for “a well-developed healthcare benefit, which was not based on the ability to pay for care”, it could not support the NHI Bill in its entirety, reports MedicalBrief. There were provisions in the Bill that lacked “essential detail which has far-reaching consequences for NHI implementation”.

SAMA highlighted existing, significant quality deficits in the public health sector, saying these would simply be incorporated into the new world of the NHI if significant strides in addressing these first were not made.

“As the Parliamentary Public hearings have served to emphasise, communities, and facilities lack basic infrastructure, staff and support systems to run quality healthcare provision. SAMA remains engaged in multiple projects to improve the quality of healthcare delivery, but these appear to be divorced from the need for an NHI.”

SAMA said:

  • We support the step-wise, resource-informed and evidence-based approach to the implementation of any major reforms in the health system.
  • Many of the proposed changes in the Bill have yet to be fully researched for their effectiveness and potential to actually improve service delivery by ensuring that there are sufficient funds and the desired framework to achieve this.
  • There is a deep-seated lack of faith amongst our membership in the ability of the government structures to provide the financial support structures for quality services.

SAMA said that the concerns expressed in relation to this latest Draft NHI Bill echo its sentiments over the Draft 2018 Bill and the policy documents preceding this piece of legislation.:

  • Quality of care – there was not enough emphasis in the Bill on quality, too much emphasis on cost.
  • Inadequate coverage for asylum seekers and illegal foreigners.
  • Non-Independence of the NHI Fund and the exceptional powers of the Minister of Health.
  • Monopsonistic purchaser – single large fund and no purchaser/provider split.
  • Board and Advisory Committees not independent and appointed by the Minister.
  • NHI Pilot programmes (2012-2016) had demonstrated little useful outcomes.
  • Uncertainty in many of the key proposals – detail is lacking.
  • Reimbursement – doctors to deliver quality care at the “lowest possible price”.
  • Contracting issues – contracting proposals are complex and need trials / piloting before they are included in an Act of Law.
  • Absence of any structures to address out of hospital specialised care.
  • Certification, Accreditation and Contracting of healthcare services providers.

“SAMA does not, though, support the governance structures as laid down in the NHI Bill as it believes the Minister of Health has too many unfettered powers in this structure.” It further believes that the Fund should be accountable to the Department of Health and vice versa. This is closer to a true purchaser-provider split as originally envisioned in the NHI policy documents.

It also objected to the Bill’s approach to asylum seekers and illegal foreigners, given that these very vulnerable groups will be entitled to emergency medical services and services only for notifiable conditions. The children of these groups will also only have limited access to healthcare.

“Doctors do not distinguish the need for care on the basis of legal status in the country and it would be unethical for doctors to do so. We cannot accept the situation for these groups unless there is a proposal for how their care will be funded and provided.”

In its statement, SAMA also expressed concern that the proposed payment and contracting mechanisms for healthcare providers are on the verge of being signed into law.

Turning to the role of medical schemes, SAMA said:

  • Clause 6(o) provides that users have the right: “to purchase health care services that are not covered by the Fund through a complementary voluntary medical insurance scheme registered in terms of the Medical Schemes Act, any other private health insurance scheme or out of pocket payments, as the case may be”. SAMA believes that application of this clause should mean that if for example, NHI benefits include hip replacements and hospitals cannot offer the service timeously, patients should have a choice to attend private sector facilities, funded through private insurance.
  • SAMA argues that, while the user’s right to use non-NHI service is being respected, a user seeking care from non-NHI providers should not be compelled by an in-comprehensive basic NHI package, or poor quality of the package, including interrupted service and goods supply, especially in the public sector.

“SAMA is in favour of evidence-based policy and law and there is far too little detail provided on these payment mechanisms for us to engage with them at this stage. The NHI pilots from 2012 to 2016 did not test these proposed mechanisms and SAMA believes that before these are signed into law, it needs to do significant work piloting these ideas and testing whether they will function for the positive benefits of the patients under NHI.

“As a membership organisation, SAMA remains worried about the uncertainty and anxiety that these vague aspects of the Bill are generating among its membership, medical doctors in training, and learners considering medicine as a career. South Africa already suffers from a shortage of medical doctors, and SAMA is of the view that it needs to work extensively with the government to ensure that the proposals for the NHI are feasible and developed further for the sake of certainty as well as in the best interests of serving the interests of the public.”

The SAMA presentation, made by Dr Angelique Coetzee and Dr Mvuyisi Mzukwa, was met with some hostility from some members of the Portfolio Committee on Health, writes MedicalBrief.

The chair of the committee, Dr Sibongiseni Dhlomo (ANC), wanted to know why Coetzee, who had not attended the previous week's input from the Health Professions Council of SA, now “would want the HPCSA to have presented a different presentation”? Dhlomo said it concerned him that Coetzee was challenging other presentations made by another entity, an entity that included some SAMA members on the SA Medical and Dental Board.

Mxolisa Sokatsha (ANC) expressed scepticism over SAMA's position on asylum seekers and undocumented migrants.  He asked how SAMA proposed that additional funding for those groups in the population be mobilised, given an environment of financial resource constraint.

Mzukwa replied that SAMA was concerned whether organisations like the Southern African Development Community could come up with a way of funding asylum seekers. Even now, people were coming from other countries to seek healthcare in the country.

It was not proper for a doctor to be chase away an asylum seeker because they were not covered. They were trained to attend to them in terms of their ethics training.

Annah Gela challenged the SAMA over its views on the public health system. Did they really think health had gone backward given positive improvements of factors like improved life expectancy?

Tshilidzi Munyai took issue withe SAMA's concerns over the powerful role played by the Health Minister. He said that  the Minister had executive power but was accountable to Parliament, which was no different from any other institution. Had they seen any other interference in that regard? Did the presenters have an issue with the Minister performing his functions as outlined by the Constitution?

Munyai wanted to know whether SAMA support the current status quo of the two-tier system which favoured the rich and medically aid funded. Since 1994, there had always been some who feared a democratic and equal society and wanted to go overseas. In any case,  SAMA poll's findings did not agree with the research done by the SA Medical Research Council (SAMRC).

SAMA's Coetzee responded that the reason doctors wanted to emigrate was because they did not trust the current system. Although they would emigrate and work under another NHI system there, that system was likely trusted and had been in place for many years. This was deemed preferable by them to working under a pilot system.

SAMA said in reply that it could not comment on the StatsSA or the SAMRC findings. Their's was a patient survey, whereas SAMA had conducted a doctors’ survey. They could only comment on what their doctors were telling them.

About 988 members participated out of 12,000 members – this was a high rate in the medical field, as doctors were known not to participate. They intended to follow-up the survey.

Coetzee said that the committee should draw a distinction: the NHI was a funding model, it was not a universal health care model. If there was not enough funding or frameworks in place, there would be difficulty in implementing universal health coverage.

Equal access, did not necessarily mean good quality healthcare, said Coetzee. It just meant one could go to a clinic or a doctor. It did not guarantee good evidence-based treatment.

Dr William Oosthuizen,  SAMA, said that he noted “some hostility” in the asking of some of the questions, which was unfortunate given that SAMA was trying to provide insight to better the system for all. Their members just wanted the best for their patients.

It seemed that parliamentary oversight was not always enough to combat some of the issues corruption, Oosthuizen sad. It was something they took very seriously. “Every penny stolen from the population and the health system is a penny that could cost someone their lives. I do not want this to be dismissed as people just making noise. This is a serious concern and it needed to be taken seriously.”

There was a severe lack of trust. Many SAMA members had been the victims of corruption and mismanagement of the systems. Coetzee said he hoped that the Committee would take these concerns seriously and start to think about ways to implement so that they had a universal healthcare system that provided quality healthcare for all of its citizens.

In other submissions

The Board of Healthcare Funders identified several constitutional issues in the Bill that might impede its implementation, including legal certainty and the rule of law – this relates to the language used in the Bill; restrictions on the right of health professionals to choose and practice their profession; restrictions on the right of access to healthcare services in the Bill, including the role of medical schemes to offer parallel benefits cover, and the role of provinces and municipalities, the second and third spheres of government in our constitutional system, in health service delivery. It proposed that the Bill be strengthened in several aspects, including the language used in the legislation; corporate governance of the NHI fund, and flow of funding from the fund to providers; the role of provincial and local government in the delivery of healthcare services, and maintenance of the purchaser/provider split throughout the national health system.

The SA Human Rights Commission expressed concern that the Bill further limited access to healthcare by asylum seekers in South Africa. It argued that the success of the NHI would depend on, among others, good governance. Therefore, the powers and function of the chairperson, deputy chairperson and board members were crucial and needed to be clearly set out to avoid conflict and ensure an efficient board and assist in the decision-making process. The Commission was further concerned about the appointment process of the board and its reporting lines. It highlighted that the proposed governance structure placed concentrated power on the minister and did not adequately ensure the independence of the board, which was essential given its extensive powers, including strategic purchasing and the buying and selling of property.

The University of Witwatersrand Oral Health and Dental Schools (OHDS) presentation by Prof Simon Nemutandani, head and CEO of the School, was in full support of the NHI, saying oral health services would have far better funding under this system. OHDS recommended that former white universities should be forced through the funding system to train dental therapists and that posts should be created for middle level oral health workers.It further advocated that NHI should be the only funding mechanism for health in the country, and should replaces all other funding mechanisms for health and take over from medical schemes.

Both the National Health Laboratory Services and the South African Medical Research Council (SAMRC) said while they were in favour of NHI, and endorsed the principles of universal health coverage, cost effectiveness and equity, they suggested several amendments to improve the Bill.SAMRC felt that the issue of provisional accreditation had not been fully addressed. There was a substantial concern – not just among colleagues at the SAMRC but more widely – that there could be issues around the accreditation of many existing facilities. Accreditation was incredibly important in ensuring the quality of care that patients deserved. The SAMRC did not want to see the accreditation process undermined by a situation where – if standards for accreditation were high and vigorous – many health services and facilities would be unable to meet those standards.

The National Health Care Professionals Association (NHCPA) said that provinces already faced many challenges like budget cuts, non-filling of vacant critical posts, failure of facility improvement teams to carry out requisite maintenance and upgrading of facilities, failure of projects and difficulty in implementing the six core standards. It said South Africa was famous for having good policies but poor implementation.Oversight did not seem to be biting enough to ensure that officials deployed to implement government’s programme of action did so in a manner that they should.It believed that NHI should be implemented immediately to ensure that access to quality healthcare services reached everyone, although members noted that the leadership and governance failings had resulted in an accumulation of enormous medical malpractice liabilities and claims that were having a huge effect on the balance sheet. Their concern was around implementing NHI immediately versus fixing governance and leadership.NHCPA President Dr Benny Malakoane said that they recognised health was a social investment and a public good, and NHI would contribute to better quality of life and improved health outcomes. However, there were stumbling blocks.

“Unfortunately, following the finalisation on NHI, it will be the biggest parastatal in the country and given government track record with parastatals, one has to be really concerned. There is also very little improvement of public infrastructure at the moment, meaning that we will still see inequality in patients who are allocated to public facilities as their designated service providers.”

The University of Cape Town (UCT) highlighted that an essential package of health care services for children and adolescents must be prioritised within the NHI baskets of care. Specific concern was raised about children of asylum seekers and illegal immigrants who will not have the formal identity documents needed to register as users and how they will gain access. They also noted with concern that none of the advisory committees had representation from child health specialists or the children’s sector. This raised concerns that children and adolescents’ specific needs were unlikely to be adequately addressed and prioritised.

The South African Psychoanalytic Confederation pointed out that mental health was overlooked in the Bill. It said this was an oversight and highlighted that mental health was an integral and essential component of health. It offered to partner with government in bringing this to fruition. Concern was raised that only one percent of the facilities in the country met the norms and standards that would allow them to register as NHI facilities. The budget cuts to primary healthcare, staffing and infrastructure were also highlighted.

In its presentation, Stellenbosch University Faculty of Medicine & Health Sciences, said the institution was committed to the principles of social solidarity and universal health coverage. However, the strengthening of the current health system should be prioritised and funded in preparation for NHI.

Echoing the concerns of SAMA and the South African Human Rights Commission, Stellenbosch said the Bill should also consider foreigners living in SA for study purposes. The suggestion for them to get private medical aid “may not be feasible or they will only be able to receive emergency care or treatment for notifiable medical conditions”. In the section of the Bill on registration of users, it was suggested that regarding “proof of habitual place of residence” be amended, as not all residences have proof of habitual residence. The implications of not having any documents should be discussed in the Bill.Where it was suggested that the NHI board be accountable to the minister, giving him/her extensive powers, it was proposed that the Fund reports directly to Parliament and that the minister’s powers be reduced.


Full Parliamentary Monitoring Group Minutes of NHI Hearings (Restricted Access)


Full Die Burger report (Restricted access)


See also from the MedicalBrief archives:


HPCSA: All medical scheme assets should go to NHI


HPCSA’s presentation on medical schemes’ role in NHI was ‘incoherent’


Pharmacists concerned over ‘limited dialogue’ on NHI Bill


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