NHI and MSA

The Department of Health invites you to submit written comments on the proposed National Health Insurance Bill (NHI) and the Medical Schemes Amendment Bill.

You are invited to object or support the Bills by providing comment below. Should you be unsure, read the live comments, a summary or official documents below the form.   Closing date is midnight 21 September 2018.

20748 active citizens in this campaign, so far.

Add your comment now.

Select NO or YES to the Medical Schemes Amendment Bill
No to the MSA BillYes to the MSA Bill

Select NO or YES to the National Health Insurance (NHI) Bill
No to the NHI BillYes to the NHI Bill

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the Medical Schemes Amendment Billthe National Health Insurance (NHI) Billboth bills

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LIVE COMMENT FEED

Displaying newest 5 comments sent.

robert
No to the MSA Bill
No to the NHI Bill
I wish to see South Africa with a flourishing private and state health service so that all our population will benefit.

The state is forever speaking out against monopolies but when it comes to the most important field it wants a total monopoly...how hypocritical ! Competition is always in everyone's best interests.

The state has failed hopelessly in every field, like Eskom, Transnet/Prasa, SAA, you name it, what on earth makes one think having a state run NHI will be any different. We are told that the Health Department is the most corrupt department, and has a myriad of claims against it, but the fund will strive to achieve good governance and stewardship 5.3

It speaks of cross subsidies between the affluent and the impoverished and the healthy and the sick - pure Marxist talk of an ideology that has failed world wide, even China has turned to capitalism. Instead we should be creating incentives and helping the poor to improve their lot in life. What incentive is it for the sick to strive to be healthy ? We are fast becoming an obese nation with one of the highest HIV infection rates in the world - who cares, the nanny state will provide !

There is no plan B, if the NHI fails. As we have seen all it takes is one family and virtually the whole state can be captured and brought to its knees.

2.1.3 (c) talks of a lack of sufficient qualified staff within the sector. Well if this is implemented you can be assured that there will be a flight of doctors and specialists in the medical field.
I am picking this up from speaking to those in this field. Thousands of those who are approaching or are already past retirement age are likely to call it a day. But it wont end there, thousands of high income earning citizens in all walks of life will pack up and leave our shores if they see health care collapse or deteriorate significantly.

11 (1) (k) speaks of discouraging and preventing corruption, fraud etc as if by waving a magic wand corruption and fraud which is so rife will come to an end. All indications are that it is only getting worse. Ask the Auditor General and you get figures in the billions ! When you are corrupt in the public service, you get transferred to another section or get a post as an ambassador somewhere and so things continue. When yo commit fraud in the private sector you get kicked out.

1.1.1.2(a) How on earth are you going to ensure financial protection from the costs of health care when you will have hundreds trying to get their hands in the cookie jar or board the gravy train.

We have a bureaucracy that loves loves drawing up new policies and endless plans but have a reputation worldwide of failing to implement. I am in the guesthouse business and it has taken
me four years to get Heritage Council approval for some building alterations and I am still waiting. Public servants generally don't like to make decisions or they wait for a bribe. People in the state don't understand or appreciate the private sector, all they can do is criticize and pay late.

I pray God will give those in authority the wisdom to see the folly of what we are heading into before it is too late. We love fixing things that are not broken, and leaving broken things that need fixing. In the multitude of councilors there is wisdom.. We are only going to do our countries growth rate more damage and end up turning to the IMF to bail us out on their terms.
Jacqui
No to the MSA Bill
No to the NHI Bill
Comments on the NHI Bill:

I read on 25 November that professor Jannie Rossouw and economist Mike Holland calculated that the new national health system will require R226 billion in financing by 2026. They said this could mean increases in: Income tax; Companies tax; Payroll tax; VAT. Government will need to hike taxes by an average of 10.8%.

Clause 3(3)- This override clause is overly broad. Proper analysis should be undertaken to identify and specify actual existing legislative conflicts. Clause 3(4)- the wording of this provision does not accurately reflect that actual implication of the other provisions of the Act. Provisions which may impact on the constitutionally mandated powers must be identified, and ensured that they do not commence operation until the necessary funding is available. Clause 6(o)- What mechanisms will be put in place to ensure that persons with serious existing conditions who are receiving coverage from medical schemes, will not end up not be able to obtain coverage for those conditions if they end up not being covered under the services provided under NHI, and might be refused coverage by other providers under the dramatically altered medical schemes sector (for example, if their existing medical aid no longer functions, or they decide to offer coverage for "top-up conditions" on a substantially different basis? There has been no progress in addressing the horrendous maladministration and corruption and appalling attitudes towards service delivery that are plaguing public sector facilities. There has been no confidence provided by the pilot projects that have been undertaken. These would be in contravention of requirements in clause 6. How will this be sorted out, there is absolutely no seriousness about addressing these fundamental problems. Also, if the extent of services that are covered under the NHI. Clause 7- access to services- linking a person to a single facility where they are registered is unnecessarily complex and cumbersome. It will create unnecessary rigidity and challenges when people travel or end up moving to another area. Why shouldn't a person be able to access any convenient facility where they currently happen to be when they need care, as long as they are registered on the system? The Minister at minimum must be required to prescribe how portability of services could occur, it cannot just be optional. Otherwise the system would be excessively rigid and dysfunctional. Clause 7(4)- the wording for refusal of funding for service is very concerning. Who determines that a service is not required? There are currently instances where services are refused to individuals at public faclities (ie people are sent home and refused treatment) with horrific, and sometimes fatal consequences. Such abuses must not be permitted. Similarly, it must be designated who may make the determinations of the other grounds for refusal. It must be clearly stipulated who can make this determination, and there must be an urgent appeal process available (including potentially an emergency hotline or some such immediate access to additional determination in emergency situations), to prevent the current abuses from being perpetuated. There needs to be some urgent mechanism for reconsideration in emergency circumstances, subclause (5) would not be adequate for those circumstances. If a person has already been seeing a specialist for a long period, particularly for a severe long-term condition that requires specialist support, it will be very disruptive if they had to go back and get another referral to a specialist, and if they might end up not being able to continue seeing the existing specialist who is very familiar with their case and needs. This must be catered for. Clause 8- there must be an expeditious appeal mechanism of when a condition is not medically necessary by the Benefits Advisory Committee. There must be a mechanism for inputs must be made to include treatments on the formulary, especially in relation to rare or uncommon conditions or treatments, which often are not properly considered or addressed. Chapter 3 of the Bill is extremely problematic, a new public enterprise must not be established to provide for medical funding. The record of the government in the management of public enterprises is appalling, virtually none of them are being run successfully, and to establish a state-owned enterprise to manage funding would be completely disastrous, and would ensure that the system cannot be effectively implemented. This entity would be a complete magnet for corruption and looting, and this has not been recognised or acknowledged. There has been a refusal by the National Department of Health to seriously engage with these concerns, and vague assurances that there will be proper control mechanisms in place to ensure it is properly managed are unacceptable. Having a Board accountable to the Minister is completely inadequate for the management of what would be such a massive fund, that would have the potential, if mismanaged or looted, would have the potential to bankrupt the country. The Health Department has failed to acknowledge the seriousness of these concerns, or even to accept that there is substantial corruption and maladministration in the system currently which has not been addressed at all. The model for managing the system must be seriously reconsidered and a properly strengthened model must be developed and presented before any legislation can proceed. Chapter 4- The composition of the Board must be reconsidered, there is not a sufficient requriement for financial management focus, and the Board cannot solely be accountable to the Minister of Health. There must be accountability to the Minister of Finance and to Parliament. There must be required involvement of the Minister of Finance in relation to the Management of the Fund, including the appointment of the Chief Executive Officer. The fit and proper requirements for the appointment of the Chief Executive Officer must be substantially strengthened. Clause 31- The Minister cannot be solely responsible for the financial management of the Fund. It is of significant concern that the proposed shifting of funds and functions between provincial and national spheres has not been clearly and effectively addressed, and clauses such as clause 31(2) seek to fudge the constitutional issues. Clause 33- what if there is uncertainty regarding whether a particular matter is covered by the Fund or not, or whether there is a dispute about whether the Fund or a Scheme should cover a matter? There needs to be a mechanism to obtain clarity in these matters. Clause 35(4)- if emergency fees are provided by private clinics on a capped fee basis, would patients be liable to cover any additional amount that the institution might normally charge? This must be clarified, and there needs to be mechanisms in place so that people would not end up being liable to pay additional costs for emergency services. References to manipulating or requirng payments to be made from the provincial equitable share are unacceptable, the funding matters must be addressed in the annual Division of Revenue Bill, and there must be agreement between the National Treasury and the Department as to funding matters in annual budget and Division of Revenue legislation. These matters should have been properly addressed with the National Treasury and the Provinces before this Bill was tabled in Parliament, which is completely unacceptable. There must be substantial strengthening of oversight over the offices responsible for contracting and procurement, there must be extremely rigorous oversight of these units. Clauses 37-38- Given the appalling state of current resourcing and procurement in the public health care system, government completely lacks the capacity and capability to implement such massive centralised resourcing and management, there has not been sufficient recognition by the Department of Health of the appalling state of services, or any meaningful progress in tackling the existing crisis in the public system. Adding to the scale of procurement, distribution, and management will be completely impossible for the system to achieve. There is not a need, or is it feasible, to immediately seek to completely centralised procurement and management, a much more realistic and phased in process should be developed and provided for, which initially focuses on rooting out the rot in the existing system, and then builds up the system and capacity, and the scope of functions, in a manner that is successfully achieveable and will produce substantial meaningful improvements in health care services to the vast majority of people. Adopting an approach to completely centralise all procurement and management would be disastrous. Clause 41- the process for determining fees that will be made must be much more transparent and consultative, and a process provided by which fees will be determined. Clauses 42-44- The complaints and appeals provisions are insufficiently detailed, and would not seemingly cater adequately for the full range of types of challenges that patients will experience and raise complaints in respect of. For such a massive system, there would need to be a substantial dedicated infrastructure to deal with complaints, and the Bill is completely scanty in this regard. This aspect needs substantial further development. Consideration should be given to developing an ombud scheme, and widely available complaints hotlines and mechanisms. Chapter 10, relating to financial matters, is a particularly problematic aspect of the Bill, as there is a complete lack of clarity that has been provided about how the system will be properly funded and afforded, and it is apparently expected legislation should be passed that will impose substantial obligations on government and taxpayers, without any clarity about the actual cost and how it properly will be funded. It is completely reckless and irresponsible for legislation of this magnitude and impact be proceeded with in this manner. It cannot simply be indicated that "the funding will be found" when the country is in such a perilous financial state, particualrly due to corruption and management of public enterprises. There is also a lack of clarity regarding what is happening with the provincial equitable share of health funding, and constitutional issues arise in that regard. To try and push through legislation without this fundamental aspect being properly established, is dangerous for the financial stability of the country. Transitional arrangements- the transitional arrangements are incredibly brief, and insufficient. In particular, there has been absolutely no progress in the health system strengthening initiatives, and there is no indication of seriousness in addressing the fundamental issues that are plaguing the health system, and until that fundamental rot is addressed, trying to develop a huge infrastructure and framework in the existing crumbling system, and pouring vast amounts more funding into such a crumbling system, will be a complete waste, will not result in substantial improvements in health care for the vast majority of people, which is what is desperately needed, and will put the country into further financial peril. What should be done is to make legislative reforms and implement programmes to root out the rot in the existing system, and also much better regulate private health care, to ensure that funding that is put into the existing system is effectively spent and managed and produces real improvements in health care outcomes. Then, when substantial progress has been made in that area, then a next phase of legislative reforms could be implement to more centralise aspects of the system. When those further reforms are sucessfully implemented, then a further stage of reforms can be implemented. A properly strategised, phased approach must be adopted to successfully implement a national health system. The approach of government is seeking to plunge the health and financial system into complete chaos, without proper regard for the consequences.

The government has been supposedly working on this project for years, but virtually no progress in providing the fundamental foundation that must exist for any change of the massive scale of reform that is envisaged to succeed. This is the real work which must be undertaken.
Cleo
No to the MSA Bill
No to the NHI Bill
Comments on the NHI Bill:

Wits professor Jannie Rossouw and economist Mike Holland calculated that the new national health system will require R226 billion in financing by 2026. The actual financing gap is currently R166.5 billion in 2019 – equal to 12.3% of government revenue for the year. They added that the only way to cover this shortfall would be a tax hike – both for companies and individuals. They said this could mean increases in: Income tax; Companies tax; Payroll tax; VAT. Government will need to hike taxes by an average of 10.8%. https://businesstech.co.za/news/finance/356785/massive-tax-hike-needed-to-fund-south-africas-nhi-economists/

Clause 3(3)- This override clause is overly broad, and not sufficiently carefully crafted. Such broad override clauses are contrary to good legislative drafting practice. Proper analysis should be undertaken to identify and specify actual existing legislative conflicts.

Clause 3(4)- the wording of this provision does not accurately reflect that actual implication of the other provisions of the Act. Provisions which may impact on the constitutionally mandated powers must be identified, and ensured that they do not commence operation until the necessary funding is available.

Clause 6(o)- What mechanisms will be put in place to ensure that persons with serious existing conditions who are receiving coverage from medical schemes, will not end up not be able to obtain coverage for those conditions if they end up not being covered under the services provided under NHI, and might be refused coverage by other providers under the dramatically altered medical schemes sector (for example, if their existing medical aid no longer functions, or they decide to offer coverage for "top-up conditions" on a substantially different basis?

There has been no progress in addressing the horrendous maladministration and corruption and appalling attitudes towards service delivery that are plaguing public sector facilities. There has been no confidence provided by the pilot projects that have been undertaken. These would be in contravention of requirements in clause 6. How will this be sorted out, there is absolutely no seriousness about addressing these fundamental problems. Also, if the extent of services that are covered under the NHI.

Clause 7- access to services- linking a person to a single facility where they are registered is unnecessarily complex and cumbersome. It will create unnecessary rigidity and challenges when people travel or end up moving to another area. Why shouldn't a person be able to access any convenient facility where they currently happen to be when they need care, as long as they are registered on the system? The Minister at minimum must be required to prescribe how portability of services could occur, it cannot just be optional. Otherwise the system would be excessively rigid and dysfunctional.

Clause 7(4)- the wording for refusal of funding for service is very concerning. Who determines that a service is not required? There are currently instances where services are refused to individuals at public faclities (ie people are sent home and refused treatment) with horrific, and sometimes fatal consequences. Such abuses must not be permitted. Similarly, it must be designated who may make the determinations of the other grounds for refusal. It must be clearly stipulated who can make this determination, and there must be an urgent appeal process available (including potentially an emergency hotline or some such immediate access to additional determination in emergency situations), to prevent the current abuses from being perpetuated. There needs to be some urgent mechanism for reconsideration in emergency circumstances, subclause (5) would not be adequate for those circumstances.

If a person has already been seeing a specialist for a long period, particularly for a severe long-term condition that requires specialist support, it will be very disruptive if they had to go back and get another referral to a specialist, and if they might end up not being able to continue seeing the existing specialist who is very familiar with their case and needs. This must be catered for.

Clause 8- there must be an expeditious appeal mechanism of when a condition is not medically necessary by the Benefits Advisory Committee. There must be a mechanism for inputs must be made to include treatments on the formulary, especially in relation to rare or uncommon conditions or treatments, which often are not properly considered or addressed.

Chapter 3 of the Bill is extremely problematic, a new public enterprise must not be established to provide for medical funding. The record of the government in the management of public enterprises is appalling, virtually none of them are being run successfully, and to establish a state-owned enterprise to manage funding would be completely disastrous, and would ensure that the system cannot be effectively implemented. This entity would be a complete magnet for corruption and looting, and this has not been recognised or acknowledged. There has been a refusal by the National Department of Health to seriously engage with these concerns, and vague assurances that there will be proper control mechanisms in place to ensure it is properly managed are unacceptable. Having a Board accountable to the Minister is completely inadequate for the management of what would be such a massive fund, that would have the potential, if mismanaged or looted, would have the potential to bankrupt the country. The Health Department has failed to acknowledge the seriousness of these concerns, or even to accept that there is substantial corruption and maladministration in the system currently which has not been addressed at all.

The model for managing the system must be seriously reconsidered and a properly strengthened model must be developed and presented before any legislation can proceed.

Chapter 4- The composition of the Board must be reconsidered, there is not a sufficient requriement for financial management focus, and the Board cannot solely be accountable to the Minister of Health. There must be accountability to the Minister of Finance and to Parliament.

There must be required involvement of the Minister of Finance in relation to the Management of the Fund, including the appointment of the Chief Executive Officer. The fit and proper requirements for the appointment of the Chief Executive Officer must be substantially strengthened.

Clause 31- The Minister cannot be solely responsible for the financial management of the Fund.

It is of significant concern that the proposed shifting of funds and functions between provincial and national spheres has not been clearly and effectively addressed, and clauses such as clause 31(2) seek to fudge the constitutional issues.

Clause 33- what if there is uncertainty regarding whether a particular matter is covered by the Fund or not, or whether there is a dispute about whether the Fund or a Scheme should cover a matter? There needs to be a mechanism to obtain clarity in these matters.

Clause 35(4)- if emergency fees are provided by private clinics on a capped fee basis, would patients be liable to cover any additional amount that the institution might normally charge? This must be clarified, and there needs to be mechanisms in place so that people would not end up being liable to pay additional costs for emergency services.

References to manipulating or requirng payments to be made from the provincial equitable share are unacceptable, the funding matters must be addressed in the annual Division of Revenue Bill, and there must be agreement between the National Treasury and the Department as to funding matters in annual budget and Division of Revenue legislation. These matters should have been properly addressed with the National Treasury and the Provinces before this Bill was tabled in Parliament, which is completely unacceptable.

There must be substantial strengthening of oversight over the offices responsible for contracting and procurement, there must be extremely rigorous oversight of these units.

Clauses 37-38- Given the appalling state of current resourcing and procurement in the public health care system, government completely lacks the capacity and capability to implement such massive centralised resourcing and management, there has not been sufficient recognition by the Department of Health of the appalling state of services, or any meaningful progress in tackling the existing crisis in the public system. Adding to the scale of procurement, distribution, and management will be completely impossible for the system to achieve. There is not a need, or is it feasible, to immediately seek to completely centralised procurement and management, a much more realistic and phased in process should be developed and provided for, which initially focuses on rooting out the rot in the existing system, and then builds up the system and capacity, and the scope of functions, in a manner that is successfully achieveable and will produce substantial meaningful improvements in health care services to the vast majority of people. Adopting an approach to completely centralise all procurement and management would be disastrous.

Clause 41- the process for determining fees that will be made must be much more transparent and consultative, and a process provided by which fees will be determined.

Clauses 42-44- The complaints and appeals provisions are insufficiently detailed, and would not seemingly cater adequately for the full range of types of challenges that patients will experience and raise complaints in respect of. For such a massive system, there would need to be a substantial dedicated infrastructure to deal with complaints, and the Bill is completely scanty in this regard. This aspect needs substantial further development. Consideration should be given to developing an ombud scheme, and widely available complaints hotlines and mechanisms.

Chapter 10, relating to financial matters, is a particularly problematic aspect of the Bill, as there is a complete lack of clarity that has been provided about how the system will be properly funded and afforded, and it is apparently expected legislation should be passed that will impose substantial obligations on government and taxpayers, without any clarity about the actual cost and how it properly will be funded. It is completely reckless and irresponsible for legislation of this magnitude and impact be proceeded with in this manner. It cannot simply be indicated that "the funding will be found" when the country is in such a perilous financial state, particualrly due to corruption and management of public enterprises. There is also a lack of clarity regarding what is happening with the provincial equitable share of health funding, and constitutional issues arise in that regard. To try and push through legislation without this fundamental aspect being properly established, is dangerous for the financial stability of the country.

Transitional arrangements- the transitional arrangements are incredibly brief, and insufficient. In particular, there has been absolutely no progress in the health system strengthening initiatives, and there is no indication of seriousness in addressing the fundamental issues that are plaguing the health system, and until that fundamental rot is addressed, trying to develop a huge infrastructure and framework in the existing crumbling system, and pouring vast amounts more funding into such a crumbling system, will be a complete waste, will not result in substantial improvements in health care for the vast majority of people, which is what is desperately needed, and will put the country into further financial peril. What should be done is to make legislative reforms and implement programmes to root out the rot in the existing system, and also much better regulate private health care, to ensure that funding that is put into the existing system is effectively spent and managed and produces real improvements in health care outcomes. Then, when substantial progress has been made in that area, then a next phase of legislative reforms could be implement to more centralise aspects of the system. When those further reforms are sucessfully implemented, then a further stage of reforms can be implemented.

A properly strategised, phased approach must be adopted to successfully implement a national health system. The approach of government is seeking to plunge the health and financial system into complete chaos, without proper regard for the consequences. The government has been supposedly working on this project for years, but virtually no progress in providing the fundamental foundation that must exist for any change of the massive scale of reform that is envisaged to succeed. This is the real work which must be undertaken, this legislation is relevant for a subsequent stage of the process, and is certainly premature now.
Heather
No to the MSA Bill
No to the NHI Bill
The government has not been able to successfully manage the present health care system and I do not foresee any improvement by the passing of this new bill.
Corruption has increased steadily and this will be just another avenue to steal taxpayers monies
Jeannine
Yes to the MSA Bill
No to the NHI Bill

Comments on the NHI Bill:

Clause 3(3)- This override clause is overly broad, and not sufficiently carefully crafted. Such broad override clauses are contrary to good legislative drafting practice. Proper analysis should be undertaken to identify and specify actual existing legislative conflicts.

Clause 3(4)- the wording of this provision does not accurately reflect that actual implication of the other provisions of the Act. Provisions which may impact on the constitutionally mandated powers must be identified, and ensured that they do not commence operation until the necessary funding is available.

Clause 6(o)- What mechanisms will be put in place to ensure that persons with serious existing conditions who are receiving coverage from medical schemes, will not end up not be able to obtain coverage for those conditions if they end up not being covered under the services provided under NHI, and might be refused coverage by other providers under the dramatically altered medical schemes sector (for example, if their existing medical aid no longer functions, or they decide to offer coverage for "top-up conditions" on a substantially different basis?

There has been no progress in addressing the horrendous maladministration and corruption and appalling attitudes towards service delivery that are plaguing public sector facilities. There has been no confidence provided by the pilot projects that have been undertaken. These would be in contravention of requirements in clause 6. How will this be sorted out, there is absolutely no seriousness about addressing these fundamental problems. Also, if the extent of services that are covered under the NHI.

Clause 7- access to services- linking a person to a single facility where they are registered is unnecessarily complex and cumbersome. It will create unnecessary rigidity and challenges when people travel or end up moving to another area. Why shouldn't a person be able to access any convenient facility where they currently happen to be when they need care, as long as they are registered on the system? The Minister at minimum must be required to prescribe how portability of services could occur, it cannot just be optional. Otherwise the system would be excessively rigid and dysfunctional.

Clause 7(4)- the wording for refusal of funding for service is very concerning. Who determines that a service is not required? There are currently instances where services are refused to individuals at public faclities (ie people are sent home and refused treatment) with horrific, and sometimes fatal consequences. Such abuses must not be permitted. Similarly, it must be designated who may make the determinations of the other grounds for refusal. It must be clearly stipulated who can make this determination, and there must be an urgent appeal process available (including potentially an emergency hotline or some such immediate access to additional determination in emergency situations), to prevent the current abuses from being perpetuated. There needs to be some urgent mechanism for reconsideration in emergency circumstances, subclause (5) would not be adequate for those circumstances.

If a person has already been seeing a specialist for a long period, particularly for a severe long-term condition that requires specialist support, it will be very disruptive if they had to go back and get another referral to a specialist, and if they might end up not being able to continue seeing the existing specialist who is very familiar with their case and needs. This must be catered for.

Clause 8- there must be an expeditious appeal mechanism of when a condition is not medically necessary by the Benefits Advisory Committee. There must be a mechanism for inputs must be made to include treatments on the formulary, especially in relation to rare or uncommon conditions or treatments, which often are not properly considered or addressed.

Chapter 3 of the Bill is extremely problematic, a new public enterprise must not be established to provide for medical funding. The record of the government in the management of public enterprises is appalling, virtually none of them are being run successfully, and to establish a state-owned enterprise to manage funding would be completely disastrous, and would ensure that the system cannot be effectively implemented. This entity would be a complete magnet for corruption and looting, and this has not been recognised or acknowledged. There has been a refusal by the National Department of Health to seriously engage with these concerns, and vague assurances that there will be proper control mechanisms in place to ensure it is properly managed are unacceptable. Having a Board accountable to the Minister is completely inadequate for the management of what would be such a massive fund, that would have the potential, if mismanaged or looted, would have the potential to bankrupt the country. The Health Department has failed to acknowledge the seriousness of these concerns, or even to accept that there is substantial corruption and maladministration in the system currently which has not been addressed at all.

The model for managing the system must be seriously reconsidered and a properly strengthened model must be developed and presented before any legislation can proceed.

Chapter 4- The composition of the Board must be reconsidered, there is not a sufficient requriement for financial management focus, and the Board cannot solely be accountable to the Minister of Health. There must be accountability to the Minister of Finance and to Parliament.

There must be required involvement of the Minister of Finance in relation to the Management of the Fund, including the appointment of the Chief Executive Officer. The fit and proper requirements for the appointment of the Chief Executive Officer must be substantially strengthened.

Clause 31- The Minister cannot be solely responsible for the financial management of the Fund.

It is of significant concern that the proposed shifting of funds and functions between provincial and national spheres has not been clearly and effectively addressed, and clauses such as clause 31(2) seek to fudge the constitutional issues.

Clause 33- what if there is uncertainty regarding whether a particular matter is covered by the Fund or not, or whether there is a dispute about whether the Fund or a Scheme should cover a matter? There needs to be a mechanism to obtain clarity in these matters.

Clause 35(4)- if emergency fees are provided by private clinics on a capped fee basis, would patients be liable to cover any additional amount that the institution might normally charge? This must be clarified, and there needs to be mechanisms in place so that people would not end up being liable to pay additional costs for emergency services.

References to manipulating or requirng payments to be made from the provincial equitable share are unacceptable, the funding matters must be addressed in the annual Division of Revenue Bill, and there must be agreement between the National Treasury and the Department as to funding matters in annual budget and Division of Revenue legislation. These matters should have been properly addressed with the National Treasury and the Provinces before this Bill was tabled in Parliament, which is completely unacceptable.

There must be substantial strengthening of oversight over the offices responsible for contracting and procurement, there must be extremely rigorous oversight of these units.

Clauses 37-38- Given the appalling state of current resourcing and procurement in the public health care system, government completely lacks the capacity and capability to implement such massive centralised resourcing and management, there has not been sufficient recognition by the Department of Health of the appalling state of services, or any meaningful progress in tackling the existing crisis in the public system. Adding to the scale of procurement, distribution, and management will be completely impossible for the system to achieve. There is not a need, or is it feasible, to immediately seek to completely centralised procurement and management, a much more realistic and phased in process should be developed and provided for, which initially focuses on rooting out the rot in the existing system, and then builds up the system and capacity, and the scope of functions, in a manner that is successfully achieveable and will produce substantial meaningful improvements in health care services to the vast majority of people. Adopting an approach to completely centralise all procurement and management would be disastrous.

Clause 41- the process for determining fees that will be made must be much more transparent and consultative, and a process provided by which fees will be determined.

Clauses 42-44- The complaints and appeals provisions are insufficiently detailed, and would not seemingly cater adequately for the full range of types of challenges that patients will experience and raise complaints in respect of. For such a massive system, there would need to be a substantial dedicated infrastructure to deal with complaints, and the Bill is completely scanty in this regard. This aspect needs substantial further development. Consideration should be given to developing an ombud scheme, and widely available complaints hotlines and mechanisms.

Chapter 10, relating to financial matters, is a particularly problematic aspect of the Bill, as there is a complete lack of clarity that has been provided about how the system will be properly funded and afforded, and it is apparently expected legislation should be passed that will impose substantial obligations on government and taxpayers, without any clarity about the actual cost and how it properly will be funded. It is completely reckless and irresponsible for legislation of this magnitude and impact be proceeded with in this manner. It cannot simply be indicated that "the funding will be found" when the country is in such a perilous financial state, particualrly due to corruption and management of public enterprises. There is also a lack of clarity regarding what is happening with the provincial equitable share of health funding, and constitutional issues arise in that regard. To try and push through legislation without this fundamental aspect being properly established, is dangerous for the financial stability of the country.

Transitional arrangements- the transitional arrangements are incredibly brief, and insufficient. In particular, there has been absolutely no progress in the health system strengthening initiatives, and there is no indication of seriousness in addressing the fundamental issues that are plaguing the health system, and until that fundamental rot is addressed, trying to develop a huge infrastructure and framework in the existing crumbling system, and pouring vast amounts more funding into such a crumbling system, will be a complete waste, will not result in substantial improvements in health care for the vast majority of people, which is what is desperately needed, and will put the country into further financial peril. What should be done is to make legislative reforms and implement programmes to root out the rot in the existing system, and also much better regulate private health care, to ensure that funding that is put into the existing system is effectively spent and managed and produces real improvements in health care outcomes. Then, when substantial progress has been made in that area, then a next phase of legislative reforms could be implement to more centralise aspects of the system. When those further reforms are sucessfully implemented, then a further stage of reforms can be implemented.

A properly strategised, phased approach must be adopted to successfully implement a national health system. The approach of government is seeking to plunge the health and financial system into complete chaos, without proper regard for the consequences. The government has been supposedly working on this project for years, but virtually no progress in providing the fundamental foundation that must exist for any change of the massive scale of reform that is envisaged to succeed. This is the real work which must be undertaken, this legislation is relevant for a subsequent stage of the process, and is certainly premature now.







SUMMARY

The National Heath Insurance (NHI) Bill aims to;

  • provide mandatory prepayment health care services in the Republic in pursuance of section 27 of the Constitution;
  • establish a National Health Insurance Fund and to set out its powers, functions and governance structures; to provide a framework for the active purchasing of health care services by the Fund on behalf of users;
  • create mechanisms for the equitable, effective and efficient utilisation of the resources of the Fund to meet the health needs of users;
  • preclude or limit undesirable, unethical and unlawful practices in relation to the Fund and its users;
  • provide for matters connected herewith.

The Medical Schemes Amendment Bill aims to;

  • amend the Medical Schemes Act, 1998; so as to exclude the application of the Consumer Protection Act, 2008, in relation to matters governed by the Medical Schemes Act;
  • extend the functions of the Council;
  • insert a new section 8A in terms of which the Council may require information from medical schemes concerning the services rendered by the health care providers to beneficiaries;
  • insert a new Chapter 3A providing for the creation of a Central Beneficiary Register and the management of that register by the Registrar and to establish risk measurement methodology;
  • redetermine the provisions relating to the admission of beneficiaries to a medical scheme and the cancellation of membership;
  • insert a new Chapter 5B, in relation to the various requirements applicable in determining the contributions payable to a medical scheme by its members;
  • provide for a Health Care Providers Register to be kept and maintained by the Registrar;
  • repeal certain sections;
  • re- determine the provision dealing with the establishment of the Appeal Board;
  • introduce an enhanced system of governance of medical schemes under the new chapter 11A;
  • empower the Council to determine broker fees from time to time and define the circumstances in which a medical scheme may receive payment of broker fees due by its members to a broker;
  • declare the carrying on of the business of a medical scheme by a person not registered as a medical scheme to be a separate offence,
  • prescribe the criminal penalties that may be imposed on persons convicted of that offence;
  • provide for matters connected therewith.

DOWNLOAD DOCUMENTS

Download the Medical Schemes Amendment Bill

Download the National Health Insurance Bill (NHI)

DearSA - National Health Insurance

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