National Health Insurance (NHI) Bill: public hearings day 9

Meeting report

Psychology Society of South Africa (PsySSA) submission
Prof Garth Stevens, PsySSA President, presented to the Committee.

Consultation process
- PsySSA is well placed as a nonpartisan NPO for psychology professionals in South Africa (psychologists, registered counsellors and psychometrists).
- PsySSA has a vested moral, social, academic, and clinical interest in the NHI and psychological services
- Consultation with members was initiated at a discussion at the 25th PsySSA National Congress in September 2019 as a response to the Parliamentary request for public comment on the NHI Bill
- An ad hoc committee collated PsySSA members’ views and analysis of the NHI Bill
- This was a second submission following a submission on the NHI White Paper, dated 25 May 2016.

Key considerations
PsySSA supports the NHI and universal health coverage (UHC) in principle – but key problems need to be resolved in the NHI Bill to strengthen its ability to respond to mental health needs:
- Integrate mental health more effectively into the NHI.
- Ensure equitable access to health services for all people.
- Improve human resources for mental health.
- Clarify accreditation standards and contractual conditions for service providers.
- Improve utilisation of private practitioners within an integrated health system.
- Include mental health expertise in the advisory structures of the NHI.
- Set out a robust accountability framework within the NHI
- Include mental health indicators in the NHI information system.

Integrate mental health more effectively into the NHI
- Provide adequate mental health services that address existing systemic challenges (SAHRC, 2019) – under-resourcing and system neglect
- Promote well-being within communities and use registered counsellors more effectively – preventative primary care and community-based care and rehabilitation
- Embed mental health into physical health services (Ohrnberger et al., 2017)
- Address violence and trauma as a cross-cutting issue in service provision (Kaminer et al., 2018)

Ensure equitable access to health services for all people
- Ensure accurate assessment for access to care especially in task-sharing contexts (Lund et al., 2019)
- Ensure access is not denied by cumbersome registration requirements for users
- Ensure timely access to care and recognise mental health emergencies
- Prioritise children and adolescents (Mokitimi et al., 2019)
- Disaggregate ‘disability’ as physical, mental, intellectual and sensory (UN, 2006)
- Provide adequate services for refugees, asylum seekers and illegal foreigners and avoid medical xenophobia (Zihindula et al., 2017)
- Recognise gender fluidity and affirmative healthcare (McLachlan et al., 2019)
- Improve access to forensic mental health services (Sukeri et al., 2016

Clarify accreditation standards and contractual conditions for service providers
- Clarity is needed on how standards will be set for contracting, monitoring and evaluating accredited health care service providers or establishments (as per Clause 39)
- Accreditation should be overseen by health care practitioners from specific disciplines.
- The Bill also makes no mention of mechanisms to accredit and fund health services which cross-district operational areas, such as tele-health services.

Include mental health expertise in the NHI advisory structures
- All committees must strive for comprehensive cover for psychotherapeutic and psychosocial treatments
- Specialised input from psychologists is needed in the Benefits Advisory Committee
- Convene a Mental Health Services Technical Committee (Clause 24) D. Discipline-specific expertise will be required in all advisory structures

Concerns
- All appointees must have impeccable moral integrity and be in good standing – robust public selection processes
- The role of Provincial Departments must be clarified relative to the National Minister of Health – the latter seems to have inordinate decision-making power in the current Bill – this relationship requires some clarity
- A central purchasing and payment system may be unwieldy, out of touch with local particularities, and may be more easily open to abuse – the relationship between provincial and national levels requires clarification again, as do the mechanisms of accountability
- The Fund cannot investigate itself and must be subject to external scrutiny – cannot be referee and player
- Explicate mechanisms the Minister will use for expenditure control of the Fund
- The role of the Health Ombudsperson should be clarified.

Conclusion
PsySSA supports the NHI and universal health coverage in principle – but key challenges need to be resolved in the NHI Bill to strengthen its ability to respond to mental health needs:
- Integrate mental health more effectively into the NHI.
- Ensure equitable access to health services for all people.
- Improve human resources for mental health.
- Clarify accreditation standards and contractual conditions for service providers.
- Improve utilisation of private practitioners within an integrated health system.
- Include mental health expertise in the advisory structures of the NHI.
- Set out a robust accountability framework within the NHI
- Include mental health indicators in the NHI information system.

Discussion
Mr T Munyai (ANC) noted that PsySSA suggested that mental health was not given the prominence it deserved in the NHI Bill. Was it aware that mental health was mentioned 11 times in the Bill, including clause 4? It stated that mental health services would be included as part of NHI comprehensive service benefits which would be determined by the Benefits Advisory Committee.

Ms A Gela (ANC) said that PsySSA had requested clarity on accreditation standards and contractual conditions for service providers. Was it aware that clause 39 provided for accreditation of public and private health establishments by the Fund. Clause 39 outlined all the requirements for accreditation.

Mr M Sokatsha (ANC) noted that PsySSA was requesting that Parliament needed to ensure equitable access to health services for all people. Was PsySSA aware that mental health service benefits would be defined by the Benefits Advisory Committee according to clause 25, supported by clauses 4 and 7?

Dr S Thembekwayo (EFF) noted that PsySSA made reference to psychological practitioners. Could PsySSA provide more information on this; where should this be placed in the Bill? How would PsySSA best describe the role of medical aid schemes under NHI? It had suggested that the majority of the population were not willing to pay higher taxes for better healthcare, she agreed as there was no trust in the government.

Ms E Wilson (DA) stated that from her experience of facilities in rural areas, seldom were there practitioners available to offer psychological support for people suffering from mental health issues. This was very concerning. How many hospitals or clinics in the public and private sector had psychological services and support for communities? These were essentially non-existent in the country presently.

Ms H Ismail (DA) understood from the submission that the NHI Bill did not adequately cover equitable access to mental healthcare. In what ways did PsySSA think the NHI Bill would negatively impact their mandate? What should be included in the Bill to properly address their mandate? PsySSA made mention of norms and standards as well as monitoring and evaluation. Was it aware that government presently monitored 7% of all healthcare facilities? Given this, how would the lack of monitoring, as it stood, affect the sector? What needed to be done to address this?

Dr K Jacobs (ANC) stated that the Committee had heard the day before that mental health needed to be mentioned specifically in the NHI Bill. Mental health was mentioned 11 times in the Bill, it would be contained within the regulations for accreditation, as with any other service under NHI. What was its view on that? Was PsySSA of the view that it needed to be mentioned specifically in terms of remuneration or could this be contained in the regulations?

The Chairperson asked if PsySSA was familiar with the Presidential Health Compact? He viewed that programme as an enabler and an important step toward the realisation of NHI. Part of it spoke to the Health Sector Anti-Corruption Forum. It touched on human resources, not only for mental health, but more generally. Would that not be one of the things that PsySSA would push to be accelerated as an enabler for some of the items highlighted as challenges in the submission? PsySSA raised mental health expertise that it wanted to see represented across all the committees. Would PsySSA be happy with a ‘generalist’ psychologist or would it want different professionals represented i.e. counselling, clinical psychologists etc.

The Chairperson asked why there were so few psychologists in rural areas, was it because the environment was not good? What would enable psychologists to populate the rural areas? The mental health services were optimal in urban areas but were negligible in rural areas. How could this be configured differently? Also could PsySSA offer advice on how registration and access could be improved for asylum seekers?

PsySSA response
Prof Garth Stevens agreed that the submission had stated that ‘mental health’ was mentioned 11 times in the Bill. It was not that mental health was not referred to in the Bill, it was that it was referred to peripherally. There were specifics that PsySSA would have liked to see foregrounded in the Bill.

On the Benefits Advisory Committee, PsySSA thought that psychological expertise needed to be involved in that process. He outlined the various types of psychologists such as counsellors and clinical. There were a number of practitioners in the field of psychology that could be included. The current rate of psychologists in the country was about 2.6 per 100 000 people with around 25 000 psychology practitioners in the country. Given the size of the population, there was a disparity in the number of patients to the number of practitioners currently registered with the Health Professions Council of South Africa (HPCSA) or in the public sector. The 2.6 per 100 000 people referred to clinical psychologists in the public sector.

The point about under-resourced was underpinned by the data from the HPCSA. The norms and standards in circulation were in some instances more than a decade old. There had been significant development in the provision of mental health services over the past 15 years. This was not only for psychological modalities and treatments, but in the area of pharmacological interventions associated with mental healthcare. Thus, these norms and standards needed to be updated.

On mental health standing alone, their argument from the outset was that there needed to be some degree of integration. There would also be a need for certain specificities to focus on mental health so that it was not left out. PsySSA suggested that it did need to be integrated – but greater emphasis needed to be placed on mental health more broadly inside the Bill and whichever policy frameworks would accompany that.

On representation on the committees, in South Africa psychologists were trained in a generalist mode in most instances, such as neuro, clinical, educational, research or counselling psychology. As a consequence, much of what psychologists were trained in up until their fourth or fifth year was probably covered by most psychologists. Most psychologists were trained in areas of psychotherapeutics, psychodiagnostics, psychometrics and psychotherapeutic interventions. There may be some instances where specific expertise would be required, but in their view, there were many generalists who would be able to cut across any of those areas. There were of course particular interest groups in all disciplines and that was no different to psychology. PsySSA would not be opposed to that level of specificity but a balance between integration and specificity was required. An advisory committee, for example, might require the expertise of someone with specific expertise.

On rural and peri-urban provision, there was always likely to be variability in the level of service delivery that was seen inside a country that was geographically differentiated. It was clear that populations had increasingly moved toward urban areas. One would anticipate that the centre of gravity would be in those areas. On rural service delivery, models of incentivisation would need to be considered for rural healthcare. There may be a need to consider the utilisation of existing structures, like community service placements to ensure that those services were sufficiently ramped up and that there was a sufficient number of posts available in those spaces for uptake.

Mr Suntosh Pillay, Clinical Psychologist in KZN Department, replied that at this stage the questions by the Members were similar to the ones PsySSA was grappling with. Mental health expenditure in South Africa, based on the latest 2019 statistics available, amounted to only 4.6% of the total public health budget. There were wide disparities amongst the nine provinces. This worked out to a 12.4 United States Dollar (USD) average on mental health expenditure, which worked out to about R200 per person, which was inadequate. Despite the mention of mental health peripherally in the Bill it was not enough. The National Mental Health Policy Framework (NMHPF) had largely been unimplemented. Mental health in the country was not prioritised. In-patient care in South Africa currently represented 86% of mental health expenditure and 45% of this was in psychiatric hospitals. This catered for the most serious types of mental illness and not community mental health, which was largely made up of depression, anxiety and trauma. Community mental healthcare was what the majority of the population required. The country needed more dedicated thinking about mental health. The NHI had the potential to do that.

Ms Anne Kramer, Clinical Psychologist in the Eastern Cape, echoed Mr Pillay on the NMHPF which had provided a good framework for the implementation of mental healthcare in South Africa but had sadly not been implemented as envisioned.

Mr Daniel den Hollander, Clinical Psychologist, replied that PsySSA was aware of clause 39, however they had technical difficulties with that clause. Those technical concerns were contained in their written submission in 2019 to the Committee. There was a need for more clarity on how the accredited healthcare providers and establishments would be monitored and evaluated. It was recommended specifically because a lot of related professions were monitored by professional boards. There was an important relationship between the scope of the profession and it was recommended that appropriately skilled and knowledgeable experts in those areas, with expertise in public mental health, be considered key stakeholders or preferred candidates for the appointments of such monitoring roles. PsySSA was willing to serve on such an independent panel for that purpose, as expressed in the written submission.

Further discussion
Ms M Hlengwa (IFP) asked how PsySSA mobilised to promote access to mental healthcare for all South Africans during the pandemic, where people lost their jobs and so on. What was their views on their potential role to reduce the treatment gap for mental healthcare in the country.

Prof Garth Stevens replied that during the pandemic, PsySSA adjusted to having a significant online presence, given lockdown regulations. All education and training moved to online platforms and this was accelerated over the past 18 months. It had been phenomenal for the uptake it had received. Digital was better than face-to-face modes in many instances. Tele-health had become another area where they had been able to consider the possibilities of access for mental health. The traditional model of face-to-face consultations had been significantly altered, especially given the possibility for increased and enhanced access through tele-health. This specifically improved access to people living in remote areas.

On closing the treatment gap, PsySSA advocated for the training of additional mental health practitioners as the current ratio was too low. There needed to be early exit points from training. There needed to be training of people for shorter periods of time which in turn would increase access to mental healthcare services through increased supply of practitioners. PsySSA advocated for evidence-based interventions that were not reliant on extended and protracted mental health service delivery models but were equipped to deal with the kinds of presentation they saw, predominantly anxiety and depression.

Actuarial Society of South Africa (ASSA) submission
Mr Lusani Mulaudzi, ASSA President, and Mr Barry Childs, ASSA Chair, presented to the Committee.

Opening comments
- Actuaries are professionally bound to act in the public interest.
- ASSA supports the objectives of Universal Health Coverage to move towards a more equitable and effective health system for South Africa.
- We suggest that a system that combines the NHI, private health cover and some targeted cost sharing mechanisms will optimise the limited resources available.
- We have a combinations of skills that are useful for matters pertaining to understanding risk, budgeting and financing, and analysis. The Society expresses it willingness to contribute to policy development and supporting research as we have done in the past.

General
- South Africa is unusual in having very low out of pocket payments for healthcare (8% versus an average of 35% for all upper-middle income countries).
- This is partly due to high poverty levels and risk pooling via medical schemes among the employed (49% of healthcare funding is pooled largely through medical schemes versus 12% for all upper-middle income countries). Although not legally compulsory many employers mandate membership of a medical scheme.
- Government’s share of healthcare spending is higher than other upper-middle income countries (43% versus 30% on average)

Access to care
Referral pathways and protocols:
- Agree these are crucial to ensure sustainability. Recommend that these should be clearly defined to apply equitably, should be evidence-based and subject to regular updating
Purchaser-provider split:
- Establishment of the Fund facilitates the purchaser provider split. This enables Strategic Purchasing and accountability of purchaser and provider. Responsiveness is key.
- Consequences for good or poor performance should be followed through.
Licensing requirements for facilities and providers:
- Recommend phased implementation as facilities with higher standards become available, rather than setting hard timelines
Inclusion of pricing in contracting:
- Pricing should not be included as part of accreditation. Value Based Care should allow higher quality of care to be rewarded

Benefit entitlements
Complimentary nature of NHI and medical schemes:
- Significant clarity is required on precisely what benefits medical schemes can provide.
- For example, may a medical scheme reimburse where a benefit is not available at a provider of choice or referrals protocols not adhered to?
- There is a significant risk of increased Out of Pocket payments if medical schemes do not fund services out of NHI protocols.
- Many countries allow complimentary cover to adapt to NHI benefits rather than being too prescriptive. We suggest the definition of complementary cover be loosened so that benefits can adapt rather than be prescribed.
Demarcation of medical scheme coverage:
- Medical schemes are conflated with other private healthcare coverage, not recognising their social solidarity basis – this will adversely affect medical schemes particularly if they play a role while the NHI benefit package is limited
NHI benefits determined taking account of funds available:
- This is supported given current fiscal conditions. We urge a cautious approach to new taxes given their impact on the economy. Care would need to be taken given variability of tax revenue

Healthcare providers
Payment based on value of services:
- This is supported and gives appropriate incentives. This will require objective assessment supported by data collection, monitoring and research
Purchasing from public and private institutions:
- Supported as a means to improve access and equity. The proposed accreditation appears to require providers to contact entirely or not at all which may limit access
Primary care capitation and DRG- based payment for hospital services:
- These payment methods promote active and strategic purchasing but require monitoring risks of volumes and costs, including under-servicing.
- DRGs require clinical and costing data for all facilities. Capitation can be complex to implement and requires data and statistical modelling to ensure fair payment.
- Suggest reimbursement models refer to value-based contracting rather than specifying reimbursement mechanisms at this early stage and that a piloting process determines a feasible framework and transition. Such a process should involve actuarial input and analysis

Collection and use of data
Mandate for data collection from beneficiaries and providers:
- Actuaries attest to many positive uses for such data and can offer assistance with model development to assist with planning, budgeting, cost monitoring and other outputs
- Data are highly sensitive and require robust systems for collection, protection, analysis and transmission

Actuarial Expertise
Benefit Pricing Committee:
- Involvement of actuaries with skills in pricing, benefit design, risk management and analytics, is welcomed.
- Long-term cost estimates:
- The Bill points out that models of the future rely on assumptions. However future planning can be improved if assumptions are set reasonably – this is important for benefit promises to be sustainable and fiscally responsible.
- Actuarial modelling can also assist with planning for human resource and infrastructure requirements to ensure consistent access to benefits
Actuarial costing model:
- We support the actuarial costing model in the Bill and the statement that this will be adapted to find a set of priority interventions. We encourage further use of actuarial modelling to assess best interventions, options for implementation and risks
Risk Management:
- A Risk committee to consider Enterprise Risks faced by the Fund should include appropriate actuarial competence

Timing and process
Sequencing of reforms:
- Significant reforms come with risk of harm to the public and private health systems if not done in the optimal order – actuaries have expertise in modelling effects of sequences of reforms
Implementation timeline:
- Concern that the proposed timing for full implantation aims for 2026. We suggest phases based on milestone achievements rather than calendar dates to ensure responsible progression
Structure:
- Caution against single minded focus on one structural form for UHC / NHI. Each country’s health system is a unique result of its context, history, trajectory and social aims, which can adapt over time

Closing remarks
- The Actuarial Society supports improvements in healthcare equity in South Africa.
- NHI reform will require a long road of coherent well planned and executed policy changes. In the interim it is vital that sufficient policy attention be paid to the medical scheme and health insurance environment to preserve current healthcare capacity in South Africa.
- The extensive work of the Health Market Inquiry should be given its proper attention. Addressing the recommendations in the HMI report could lead to a more rapid achievement of UHC that incorporates both public and private sectors effectively.
- We suggest implementing the NHI in a phased approach, supported by ongoing analysis and modelling will yield the most efficient pathway to UHC.

Discussion
Dr Jacobs valued the suggestion on phased implementation that was milestone oriented rather than timeline oriented. The phased implementation approach would influence licensing and the accreditation process. This was supported by clause 10(1)(l) of the Bill. On out-of-pocket expenditure, he noted that the presenters had suggested that out-of-pocket expenditure in South Africa might be low. The important question was the relative value of individuals contribution toward their medical aid to get an all inclusive comprehensive benefit. The extent of out-of-pocket expenditure was considerable given what some people paid for private medical aid to begin with.

Ms Wilson noted that for benefit entitlements, ASSA spoke about the wording being very loose in some of the categories. She asked it to provide suggestions on how that should be worded. It helped the Committee understand what ASSA was proposing and look at alternatives. She suggested ASSA submit any concerns they had about wording in writing. If one had limited staffing, there was limited access to healthcare. Primary healthcare was the most critical part of health at the moment. If there was adequate primary healthcare it could prevent a lot of other health issues. Staffing, infrastructure and primary healthcare were the three areas where the budgets had been cut for the next three years – and these were paramount to affording access to healthcare. It was alarming. However, she was excited by the ASSA proposal that milestone achievements must be the key as opposed to a time based approach. In 2026, NHI was supposed to be in place, this would not happen, as it was already 2021 and the issues were not yet addressed in the Bill, let alone being rolled out.

Ms Gela noted that ASSA stated that pricing should not be included as part of accreditation. Clause 39(2)(b) talked about adherence to the National Pricing Regimen for service delivery. It was not possible to have value-based contracts that were not priced. On imposing user fees to manage demand, what was their view on ‘pent-up’ demand in the South African context? How could demand be managed? Was there a need to have a comprehensive understanding of demand out there?

Mr Sokatsha said that ASSA mentioned the perception that private healthcare was expensive. Was it only a perception or was it a reality? Had ASSA seen the findings of the Health Market Inquiry on the key cost drivers in the private sector?

Mr Munyai stated that ASSA had recommended phased implementation as facilities with higher standards became available rather than setting hard timelines. Clause 57(4)(a) stated that transitional arrangements for the phased implementation approach influenced the licensing and the accreditation process. This was supported by clause 10(1)(l) of the Bill. ASSA said that pricing should not be included as a part of accreditation.

Clause 39(2)(b) spoke about the adherence to the National Pricing Regimen for services delivered. It was not possible to have value-based contracts that were not priced. Significant clarity was requested on price, precisely because the benefits needed to be provided. The Benefits Advisory Committee would outline the package of services. It would be clear what complementary service medical schemes would provide. It was important that ASSA clarified its questions.

Ms X Havard (ANC) asked if ASSA was concerned about the delineation of prices. Had they considered the Office of Health Products Procurement or the purchasing clause of the Bill?

Chairperson Dhlomo referred to the submission where it cautioned Parliament that due to demand-side consequences, fair cost sharing needed to be considered to help manage benefits and costs for all. Clause 7(2) outlined circumstances where some form of cost sharing would apply when users did not follow the defined care pathways. Thus NHI did support this principle. A fee would definitely be imposed for non-adherence. On medical aid scheme cover, ASSA had suggested duplicative medical aid scheme cover. This would assist some users to bypass the NHI service platform. Under what circumstances would ASSA suggest that the NHI service platform be bypassed? Was this based on research done elsewhere in the world? What would ASSA’s response be if one were to say that it would ‘have a long-term negative economic impact’ as well as impact the NHI Fund?

ASSA response
Mr Barry Childs replied that ASSA noted there was discussion in the Bill about phased implementation. It was proposed that clear milestones be set as opposed to artificial timelines. Timelines were fine as targets but it would be a mistake to rely on them, as it would create a false impression about where the country was in the development of NHI. There should be a monitoring mechanism to keep tabs on the targets to reach the milestones, and how the country progressed along the milestones, so the process remained honest and transparent.

On loose wording, he gave the example of ‘benefits that were not funded by the NHI,’ and in other places it spoke about ‘benefits that were not covered by NHI.’ Would NHI cover appendectomies, would one need to go through certain referral pathways and follow certain protocols to qualify? If there was a benefit list, would it appear on the list and be covered by the NHI? It was suggested that if one did not follow the correct treatment referral process and protocols then the NHI would not pay for the appendectomy.

On the price regimen, if one wanted to have one's appendix removed at a healthcare provider that had not met the NHI health pricing regimen – how would this be covered? The benefit would likely be covered by NHI but was not paid for by the NHI if one chose to go to a healthcare provider that was not accredited by the NHI. The question was under what circumstances was one then paying for it. This needed to be explored and exhaustively written down so it could be addressed materially by stakeholders. There were some grey areas that were stopping engagement on the issues.

He replied on whether private healthcare was expensive saying it came down to affordability. Was the private sector expensive for the country as whole? Yes, it was. Was it expensive for the current medical scheme population, this was a debating point. He was sure it was likely a meaningful part of household budgets, even amongst upper incomes but it would be less expensive relatively speaking for the insured population. They would likely perceive it as an essential service. This was evidenced in the resilience that medical scheme membership had shown despite economic contraction. The market was continually evolving to find lower cost solutions and better forms of rationing and contracting.

On medical scheme benefits running out, he knew this was a problem for medical scheme members. It came to the other question of demand-side management. Generally speaking demand for healthcare services was insatiable and far exceeded supply. The literature suggested that there needed to be some form of rationing. It manifested differently in different countries. In some countries it involved constraint on supply. There were various rationing mechanisms which were more relevant to the public sector where there were supply constraints.

He was not suggesting that NHI should pay whatever providers charged. There should be an NHI pricing schedule. It should not be as simple as a tariff price list. It needed to be more nuanced if there was a desire to award better quality and value. There should be a separation between accreditation and whether or not it could be provided at a price that was affordable for NHI. Both of them were important, but should be separated. One could be accredited but might not be contracted.

Value based care was a fairly broad term that was used currently to try get health systems to a place where one was paying for improvements in health, not just for activity and the facility. One was paying for outcome. One was paying for health not healthcare. Internationally there was a strong move toward contracting providers on that basis, rather than just paying for services. As reforms were currently being considered under NHI, this approach could be looked at. For the Public Finance Management Act (PFMA), it was important to have an appropriately structured reimbursement model and contract. Typically, when there was a purchaser-provider split, it allowed an explicit contract to be established between purchaser and provider. All these elements could be enshrined in that contract. If there was a typical value based contract for primary care, for example that involved a basic capitation fee on a risk adjusted basis, there would be a baseline fee for providing services and then prescribed enhanced fees based on upfront objectively verifiable set of outcomes. If the provider could achieve those outcomes, then they should be rewarded. It needed to be properly enshrined contractually in the PFMA.

On the level of pent-up demand – this was unknown - partly because the demand of many healthcare services was insatiable. In emergency care, it was generally difficult to fake pregnancy and maternal cases, for example, but for many other healthcare services the nature of demand was a lot looser. During COVID-19 it was observed how demand could flex because it forced some inefficiencies out of the system. This was problematic in areas such as cancer treatment – as seen during the pandemic. Demand manifested quite fluidly. There was not one nominal objectively definable demand. The problem was that if one just let it run, to curtail it back, could impact the system negatively. The real question was about balance.

What made medical schemes slightly complex was the array of options. The open medical scheme market had a plethora of options available with different price points and different benefits. People with different levels of affordability could choose what was most appropriate to them and their family. In an NHI context that would all be standardised. The benefits would be the same for everybody which could create equity but pose constraints in the affordability of how many of those benefits could be afforded and what to do with excess demand. This would pose a conundrum.

Educational Psychology Association of South Africa (EPASSA) submission
Mr Chris Uitzinger, EPASSA Chair of Education and Training Subcommittee, and Dr Matjhabedi Mazibuko, Chair of Community Outreach Subcommittee, presented to the Committee.

Introduction
- EPASSA is supportive of the spirit of the NHI and UHC, including the drive towards ensuring all South Africans have equal access to quality healthcare
- Of particular concern to us is equal access to quality mental healthcare
- EPASSA acknowledges previous inequalities in access to healthcare services and the urgent need to create equitable healthcare services across all communities in South Africa

Mental health under NHI
- We do not believe that mental health is given the prominence it deserves in the NHI Bill
- SA Human Rights Commission report (2017) states that there is currently considerable under-investment in mental health in SA
- NMHPF states mental healthcare services should have parity with general health services. This is not being realised
- According to the WHO (2017) mental health is an integral and essential component of health; there is no health without mental health.
- Goal 3 of the 17 United Nations Sustainable Development Goals (SDGs), in force since January 2016, explicitly notes the centrality of mental health and wellbeing to the overall health status of nations
- It is essential that a national healthcare system caters for the provision of mental healthcare services at a primary (prevention), secondary (district hospital) and tertiary level (specialist hospital), as is the intent of the Mental Health Act, 2002.
- Mental health interventions work best at the preventative, primary care level, where they can have the broadest impact and highest levels of success
- Admissions to specialist hospitals can be significantly reduced through preventative care and thus access and funding to primary psychological interventions is essential
- Investment in mental health has proved cost effective in the long run
- Improved mental health directly reduces physical illness
- A society with optimal mental health will be more economically viable
- South Africa is a traumatised society that is fractured and in distress, we need to prioritise mental health to heal as a nation and be free; not just politically but in our relations together and inside of ourselves (South African Psychoanalytic Confederation).
Some social ills that can be alleviated through the provision of adequate mental healthcare include:
- Suicide
- Substance use disorders
- Interpersonal violence
- Gender based violence
- Violence towards children
- Untreated trauma
- Teenage pregnancy
- High school-dropout rates and academic underperformance

Levels of care
- Mental health care at primary, secondary and tertiary level, including in and outpatient psychotherapy, for a wide range of mental disorders, must be covered by the NHI and not be left as a service to be covered solely by private medical schemes.
- Psychotherapy (in and out of hospital) for a wide range of mental disorders, [as recommended by the WHO Special Initiative for Mental Health (2019-2023)] must be made a reimbursable service by the NHI fund

Benefits
- Mental disorders that are covered by the NHI must not be limited to the list of Prescribed Minimum Benefit Conditions as stipulated in the Medical Schemes Act 131 of 1998, Clause 29(1), but must be far broader, including neuro developmental disorders (which will allow for the psychological assessment of children), anxiety disorders, as well as trauma and stressor related disorders, such as Post Traumatic Stress Disorder.

Role of education psychologists
- Educational psychologists are first and foremost psychologists, and are registered as health professionals with the HPCSA (we are not registered with the Dept of Education)
- Educational psychologists share the same core competencies as clinical and counselling psychologists, which include:
- Diagnosis and treatment of mental disorders
- Provision of psychotherapy
- Regulation 993 of 16 September 2008 read with Regulation R717 of 2006 (Health Professions Act)
- Educational psychologists are involved with broad areas of psychology. Some areas of activity for educational psychologists may include: Preventative and primary care work, including school and community based preventative work; Assessments, including, psycho-educational, neuropsychological, medico-legal and forensic assessments; Interventions, including psychotherapy (individual, family & group therapy), and the treatment of psychopathology.

Role of educational psychologists under NHI
- While particularly skilled in working at the level of prevention, educational psychologists must be included at all levels of service delivery under the NHI
- To exclude educational psychologists as legitimate providers of mental healthcare under the NHI (at all levels) would be to lose out on a valuable national resource
- Educational psychologists should be able to register as healthcare providers, alongside clinical and counselling psychologists, and claim reimbursement from the NHI, and receive the same level of reimbursement as all other psychologists
- Primary Healthcare providers, (Clause 4.4 of Bill) and be included in outreach teams (Clause 4.4.3) and in school health services (Clause 4.4.4)
- Contractors providing services as part of the proposed contracting units (Clause 4.6 & 4.7 of Bill) to provide mental healthcare across all communities.
- Educational psychologists should be able to register as healthcare providers, alongside clinical and counselling psychologists, and claim reimbursement from the NHI, and receive the same level of reimbursement as all other psychologists.

Discussion
Chairperson Dhlomo requested clarity on the representation of different psychology professionals (i.e. counselling and clinical psychologists) on EPASSA’s position on the NHI.

Ms Gela stated that EPASSA did not believe that mental health was given the prominence it deserved in the NHI Bill. Were they aware that mental health was mentioned 11 times in the Bill, including clause 4? This was supported by the NHI policy which stated mental health services would be included as part of NHI comprehensive service benefits, as determined by the Benefits Advisory Committee.

Dr Jacobs noted that EPASSA had said that reimbursement should not necessarily be limited to the prescribed minimum benefits list. Was EPASSA aware that the Medical Schemes Act had no role in this? NHI services would be determined by the Benefits Advisory Committee, which would be constituted according to clause 25, supported by clauses 4 and 7 of the Bill.

Mr Sokatsha stated that EPASSA was cautioning Parliament that, due to the demand-side consequences, fair cost sharing needed to be considered to help manage benefits and costs for all. Was EPASSA aware that clause 7(2)(d) outlined circumstances where some form of cost sharing would apply when users did not follow the defined care pathways? The NHI Bill supported this principle. A fee would be imposed for non-adherence to referral pathways.

Dr Thembekwayo asked what school health services they would like to provide, especially as EPASSA said they wanted to claim reimbursement from NHI for that. Would EPASSA offer education school health services and be placed in schools? Would they be based in schools on a daily basis?

EPASSA response
Dr Matjhabedi Mazibuko replied that EPASSA knows that mental health is mentioned 11 times in the Bill. EPASSA would like more detail on mental health in the Bill.

Mr Chris Uitzinger replied that EPASSA was aware that what was prescribed in the Medical Schemes Act in the prescribed minimum benefits list had no bearing on NHI. EPASSA wanted to point out that the list of conditions currently on the PMB list was insufficient and did not serve the public well. It highlighted this to caution the Committee not to rely exclusively on that list but to look at the recommendations made by the World Health Organisation (WHO) on the range of conditions that ought to receive coverage under the Bill.

Ms Vanessa Gaydon, EPASSA Executive Committee members, replied about EPASSA’s concern about clause 7(2)(d). EPASSA was asking for clarity on how that would take place and what systems would be instituted. The PsySSA submission had covered this quite well earlier in the meeting. EPASSA had specifically looked at the role of education psychologists. This applied to the preventative level on how EPASSA could participate there.

On school health services, EPASSA did advocate for mental healthcare services to be placed in schools, to be central within the school environment where prevention would be effective, as opposed to only treatment thereafter. This did not only apply to educational psychologists, but to counsellors who trained at a four year level, and possibly social workers as well. Schools required mental healthcare services to be placed in them. Schools were well-placed for community work and offered opportunity for provision of healthcare services in rural areas. Schools had infrastructure in place. If one had mental healthcare services within the school environment, as well as using the facilities for further after school family mental healthcare and child healthcare, they would be ideally placed to serve the community.

Mr Chris Uitzinger replied about reimbursement. EPASSA would like to be included and made eligible to be a part of school health services, particularly to fill salaried posts as part of both community outreach teams and school health services. There were very few internship posts for educational psychologists in comparison to other categories of psychologists. These internship posts could be in schools, rural areas and impoverished communities. There was also no community service requirement for educational psychologists and that could offer a mechanism to provide services in rural areas and impoverished communities. Besides that, EPASSA would like to register under the contracting units as private practitioners who were able to provide services to the public and bill the Fund for services provided, according to an agreed schedule.

Afternoon session
Council for Health Service Accreditation of Southern Africa (COHSASA) submission
Dr Bradley Beira, COHSASA Chairperson, and Ms Jacqui Stewart, CEO, presented.

Statement of Commitment
COHSASA believes that quality improvement and compliance with robust standards are the cornerstone to achieve universal health coverage. The Office of Health Standard Compliance (OHSC) has a “mammoth task” ahead of it. The extent of the tasks has been indicated in its reports which showed the enormous gaps in quality of healthcare services through the lack of compliance with the regulatory standards across the public sector facilities, particularly weaknesses in leadership and management. All need to appreciate that quality improvement is a lengthy process and patience is needed to achieve the desired outcomes. It necessary to keep monitoring constantly to maintain a safe quality environment for patient care. There needs to be a strong commitment to working together over an extended period of time, because none of it will happen overnight. Policy improvement is founded on the values of excellent governance, leadership and management.

A lot of people talk about accreditation as a quality assurance mechanism. She strongly believed it does have a quality assurance angle, but it is a lot about quality improvement. COHSASA used internationally accredited standards to achieve that improvement. It trains the facility teams to not only understand the standards, but also to be able to carry out the self-evaluation of their own services using the standards. It trains teams on quality improvement activities that can then be implemented to support compliance with the standards. Most importantly, to instill a culture of continuous improvement. It is not about a compliance mentality, it is about a culture of improvement.

To encourage facilities that are starting from a low base, it developed a graded recognition programme with three levels of recognition. All services must score at least 80 out of a potential 100. These are weighted scores, and there must be no non-compliant critical criteria. COHSASA has public and private healthcare facilities in the programme. It covers the full range of health care facility from hospitals primary health care clinics, hospice and palliative care services, environmental health services, and consulting rooms, including where sedation services are provided, which is a move to get patients out of hospital a lot more procedures are now being carried out in consulting rooms. To date, 627 healthcare facilities in 11 countries have entered the programme. As some facilities have entered multiple times, 873 awards have been conferred:
• 642 Full Accreditation awards
• 75 Graded Recognition at Intermediate Level awards
• 57 Graded Recognition Entry level
• 99 Graded Recognition at Progress Level awards
Some will have gone on through those various levels of recognition to achieve full accreditation.

South African facilities in the Accreditation programme
COHSASA had facilities in six of the nine provinces in the programme. There was a large presence in the Eastern Cape, Free State and KwaZulu-Natal. In both Mpumalanga and the Eastern Cape, none of the hospitals achieved full accreditation, not because they do not have the potential to do so, but sadly, the programme was terminated. All the public sector facilities have now stopped the accreditation programme. This was because of the introduction of national core standards, because the provinces or the Department of Health (DoH) decided that they should only be implementing national core standards and not the accreditation programme. Currently COHSASA has 56 private health care facilities in the programme in South Africa.

COHSASA presented proposed amendments for some clause of the Bill:

Access to Care
- Clause 7(2)(a): This implies that users will have to register at multiple facilities and providers.
- The process should allow for once off registration process with user profile accessible to multiple facilities through unique user ID.

- Clause 7(2)(d)(ii): The process of the referral pathway development is not clear.
- Most will need to be specific to geographical areas. There could be some generic referral pathways on levels of care in the healthcare system.

- Clause 7(2)(d)(iii): A user is not entitled to healthcare services purchased by the Fund if he or she fails to adhere to the prescribed referral pathways.
- There need to be mechanisms in place to safeguard patients transferred outside the pathways for specific reasons, with some degree of choice available to patients in consultation with the referring doctor.

- Clause 7(2)(f): This clause raises concerns about the capacity at the NDOH to efficiently govern such geographically dispersed, disparate facilities and still consider the local population needs.
- It is critical to put in place measures that will ensure that the performance of these facilities is not compromised by a dual management/leadership structure.

- Clause 7(4): Treatment must not be funded if -
a) no medical necessity
b) no cost-effective intervention as determined by a health technology assessment
c) the product or treatment is not in the Formulary
- Safeguards need to be in place to avoid patients being refused treatment under this clause on financial grounds. Health technology assessments need to be available for scrutiny to demonstrate they are objective. There needs to be an appeal mechanism.

- Clause 8(2)(b): If a user fails to comply with the NHI referral pathway, they must pay for services directly via health insurance (or out-of-pocket).
- This requires clarification as it appears to contradict clause 33 which explains that only complementary services (not covered by the NHI) can be covered by private schemes.

- Clause 37: Will the provincial health departments be responsible for operating the contracting units for primary healthcare?
- If not, what role will they play in identifying the priority services required by the sub-districts?

- Clause 37(2)(b): A Contracting Unit for Primary Care comprises a range of public and private providers and must assist the Fund to identify accredited primary care providers.
- The contracting unit is then both the purchaser and provider of services which implies a conflict of interest.

General quality issues
- Clause 10(1)(i): Utilisation data and information management systems to monitor the quality and standard of health care services, medicines and products purchased by the Fund.
- SAHPRA will obviously be responsible for the quality of medicines and products. It needs to be transparent which standards will be used to measure quality of services
- Clause 10(1)(o): This clause refers to measuring the impact of the NHI on national health outcomes.
- An objective third party should assess the performance of the Fund in addressing the healthcare needs of the nation.
- Clause 11(1)(h): The investigation of complaints against the Fund, health care service providers, health establishments or suppliers.
- The relationship with complaints handled by OHSC needs clarification. The public needs to be able to differentiate the type of complaint and where to lodge it.

Quality of services
- Certification by OHSC and registration by a recognised statutory health professional council have been added as requirements. It is not clear if these replace the current DOH licensing and BHF practice coding system, as the Bill is silent on these two processes.
- Other than the certification by OHSC, which is measured against the regulated minimum standards, there is no other mention of the quality of the facility and the services to be provided.
- We believe that quality is key to ensure safe health care delivery in all healthcare settings.

Accreditation of facilities
- Clause 39(1) outlines how the NHI Fund will accredit the providers. It is our submission that contractual obligations and the process of accreditation should be kept separate.
- The term accreditation seems similar to the approval that current Medical Aids do to approve service providers to join their networks.
- Accreditation should be undertaken by an independent third party.
- We support the proposed process whereby facilities will be accredited on an ongoing basis and suggest the period should be shorter in the early stages and be extended as the process beds down.

Discussion
Mr T Munyai (ANC) asked what wording COHSASA suggests would clarify clause 8(2)(b). COHSASA recommended that health technology assessment needs to be available for scrutiny, and that there should be an appeal mechanism for clause 7(4). Clause 57 states that a Ministerial Advisory Committee on health technology assessment will be established. This is supported by clause 7(4)(b); and also, clause 42 outlines the appeals process.

Mr M Sokatsha (ANC) asked for COHSASA’s definition of international quality standards that it measures?

Dr K Jacobs (ANC) said COHSASA mentioned the patients being referred by the doctors. It recommended that some degree of choice should be available to patients in consultation with a referring doctor to go outside the referral pathway. The Committee is certain that clause 37 seeks to ensure the referral pathways are functional, including transportation of users between different levels of care, and between accredited public and private care service providers if necessary. He asked COHSASA to comment on clause 37.

Ms M Hlengwa (IFP) asked: What are COHSASA’s proposed changes to the country's health care system in light of the proposed National Health Insurance (NHI) Bill? In terms of accessibility, what is COHSASA’s role there such as in extremely rural areas?

Ms A Gela (ANC) said that COHSASA had made a recommendation that the process should allow for a once-off registration process with the user profile accessible to multiple facilities through a unique user ID. However, Clause 7(2)(b) allows for portability of access and clause 7(3) explains how portability will apply.

Ms H Ismail (DA) wrote in the chat box due to network connectivity issues:
1. In your submission you mention a concern about DoH able to efficiently govern such geographically dispersed facilities. Would you suggest that more power be given to the provinces for NHI implementation?
2. OHSC is unable to monitor even 20% of facilities. In your opinion, how could this impede compliance and the handling of complaints?

Ms X Havard (ANC) asked: Does COHSASA support the Bill as a single-payer, singe-purchase fund?

The Chairperson said that COHSASA is a southern African institution. South Africa had an independent institution called the Office of Health Standards Compliance. It was, among other things, trying to assist the quality improvement in facilities, to improve systems, and to ensure that it is one of the enablers for the NHI to be implemented. What is COHSASA’s assessment of OHSC? Does COHSASA want to complement the work that it does? Is COHSASA familiar with the work of OHSC? As Ms Ismail said, there are many facilities, both private and public, and OHSC seems to be behind in accrediting those. Does COHSASA think that if those facilities were to be capacitated, they would be sufficient? Is COHSASA familiar with the accreditation criteria that OHSC uses? Clause 32(2) describes there would be a changing role of provinces and their responsibilities. That means that there will be an amendment to the National Health Act in the schedule of this Bill. Does COHSASA want a clause outlining in detail the roles of the provinces?

Mr Sokatsha asked about clause 39(1): What is COHSASA’s understanding of strategic purchasing and value-based contracting?

Mr Munyai asked: Is it COHSASA’s view that there is confusion between the terms: licencing, quality improvement certification and accreditation?

COHSASA response
Ms Stewart replied that COHSASA is asking for clarification of clause 8(2), in making sure that there is some kind of appeal mechanism. A Member noted that that is covered elsewhere in the Bill. COHSASA wanted to ensure that patients do have the opportunity to purchase from other sources, and that the health technology assessments are available for scrutiny. As a Member pointed out, the Ministerial Advisory Committee set out an appeal process.

Ms Stewart replied about COHSASA’s definition of international quality standards. It is derived from the fact that its standards are accredited by the International Society for Quality in Healthcare (ISQH), namely their External Evaluation Association. That is the global body that accredits healthcare facility accreditation bodies and standards. COHSASA believes it is best practice globally to have health standards accredited by ISQH. Value-based contracting is mainly about looking to services that may be provided by teams, not necessarily a fee for a service from an individual practitioner. Particularly in areas such as chronic diseases and palliative care, there is an argument for value-based contracting to enable a team approach to give the patient the best options. It believes that this also avoids the perverse incentives of over-servicing patients when they do not necessarily need particular investigations or treatments.

On clause 37, COHSASA believes that referral pathways are essential, and they are the best way if people have [audio cut out 00:46:55]; it allows for much more clarity, and it allows for certainty for the receiving doctors or teams to take patients through transfer or elsewhere. COHSASA feels that patients and doctors – in exceptional circumstances, it would not necessarily be the norm – should be given the opportunity to move outside those pathways if there were very good reasons to do so. But such reasons would need to be very clear, and have a mechanism for ensuring that those can take place.

On Ms Hlengwa’s question on changes in the healthcare system in light of the NHI: There will be changes in the system. One of the good changes will be much transparency and co-working between the public and private sectors, which has to be good. More horizontal movement between the public and private sectors, and benefiting from the expertise in both sectors. Ms Hlengwa mentioned accessibility. Many of the health facilities in South Africa are indeed in remote rural areas, and part of the NHI’s role will be to ensure that the country improves the access to care for the most vulnerable populations, and to ensure that it is not just the metropolitan areas that have good access to care.

On the once-off registration, COHSASA is not saying the Bill does not allow for portability, but it thinks that there needs to be more clarification to ensure that patients understand that registration process, and that it is kept as simple as possible, to ensure people have good access and access when they need it the most.

Ms Havard had asked about a single fund, Ms Stewart said she herself was not a finance expert, and would not claim to have a strong opinion on that. She asked Dr Beira if he wanted to comment on that question.

Dr Beira replied that COHSASA stands between two different positions. It advocates strongly the opinion on value-based care and quality improvement. On whether it supports the NHI as a payer, COHSASA is fully supportive of the initiatives driving towards universal care, driving towards both autonomy of care at practitioner-user level, but also at the level of the integrated role of value-based purchasing of care. The alignment of how that care should be funded is not something that Dr Beira believed COHSASA could comment on, other than to say that COHSASA is respectful of the manner in which it has been proposed, without denigrating the role.

On the future role of the provinces in clause 32(2), there is sufficient information available for the Committee to be making those decisions on the role of provincial health departments contracting for and costing primary care, using techniques such as diagnostic therapeutic pathways (DTPs), understanding the history of where South Africa has been, and understanding the cost of Prescribed Minimum Benefits, and access and rollout.

Where COHSASA has an interest, and believes that both accreditation and quality improvement plays a big role, is that COHSASA would be able to see outliers in funding, or payment for care along a DTP using diagnosis-related grouping (DRG). That would give further insight into both affordability and control of care. On the portability of access to care and the strategic purchasing and value-based purchasing of care, COHSASA fully supports OHSC on how it wishes to create standards, supporting it through providing adjunctive accreditation standards, and by supporting the South African standards already in place. The view is to gradually encourage facility management to not just do the facility management, but to ensure that hospital managers, clinic managers and provincial advocacy ensure that the facilities and the access to standards of care are raised. As access to care rises and the quality of care rises, the adverse outcomes reduce, the cost of care reduces in the same way, with more efficiency and better outcomes. If one calculates better outcomes using actuarial models, one might find quality improvement via COHSASA supporting OHSC even though it can currently only monitor up to 20%, the view would be that hospital managers in facilities and provincial organs would be doing the monitoring and support themselves. OHSC and COHSASA would support in setting where the next areas of improvement might be.

That would give coordinated views on areas where South Africa can improve nationally, provincially, or improve in specific local areas where care needs to be improved. Dr Beira used that as a preamble because that gives a sense where finance needs to be focused in areas where one province may stronger, and another might be less strong in moving through a graded system.

Ms Stewart replied about her comment about DoH being able to manage very geographically dispersed areas. She was not advocating where power should be allocated; she just thought it important that the management lines to the facilities must be clear to ensure the needs of local populations are met. However management is delivered, it needs to be clear that South Africa’s population is very varied. There are large urban populations, large rural populations, different age groups, and different needs. It is that clarity of ensuring there are very clear lines of responsibility and management, that the service providers know exactly who they need to report to, and where any concerns or changes need to be addressed. The Bill needs to be clear on how that is organised.

On the confusion between licencing, quality improvement certification and accreditation: Licencing is the very basic part that a healthcare facility, before it opens its doors, has the basic infrastructure and those are the minimum standards to provide its services. COHSASA sees certification as OHSC has a regulatory function to ensure that official standards are met. COHSASA as an internationally accredited healthcare facility accreditation organisation understands accreditation as a voluntary process where people choose to enter an accreditation programme. In some countries, such programmes are mandatory. There is a fine line between where people see the mandatory process ensuring that they comply with the standards, and quality improvement. That is the huge difference, that when one complies with standards, it is not about ticking the box on the day, it is about complying with the standards because it is the right thing to do to ensure healthcare workers and users of the service are safe and guaranteed a quality environment. COHSASA needs to help people with the change of mindset that it wants to see with local services, that are continually improving. Ms Stewart said she would like to see COHSASA being complementary to OHSA, as the latter has its mandate to ensure that the regulations are met, and that is a huge mandate, and it needs the capacity to do that. But COHSASA sees that accreditation could be part of a trajectory of that continuous improvement.

Mr Munyai asked if the presenter was implying that the Board of Healthcare Funders’ (BHF) practice code numbering system, and the DoH issuing of a facility licence is some form of quality assurance.

Mr Sokatsha said that strategic purchasing and value-based contracting ties the price to performance of a provider. Is it COHSASA’s view that strategic purchasing must be separate from accreditation?

Dr Beira replied that registration with the BHF, and the use of the International Classification of Diseases (ICD) and procedure coding, are elements to create the licensure to provide services under BHF. The mechanism creates both singular and multivariate models to measure what procedures are being done, at what cost, in which region, with what quality outcome. From the experience of COHSASA, where there is the discipline of integrated record-keeping on an integrated repository or dataset – e.g. the Electronic Vaccine Database System (EVDS) of the vaccination programme has the ability to integrate data in a way that allows one to see various aspects. These include which users are getting what kind of care, on which pathways (referral and care pathways). It provides both the administrators and the legislators with significant insight into how effective levels of care are, how many users are being reached, at which region and demographics, with what type of primary, secondary and tertiary rehabilitative care. COHSASA does support, as quality measures, the registration of facilities and practitioners, and the use of coding. That was not an issue as long as such measures are being consistently provided.

That also speaks to the question raised earlier whether COHSASA proposed changes to the country’s healthcare system, and what COHSASA’s role might be. Dr Beira believed that the ability to have integrated records and shared record-keeping allows increased collaboration amongst healthcare practitioners and providers. Secondly, it allows push-and-pull information around formularies and where care and facilities are needed, and where there is capacity in areas and where there is not. It also gives a strong understanding of where users need continuation of care because of the mobility and portability of their own lifestyles, either socially or as a result of work. That goes back to the Member’s question on whether there should be a quality standard aligned and COHSASA would certainly answer in the affirmative.

On whether strategic purchasing and value-based contracting should be a separate function from accreditation, the process of looking at the effectiveness of how a healthcare facility is providing its services should be separate from but aligned to strategic purchasing and value-based contracting. This is because the accreditation process may, under its parameters, look at how strategic purchasing is done, or how value-based contracting is entered into, and look at the effectiveness of service-level agreement (SLA) measures. COHSASA believed that accreditation should be separate, in the sense that there is always the potential of a conflict if the person involved in the purchasing and contracting is also part of the evaluation of the efficacy of services at service delivery and accreditation level. In summary, licencing through BHF and DoH is important. The recognition of services both through pathway and through coding is essential. The separation of services so accreditation directly through OHSC, and through partners like COHSASA, would allow an unfettered drive towards excellence without conflict of interest.

The Chairperson thanked the COHSASA team for its contribution and Dr Beira said COHSASA would avail itself to the Committee at any time for further discussion or information.

South African Dental Association (SADA) submission
Mr Khomi Climus Makhubele, SADA CEO introduced the SADA delegation: Dr Rhonin Naidoo, President; Dr Nadeem Osman, Acting Board Vice Chairperson; Mr Punkaj Govan, Head: Corporate & Legal Services; Dr Nthabiseng Metsing, Head: Professional Development, and Dr Tinesha Parbhoo, Head: Clinical Support Services.

SADA is a non-profit company and professional association representing the majority of dentists and dental specialists in both the private and public sector. SADA is also known for its coding book, which it created and has maintained over the years, and has become the language of dentistry in South Africa. It is also affiliated with the Federation of Dental Associations (FDA).

• Healthcare outcomes in South Africa are bad partly because of the prevalence of poverty and, for many people, lack of the basic infrastructure for healthy life. Another contributing factor is exposure to interpersonal violence and lifestyle issues such as alcohol and tobacco abuse.
• We support resource informed and evidence-based approach to any implementation of major reforms in the health system.
• We are concerned about the limited time frames to process enabling legislation to put the provisions into place.
• The NHI Bill makes provision for the Fund to establish an independent board that will report to Parliament. However, it makes no mention of how the board will engage with the health minister (political custodian) and health department. Nor does it explain how the performance of the Fund will be evaluated. We are concerned about corporate governance.
• First phase calls for central hospitals that are currently nationally funded and managed need to be migrated to so-called ‘semi-autonomous entities’. This term is not defined anywhere and the precise intended status of central hospitals is therefore largely unknown.
• A contracting unit for primary healthcare needs to be structured. The precise terms and conditions of a ‘co-operative management arrangement’ are not detailed in the Bill at all.
• A Health Patient Registration System needs to be established in terms of clause 5. Like the Fund itself, this objective requires clause 5 of the Bill enacted for its provisions to take effect legally and for the proposed registration system to be established.

NHI Bill
• Eligibility as beneficiaries of Fund: Despite s27 of the Bill of Rights which provides everyone with right of access to healthcare, refugees and asylum seekers are excluded from comprehensive healthcare and rights to healthcare. Doctors do not have the luxury of turning away patients in need of care.
• “comprehensive health service benefits”: no information on what this entails but the Fund is given the responsibility of purchasing these for the entire country.
• Registration of users: It is difficult to see how the current capacity will cope with an additional administrative burden of registering all users on an IT system that would have to be extremely robust, but is yet to be developed. Recent registration for vaccinations is a case in point.
• “Rights of users”: rights are limited in that each patient needs to register with a primary healthcare facility as an entry point to the system. The patient therefore does not have a choice at which level to enter the system.
• Reimbursement for services rendered: price controls in the private sector, including a national price list will punish those health care professionals who do not follow the prescribed pricing list. The Fund reserves the right to withdraw accreditation of a service provider if the service provider fails to adhere to the national pricing regimen for services delivered. In view of the scarcity of doctors, it would not be a good strategy to freeze out doctors who do not stick to the NHI rates.
• Health service benefits coverage: no details on what services will be provided under “health service benefits coverage” to properly provide detailed comments. ‘Benefits Advisory Committee’ is anticipated to decide what the content of this package will be. No provision for public participation in these processes.
• NHI Board: technical requirements of board members is of concern, even medical schemes who manage smaller budgets, have very strict requirements on trustees.
• “Stakeholder Advisory Committee”: healthcare professionals are not represented as stakeholders on this committee of 18, and not have single healthcare practitioner, medical aid representative or any other medical expert as members.
• Role of the Provinces: despite collapse of North West Health, collapse of oncology in KZN, it is noted provinces retain the stewardship of public sector health facilities.
• National Health Information Repository and Data System: state seems to be adamant that administration of the Fund will be government run and yet the IT component is outsourced to an independent data company. The irrational nature of such a proposal, makes one wonder what the motives are for this outsourcing of data storage.
• Payment of service providers: entire Bill refers to specialists. Capitation-based remuneration will have even worse consequences for general practitioners because changes in the number of people could mean drastic differences in workload without the doctor’s remuneration being adjusted.
• The NHI Fund will effectively be a huge, single-payer medical scheme with 25 times as many members as Discovery. We are concerned that government may not have the necessary capacity to administer such a large scheme.
• The Compensation Fund is closest to the NHI Fund, it fails to pay on time and manages to pay R2bn. The NHI Fund will manage over R200bn which is hundred times the Compensation Fund and Bill is silent on the bureaucracy it will require and how much it will cost.
• As a membership organisation, we are concerned about the uncertainty and anxiety that these vague aspects of the Bill are generating among our membership, dentists in training, and learners considering dentistry as a career.
• 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.
• As a membership organisation, despite these concerns SADA remains supportive of government and opportunities to work together to reform the healthcare system in a manner that will result in improved access to quality affordable care for all South Africans.
• SADA remains committed and is willing to offer its expertise and assistance to the NHI committees and working groups on oral healthcare provision in the NHI.

Discussion
Ms Ismail understood that the NHI Bill does not adequately cover equitable access to dental health. In what way does SADA think that the NHI Bill will negatively affect its mandate? Has SADA submitted everything that it wants reflected in the NHI Bill to reflect dental health? Does SADA support the NHI Bill as it is now?

Mr Sokatsha said that clause 51 describes how the Fund will be subject to parliamentary accountability and the Auditor General. Is it SADA’s view that these processes are not adequate? How does SADA propose that equity in access for oral services can be improved, especially for the most marginalized populations?

Dr S Thembekwayo (EFF) asked for clarity on the resource-informed approach and evidence-based approach in NHI according to SADA. It stated that the Minister has too much power when it comes to the Fund, specifically handling those billions of Rands. SADA referred to the “capturable” government. What is its suggestion and/or amendment to this?

The Chairperson asked what “capturable” means.

Dr Thembekwayo replied that the submission used the term and put it in quotation marks.

Dr Jacobs heard the presenter calling the NHI Fund a state-owned enterprise (SOE). He noted that the intention is to have it as a Schedule 3A entity. There are distinct differences between an SOE and a Schedule 3A entity. He asked where in the Bill does it indicate that the national health data repository will be outsourced to a private company?

Mr Munyai asked if SADA members are regulated under the Health Professionals Council of South Africa (HPCSA). The HPCSA regulates more than 90 professional disciplines, does SADA expect each of the 90 disciplines to be mentioned individually in the Bill? Is SADA suggesting that quality must be compromised because of a few dentists? Why in the National Health Service (NHS) in the UK, have a lot of South African dentists been disqualified from practicing because of quality challenges? How can South Africa allow quality requirements not to be a prerequisite?

Ms Gela asked: Why is SADA alluding to the Bill excluding dental health services? Does it regard itself as being outside the multidisciplinary teams and comprehensive health package?

Ms Havard asked what type of reimbursement SADA suggests for dental care at the primary care level.

The Chairperson said that one is under the impression that doctors are given the status of leading multidisciplinary health teams. But doctors remain a leader within the team; they do not make comprehensive work by themselves. Is SADA making a suggestion that it does not see doctors being part of the multidisciplinary team? Are doctors supposed to be standalone outside of the multidisciplinary team? He thought the reference to the voluntary EVDS was unfair. The Health Patient Registration System (HPRS) system has now registered close to 40 million people in the country. This is part of a process to enable the success of NHI, because it says that there shall be a registration of all citizens. SADA did not seem aware of that process.

He asked SADA to indicate how many dentists are in the private sector compared to the public sector. He then asked if SADA could amend the statement made in the submission which said that the public sector does not have equipment for dentists. Does it mean that from Cape Town to Musina there is no equipment for dentists in all public facilities? The Chairperson did not think that SADA “could boldly make such a statement”. He would wish for that statement to be qualified.

SADA response
Mr Makhubele replied that he had not stated that all hospitals do not have dental equipment. His statement was that SADA does know that there are a few hospitals that have equipment. But the majority of the public sector hospitals do not have adequate dental equipment. He was sure the Committee was aware of this, and the Ministry had also indicated this. This leaves the dentists at such hospitals only able to do pain management and extractions. Extractions are part of what dentists do; however, the first thing that one wants to do is to prevent the removal of a tooth. Once a tooth is removed, it is gone. That is what the majority of South Africa’s dentists do because they do not have the proper equipment at hospitals. SADA is in touch with the people leaving university and going into hospitals, and they tell SADA their experiences.

The majority, even those doing community service, in that first year, because of a lack of equipment, tend to lose what they have learned at university. This happens because graduates cannot practise what they have learned. This is the opposite of what one finds in the private sector, because as a private sector dentist, one needs to have the equipment to treat a patient. This is a concern that needs to be looked at. However, every time it comes to health discussions, the medical doctors seem to be prioritized. When one goes to a hospital, there is various equipment, but the dental side seems to be “an orphan" in Health, yet these professionals play a huge role. Mr Makhubele could mention the hospitals which SADA knows have better equipment; it gets this information regularly. It attends a meeting of various Departments of Health practitioners, so it gets to know what the provincial coordinators are telling it is available in their provinces.

SADA was not saying that medical doctors are not part of the multidisciplinary team. When one looks at the Bill and discussions on the Bill, it seems that medical doctors are the ones recognised most of the time. Even in the pilot project, it was more the medical practitioners that were very much involved. SADA does see every health practitioner as part of the multi-disciplinary team. There is a need to recognise the unique contribution of each member of that particular team. SADA feels that the way the Bill has been drafted may seem to take medical doctors as being higher than others. That is its concern, particularly for dentistry.

On information technology (IT) registration: SADA was highlighting that when South Africa goes for the implementation of the NHI, it needs to be ready. SADA has been involved in the Sisonke trial and in the EVDS a bit as well. It knows the issues that have occurred there, where systems were cleaned up later for implementation – these were not pilot projects – and some of it failed, of which the public may not be aware. SADA is saying that if South Africa is going to implement the system appropriately, it needs to put in timeframes. He was assuming that a project management strategy is there to ensure that by the time things are implemented, everything is running smoothly. SADA is not saying that it is not happening.

Mr Makhubele was aware that with the vaccine registration in rural communities (he comes from a village that is far away), community members have assisted the elderly to register. But he was talking of the particular infrastructure that South Africa will have to be deal with the many millions that make up its populace.

On where SADA stands with the Bill: SADA, overall, is in support of a universal healthcare system. It feels that the Bill lacks clarity on some things, and in some of the models chosen. For example, SADA does not believe the capitation model as it stands will assist with the objectives of the Bill.

On services: If one goes through the Bill, one will realise that particularly when it comes to the medical side, it tends to list quite a few things that need to be covered. SADA is saying that when it comes to oral health, it is unsure if the drafters of the Bill had someone who understood dentistry enough, or perhaps it was something that was excised from the Bill. It does not list the services. With oral health, SADA indicated in its submission that things that make people sick come through the mouth. Oral health professionals can diagnose if a person is suffering from certain diseases. It is important that dentistry is well-covered if South Africa is going to reach the NHI Bill objectives.

On equity in accessing oral health care: It is through the universal healthcare system. It needs to work for the populace of South Africa. It is important that right at the beginning, when the Bill is implemented, let there be detail, understanding, and also phases. Perhaps there should not be a rush to cover everyone who is already covered. “Let us relook at how we deal with that. Maybe to start to get equity, “let us look at the people that are currently suffering because they are not covered by NHI, cannot see a dentist or a specialist doctor, or whatever the case may be”.

As the system covers those people, then one can start to bring other people in. That will mean that the model of funding will have to be rethought. The biggest impetus of why every single person, including those who buy these services from the private sector and medical schemes, are to be brought together in one system is to help fund each other. SADA would have liked to have seen the people who are suffering currently be covered first. South Africa would also get the time to learn through implementation with a smaller number and go on, until it reaches the outcome that it wants. Take those who are not covered currently and put them in the system, that will help the country, because everybody will have access. Leave those who are able pay to pay for private coverage if they can afford it.

On “capturable” governance: When there is power in the hands of a few people, the risks are high they will drive that process the way they want, whether it is correct or not. SADA is suggesting that there is a need to relook the governance of the NHI. There is a need to ensure that power is not given to a few people; it is broad and checked. There need to be terms and conditions, and enough protection in governance and decision-making.

SADA is saying that when it looks at the technical qualification required for members of the various committees, it is not strong enough. It needs to be made stronger to ensure that the quality of decisions, and therefore the quality of the offering of the NHI is strengthened. SADA is part of the HPCSA. If one goes through the Bill, the majority of the main HPCSA disciplines are mentioned. Even when the pilot project started, those disciplines were mentioned specifically by name, but dentistry was not, and that is what SADA is decrying. It is not saying to treat SADA as a special project. SADA is saying understand the importance of dentistry. Dentistry is more important than many people understand. If one is to ensure that the people of South Africa get quality coverage and service, dentistry cannot be left out. Therefore, it should have been prominent in the Bill, and it should have been prominent in the pilot project. Dentistry has not been prominent thus far.

Mr Makhubele noted the difference between Schedule 3A entities and SOEs. When he spoke about the repository, he assumed that Members would understand: If one is going to plan for oral health work and dentistry, for example, the country needs to understand what is the biggest problem in dentistry. What is the most prevalent disease amongst people, and at what age? South Africa does not have such information, while other countries have it. Such information is called the burden of disease. Such data might say what the burden of disease is nationally, but when looking at provinces, KwaZulu-Natal might have a different picture to Gauteng, for example. Once one has that, it helps in how one plan services. SADA is saying that the Bill is silent on this. SADA has actually engaged with the Department, and it has acknowledged that this is a challenge, but there has not been anything happening to address this. With the repository, SADA is already giving information to government, and the Council for Medical Schemes has access to that in terms of the ICD-10 for every single treatment or procedure done by a dentist. However, that information that is supposed to help South Africa and help the NHI plan better. South Africa does not have that. Currently SADA is engaged with the Department and CMS to ask, “why are we being forced to give this information, yet nobody wants to give us the feedback”. No one is collating the data, and giving feedback to the profession and the Department, which is what the NHI requires.

On the UK qualification: Mr Makhubele did not have an answer to the Member's comment that many South African dentists are disqualified in the UK. Such people are not SADA members. He supposed those people would be members of the British Dental Association. If need be, SADA could find out about that. If the Member was talking about South Africa, he would be able to speak to that, as SADA fully understands the landscape in South Africa. All he was referring to about the UK was that there had been problems with implementation of the NHS system. But in certain places, the UK has fixed the problems. He hoped that there would be learning, particularly in dentistry, because in the UK mistakes were made in implementing dental healthcare.

He emphasised that SADA was not saying that everything was wrong with the Bill as it is. Due to limited time, it highlighted the issues it believed still needed to be improved. It has offered to engage at all levels and to provide information. It has spent money on research that neither the country nor Africa has. It will share that information. SADA is willing to help the process. It thanks the Committee for this platform, and wants to see more such engagements. SADA can deal directly with the various committees if given that chance to improve the outcome of the NHI, particularly when it comes to the oral health.

On the NHI Fund accountability, Mr Punkaj Govan replied about parliamentary oversight that “With due respect to Members of this Committee, as well as to Parliament, Parliament’s past record of parliamentary oversight is nothing but disappointing, and you must admit that”. The current oversight of state entities leaves a lot to be desired. SADA does understand the difference between an state owned entity and a Schedule 3A entity.

On evidence- and resource-based approaches, it may well be that the committees working on the NHI might have done some research apart from looking at overseas models. SADA is asking what type of research has been conducted on South African conditions, and the extent to which the NHI framework is workable for those conditions. There has been very little interaction with the stakeholders. He supposed that some professional health associations may have had interactions. But there has been very little interaction with SADA as a stakeholder in this process, and therefore, it may not be aware of some of the workings of the various committees behind the scenes.

Dr Rhonin Naidoo clarified about the distribution of dental equipment that in some provinces, there are very efficient hospitals, which have adequate dental services and equipment, especially where there are dental schools. In the Western Cape and Gauteng, for example, there are hospitals with adequate equipment. In provinces where there are no dental schools, there is a gross shortage of services. For example, oral cancer is treated in a big way within dentistry. Dentists are responsible for diagnosing pre-malignant lesions and oral cancer. There are very few services in the majority of provinces. It is fair to say that in some areas, there is sufficient equipment, but there is also a gross shortage of equipment and personnel in other areas.

Mr Munyai said that SADA’s submission is diametrically opposite to the submission made by its regulator and the dental academic sector. Is there a possibility that SADA members “feel threatened that they might not be able to make exorbitant profits that they are making if the status quo remains?” SADA said that it is not taken seriously. Where in the Bill is it indicated that it is not taken seriously? He assumed SADA understands about policy formulation that the Bill is now before Parliament, not before the DoH.

Ms Gela asked why SADA compared NHI to the Compensation Fund – where are these two funds the same? Did it agree that the NHI would be using a strategic purchasing and value-based contracting, using alternative reimbursement strategies that are different from fee-for-service reimbursement?

Dr Jacobs asked how SADA members managed undocumented migrants at the moment, as the presenter had said that doctors do not have the luxury to turn patients away. He asked if SADA is certain that oral health was not part of the pilot projects. According to his understanding, oral health was prioritized in the pilot projects. Also the school health programme included oral health services for learners; it was one of the critical programmes delivered. Does it agree with that statement? Does it realise that the Department is the custodian of ICD-10 codes, and not the CMS?

Dr Nadeem Osman responded that SADA is not saying that it does not agree with universal health coverage. Research has been done overseas where entities have implemented this system, specifically the NHS. In March/April, it was reported that there was a waiting list of four to five years for dental visits in the NHS system. “Our objective is to ensure that when this is implemented, there is a strategy in place, and SADA, having the experience and knowledge of the finer workings of the oral health spectrum, is able to give input and ensure that it is sustainable”. Implementation is one thing, but it must be something that is sustainable.

Mr Makhubele replied that dentistry in South Africa is struggling at the moment. Dentists do not make exorbitant profits as the Memeber alluded to. Dentistry tends to subsidise the patient. Of all the health professions at the moment, dentistry has so many laws and regulations that dentists have to comply with which costs money to get the compliance right. If one is a medical doctor, one opens a surgery and charges what one wants; patients are then given a prescription and have to get the medication from a pharmacy. Dentistry is different. When a person comes to a dental surgery, dentists have to do everything from diagnosis to treatment; they will not refer a person somewhere else, and a person has to be dealt with in that space. Therefore, dentists have to buy a lot of expensive equipment. It is not just a room, a stethoscope and a probe. “We do not make money”. He implored the Committee to study the cost and profitability of dental surgeries in South Africa. Many dental surgeries are closing.

HPCSA is the regulator; its views are not necessarily those of its members. If SADA is diametrically opposite in some areas, it is because SADA understands what happens at the grassroots level of dentistry. HPCSA is speaking about the umbrella view of what is happening. SADA and HPCSA may agree on many points, but SADA is speaking about the grassroots level. Those treating the patients under the NHI will not be the HPCSA, but the members of HPCSA, such as dentists.

Mr Makhubele acknowledged that schools were included in the pilot project. Due to the lack of input from dentistry, it could have been even better. The consultation was not strong enough at that pilot level, it did not achieve what it should have really achieved.

The Chairperson said that SADA could have spent less time explaining who it is and more on the NHI, specifically what SADA consider as its inputs on the NHI. If one expands too much about who one is and is not, the Committee misses the gist of what is required in the Bill. He thanked SADA, and said that the Committee would continue interacting with it.

Mr Makhubele replied that SADA appreciated the opportunity to give input and the engagement. All it is saying is that this is for country, and not Parliament only. SADA is there every step of the way to assist; if it is called upon in any way, it will be there.

Progressive Professionals Forum (PPF) submission
The PPF delegation included Mr Kashif Wicomb, PPF President; Dr Honours Mukhari, PPF NHI National Convenor; and Dr Cynthia Sathekga. Mr Wicomb noted that the team had both public and private sector medical experience. The PPF was formed in 2013, as it was felt that the professional and the middle class of South Africa is not contributing as much and as often as it should towards building this country and Africa. PPF felt that the middle class, professionals, intelligentsia and entrepreneurs are most removed from the state, yet it is they who have benefitted most from government progressive transformation policies.

- The Progressive Professionals Forum (PPF) supports and recognises the importance of the introduction of the NHI Bill for public consultations as the country is faced with a myriad of health care challenges and the NHI Bill is a critical and indispensable vehicle that can transform the national health care system towards a Universal HealthCare Coverage.
- The introduction of the NHI Bill is in line with the Constitution which advocates for rights to free quality health care services to the citizens of South Africa.
- When implemented the Bill will transform the current two-tier health system into an integrated unified single Health care system.
- The NHI will be a solution to the structural challenges in both private and public health sectors.
- The NHI is the biggest transformation program of the health system since the end of apartheid and is without a doubt, the most complex system to be implemented since the dawn of democracy.
- During the nation-wide public hearings by the Health Portfolio Committee, the PPF conducted seven NHI public participation workshops in five provinces: Gauteng, Limpopo, KwaZulu Natal, Eastern Cape and Western Cape.
- This meeting was attended by approximately 600 disciplines of health care workers, academics, and professionals' associations mainly from the Private health care sector.
- The PPF’s position and recommendations on the NHI Bill is a summation of the inputs received.

Endorsement
Dr Honours Mukhari presented.
- The PPF endorses the objectives of the NHI Bill, particularly that this NHI Funding system will ensure quality health access for all South Africans irrespective of their socio-economic status.
- It views the NHI Bill as a system intended to ensure that the use of health services does not result in financial risk to the people, and it seeks to ensure universal health coverage for all, based on health needs and not affordability.
- The PPF is also encouraged by the principle of Social Solidarity (Ubuntu), and social justice in the Bill where there is cross subsidization across all sectors of society, rich and poor, young and old, employed and unemployed, the physically-abled and people with disabilities.
- It supports the purpose of the NHI Bill to establish a NHI Fund which will buy health services on behalf of the population from accredited private and public health care service providers.
- Through strategic purchasing as the single purchaser and a single payer of health care services, the NHI Fund will ensure the equitable and fair distribution and use of health care services.
- This equity and fair distribution of health care services will be enhanced by Clause 33 of the NHI Bill about the role of medical schemes in the NHI.
- It fully supports that once NHI has been fully implemented, medical schemes must only offer complementary cover to services not reimbursed by the Fund.
- This will ensure that the state complies with its constitutional obligation of right to free quality health care for all irrespective of socioeconomic status.
- About 8% of the country GDP is spent on health care services. Of this almost 4% is spent in the private health sector which services only 16% of the population and the other 4% is spent in the public health sector which services 84% of the population. This is an anomaly that is not sustainable and PPF believes that the NHI system is the only solution.

PPF Concerns About the Implementation of NHI
- Lack of capacity and poor infrastructure in the Public Health Sector
- Inequality and imbalance between the Urban and Rural Health Sectors.
- The NHI Bill does not make provision for Traditional Healers and religious leaders who can play a role in the Primary Health Care system.
- Requirements for Users Registration, Users Relocation or Interprovincial and Interdistrict Health Services.
- Point of entry into the NHI system for emergency cases.
- NHI system vulnerability to corruption.
- Timeframes for NHI implementation and improvement of infrastructure for certification and accreditation.
- Training of healthcare workers and the Problems of nursing training at Universities and Colleges.
- Clarity on the system to be used for the reimbursement of Primary Health Care Service Providers
- The role of General Practice in its current form (Solo Practices).
- The Bill must ensure that the NHI Fund is publicly administered.
- Lack of public communication about NHI.
- Management and allocation of Contracting Units for Primary Health Care service providers.
- Loss of NHI Fund accreditation by the Healthcare service provider or Budget run out.
- Role of unaccredited service providers.

PPF Proposals and Comments on Clauses of the NHI Bill
1. Poor infrastructure and lack of capacity.
- Clause 39(2)(a): Health establishments has to be certified by the Office of Health
Standards Compliance(OHSC).
- Improvement of infrastructure in Public hospitals and clinics through the implementation of the National Quality Improvement Plan (NQIP) in order to comply with OHSC requirements. This will ensure that these facilities are ready for accreditation by the NHI Fund, and this will result in the standardisation of the public health facilities and their participation when NHI becomes law.

2. Inequality & imbalance between Rural & Urban Healthcare Facilities.
- Clause 2(a): The purpose of the NHI Fund is to ensure the equitable and fair distribution and use of health care services.
- Equitable and fair distribution should start with improvement of the rural health care facilities to be at the same level with the urban health facilities. Priority in the implementation of NHI should first be given to the improvement of conditions in the rural health care sector.

3. The Bill makes no provision for the role of Traditional Healers and Religious Leaders
- Clause 37(2): A contracting unit for Primary Health Care must be comprised of a district hospital, clinics or community health care centres and ward-based outreach
teams and private providers organised in horizontal networks within a specified subdistrict area.
- Traditional Healers and Religious Leaders have a critical role to play in primary health care services. They can also be used as part of the NHI communication strategy to educate society.

4. Registration of users, Relocation and inter-provincial travel.
- Clause 7(2)(a)(b)(c): (a)Users must receive health care services from health care service providers or health establishment where they are registered. (b) Should a user be unable to access the service provider with whom or at which the user is registered, such portability of health services as may be prescribed must be available to the user.
- The Bill should give clarity and guidelines that required for portability entry when users are unable to access health care providers with whom or at which health establishment they are registered.
- The Bill must be clear in terms of the radius of portability entry in order to prevent system abuse.

5. Point of entry into the NHI system during Emergency Cases.
- Clause 7(2)(d)(i)(ii)(iii): The user must first access health care services at a primary health care level as the entry point into the NHI health system.
- The Bill is not clear as to how this will apply during emergencies.
- The Bill needs to be clear about required adherence to referral pathways in cases of emergency.

6. NHI vulnerable to corruption.
- Clause 12,13,14,15,16,19,20(3)(i),38
- Chances of collusion between service providers, users and other stakeholders make the system to be more vulnerable to corruption.
- Governance, accountability, oversight and consequence management will be very important to mitigate the risk of corruption. Best practices from other countries may assist.

7. Time frames for NHI implementation and improvement of infrastructure for certification and accreditation.
- Clause 27(2) of the Constitution: The State must take reasonable legislative measures, within its available resources, to achieve the progressive realisation of the right of access to health care.
- The current phase in the implementation of NHI is for the Bill to become an Act. Thereafter it is certification by OHSC and Accreditation by the NHI Fund. Our submission is that implementation of the National Quality Improvement Plan (NQIP) is supposed to be improved and to be ahead of this process. It is important to ensure that when the Bill is passed, most of the public facilities are already certified by OHSC and waiting only to be accredited by the NHI Fund.

8. Human Resources and the training of primary healthcare workers
- Clause 37(1)(a): A Contracting Unit for Primary Health Care manages the provision of primary health care services, such as prevention, promotion, curative, rehabilitative ambulatory, home-based care and community care in a demarcated geographical area.
- Many health care professionals will be needed to participate especially at primary health care level which is a point of entry into the NHI health system. Continuous engagement and education on NHI for health care service providers and all stakeholders is important for the success of NHI.
- Challenges of the Nursing Profession training at Colleges and Universities should be resolved with the Department of Higher Education so that more nurses are trained.

9. Reimbursement of Primary Health Care Service Providers
- Clause 41: The NHI Fund in consultation with the Minister of Health, must determine the nature of the service provider payment mechanisms.
- The Bill is specific in terms of remuneration mechanism for
specialists and hospital services which will be based on
health service performed. (Clause 41(3)(b).)
- The Bill is also specific for Emergency Medical Services which will be on a capped case-based fee basis. Clause 41(3)(c).
- Yet the Bill is non-specific in terms of remuneration for accredited primary health care service providers. (Clause 41(3)(a).) The Bill should indicate if it will be service performance based or risk adjusted capitation in order to bring certainty to the Primary Health Care Service Providers.
- This uncertainty can bring a sense of income insecurity to primary service providers which can result in a negative attitude towards the NHI system and what it seeks to achieve.

10. Role of General Practice in its current form (Solo Practices).
- Clause 39(2)(b)(ii): In order for the service provider to be accredited by the NHI Fund, the health care service provider has to comply with the allocation of the appropriate number and mix of health care professionals.
- Clause 39(7)(c): The Fund may withdraw or refuse to renew the accreditation if the appropriate number and mix of health care professionals are not complied with.
- The Bill must be clear on the guidelines for the number and the mix of health care professionals, and if all health disciplines must be included in the mix of professionals.
- The Bill can consider a phased-in approach to allow healthcare service providers to prepare for the transformation from the current solo practices to the mixed type NHI compliant practices.

11. Administration of the NHI Fund.
- Clause 9: The NHI Fund is established as an autonomous public entity, as a Schedule 3A entity.
- The Bill must be clear that the NHI Fund will be publicly administered and will not be outsourced to the private sector.
- This will ensure that all available resources will only be allocated towards health care needs of the population.

12. Lack of Public Communication about the NHI.
- National Health Insurance Bill.
- Good Communications strategy is important to forge relations with civil society and all sectors of the population.
- The public and most professionals do not trust NHI because of a lack of information and uncertainty.
- It recommends active civil society participation and public education to create public awareness on NHI.

13. Management and Allocation of for Primary Health Care services by Contracting Units.
- Clause 37(1)(2): The Contracting Unit manages the provision of primary health care services. The Unit must be comprised of a district hospital, clinics, community health centres, ward-based outreach teams and private health care service providers organised in horizontal networks within a specified geographical sub-district area.
- The Bill is not clear in terms of how the Contracting Unit will work and allocate services to the different Primary Health Care service providers.
- This is potential for duplication of services by the different primary health care service providers.

14. Loss of NHI Fund Accreditation by the Health Care Service Provider or Budget run out.
- Clause 39(9): The NHI Fund can withdraw or refuses to renew the accreditation of a health care service provider or health establishment.
- Workers in public sector will still regard themselves as public servants with guaranteed jobs. What happens when the accreditation of the health establishment is withdrawn, or when the NHI budget runs out? The Bill must be clear on this.
- The PPF recommends the Bill to consider conditional rehabilitation of the providers back into the system when the appeals process is completed.

15. Role of unaccredited service providers.
- Clause 5(7): Unaccredited health establishments whose particulars are published by the Minister in the Gazette must, on behalf of the Fund, maintain a register of all users containing such details as may be prescribed.
- The PPF recommends that the Bill must be clear about the role of unaccredited service providers and health establishments, both private and public, during the implementation of NHI.

Conclusion
1. The PPF appeals to the Health Portfolio Committee to consider these comments and recommendations presented on behalf of health care workers, academics and other professionals who have made inputs in this submission.
2. With all the challenges facing national health care in the country, and as outlined in the Health Market Inquiry, we believe that the implementation of the NHI must happen now.
3. We appeal to the Committee to take note of the following:
• NHI is not an event but a process.
• NHI cannot happen overnight, but it shall happen over time.
• NHI is addressing inequality in health care services and not free-market concerns or satisfaction.
• Where there is change, there is always fear of the unknown, but change has to happen.
• COVID-19 has taught us that both public and private health sectors need each other in order to address the health needs of the population.

Discussion
Dr Jacobs noted PPF stated that OHSC would have had to accredit all facilities by the time the NHI was implemented and that Parliament must take a serious view of resourcing and funding OHSC so that it can prepare the facilities in time. However, what is view of the PPF on the quality improvement plans, especially as such plans are delegated to relevant provinces to improve the quality of facilities? Is it PPF’s proposal that Parliament must pursue this objective?

Mr Munyai asked if the PPF would find comfort if some of the concerns about guidelines are included in the regulations and not the Bill.

Ms Havard asked: What is PPF’s view on how traditional health practitioners are not adequately regulated?

Ms Hlengwa asked: Does the PPF believe the NHI will help to transform the medical profession, and which medical skill will benefit from transformation under the NHI?

The Chairperson said the PPF was alluding to a need to reimburse primary healthcare practitioners. The reimbursement strategy is also a very important process, specifically, what it is going to look like and so on. Would the PPF suggest that it be visible in the Bill, or would the PPF be comfortable to see those details in the regulations?

Ms Ismail wrote her questions in the chat box:
1. You mentioned compliance - presently OHSC is unable to monitor even 20% of facilities. In your opinion, how could this impede compliance and the handling of complaints?
2. What is your opinion of the NHI pilot projects?
3. You mention timeframes - do you feel the NHI should be implemented in a phased-in manner?

PPF response
Dr Mukhari replied about the National Quality Improvement Plan (NQIP), and how it can improve quality in different provinces. The PPF’s view is that the NQIP is the basic foundation for preparations for the NHI implementation. That speaks to auditing the current state, in particular, of public health facilities, without excluding private health facilities. These national quality improvement plans should be implemented from local government level to provincial level in the public sector, so South Africa is able to note the state of where it is after the state of facilities has been measured by OHSC. Different facilities will, after assessment, and inspection, achieve different results in preparedness. That will assist local government or provincial level management to know what they have to do to ensure the facilities improve or upgrade. PPF’s understanding is that after the OHSC assessment, a report with a score will be given. What will be the responsibility of management will be a programme of action that states what needs to be done to improve its level. A programme of action should then be embarked on. It can be the responsibility of a committee such as the Portfolio Committee on Health as oversight to say that at all levels, the NQIP has to start now and not wait until the Bill has been enacted. It has to start now, because when the Bill becomes law, the NHI Fund will then need to accredit facilities, and those facilities must have been certified. Before certification, the process of quality improvement plans has to take place. PPF’s submission is that OHSC must be strengthened as it is now the foundation, and it is the beginning of the implementation of the NHI.

On whether PPF will find comfort if its submission is included in the regulations and not in the Bill, Dr Mukhari replied that if PPF’s concerns can be included in the regulations, it will appreciate that.

On PPF’s view that traditional healers are not adequately included: When one goes through the Bill, one can see the services covered by the contracting unit, which are basic health services, and what it will comprise of, which does not include traditional medicines, practitioners or healers.

Dr Mukhari replied to Ms Hlengwa that PPF’s view is that the NHI will transform the medical profession from the way it is now. PPF picked up in the Bill the requirement for accreditation of healthcare service providers and primary healthcare practitioners, that they will have to comply with a certain number of providers that must be included, and also the mix of professionals. That in itself will transform the medical profession. Instead of the current solo practices, the medical profession will have to transform itself into working as a collective of different disciplines working together to provide a service.

The PPF shared Ms Ismail’s view on OHSC, and it is the PPF’s submission that OHSC should be strengthened. Whether is the private or the public healthcare sector, the beginning is OHSC making an assessment of a facility and if it will be ready for the NHI. That Office is the one that will go and measure, do inspections, and give a report on preparedness and the recommendations on what needs to be done for an entity to be compliant. The PPF agrees that that OHSC is not as strong as it is supposed to be. Due to the implementation of the NHI, it is the PPF’s submission that OHSC must be strengthened.

On NHI pilot projects undertaken in the earlier phases of the implementation, the PPF hopes that the DoH learned lessons from those pilots. On timeframes and a phased-in approach, the PPF strongly believes that the Constitution in section 27(2) is clear on that. Implementation of the NHI is a progressive realisation. It is not an event; it is a process that should be phased in based on, firstly, the preparedness of facilities in compliance with OHSC requirements. When the NHI Fund is established, then those facilities that are not compliant can be progressively accredited. Accredit those that are ready, and implement the policy progressively.

Dr Cynthia Sathekga added that Ms Havard’s question was not about if traditional healers should be included or not. Traditional healers should be included because in South Africa, they form an integral part of primary healthcare. Having studied in China, she recognised that it has Western medicine hospitals, and even next to that are traditional medicine hospitals (such as acupuncturists, herbalists). This is something that can be done. Although traditional healers do not have much regulation at the moment, they should be included in NHI. A lot of South Africa’s population, for most ailments, even now with COVID-19, go the herbal route in treating themselves in a home setting. There should be space for that.

Dr Sathekga replied on how the NHI will transform certain medical profession skills: Having worked in Gauteng, in Chris Hani Baragwanath Hospital, a part that should transform is that it will help a lot to go back to making Primary Health Care (PHC) the most important level. If level one or level two do not work, if those systems do not work, then there is overburdening of level three tertiary institutions. This is working very well in Cape Town. If PHC services can work in Gauteng, that would help a lot. However, one can just walk in from Diepkloof to Chris Hani Baragwanath Hospital with a minor ailment, and not be turned away. Also what would help is if the system could go back to nursing being pivotal, by opening up the nursing colleges to get more nurses, so South Africa can improve the strength of its PHC.

Mr Wicomb emphasised that NHI is not an event. If one looks at when the NHS was implemented in the UK, it was implemented just after World War Two, when the economy was in the doldrums, yet that process was started. South Africa cannot expect that its public health system would be NHI-ready tomorrow. It is a process. When one speaks of the NHI and the DoH, there must be partnership between it and the Department of Public Works and Infrastructure, in that DPWI must get the public health facilities ready for when the NHI is being implemented. NHI will be a process over the next decade or so. South Africa must come together as both the public and private sectors to galvanise, to ensure that the poorest, weakest and most vulnerable are guaranteed the same healthcare as the intelligentsia, the middle-class professionals, entrepreneurs. All people should experience the same health and quality of life as the Constitution envisions. If the Committee has further questions, the PPF is readily available to assist. The work of the PPF is to partner with the public sector to ensure the citizens of South Africa achieve their dream of quality healthcare.

The Chairperson thanked the PPF. The Committee is fortunate as it receives a vast number of people coming in to help it understand their perspectives. The PPF is saying that NHI is not an event. There are countries in the world that have gone the route that South Africa is attempting to go through. Some of those countries were in worse situations, but they started nevertheless. The Committee is being assisted to look into the lessons from those countries; it will assist the Committee to refine its contribution as it goes forward. He thanked the Members for their participation and their robust engagement.

The meeting was adjourned.