Caution and consultation should be prescribed for the NHI Bill

Leading up to the Minister of Finance (MoF) delivering the Medium-Term Budget Policy Statement (MTBPS) in October/November this year, parliamentary committees are conducting oversight over departments and government entities.  The MTBPS will provide an indication of the state of government finances.  In the MTBPS of 2017, the then MoF announced that government had a budget deficit of R48 billion.  This is one of the factors that led to the 1% VAT increase in April this year.

Departments reporting to Parliament must explain how they used funds allocated to them for the financial year.  Annual reports of departments are accompanied by the department’s financial statements which include an assessment from the Auditor-General South Africa.

Parliament’s oversight function stems from the Constitution and gives committees powers to call departments and government entities, to interrogate, guide policy decisions and implementation thereof.  Members of Parliament (MPs) recommends to the National Assembly (NA) to approve the departments’ budgets.

The Portfolio Committee of Health and Select Committee on Social Services were briefed by the Minister of Health (MoH) and National Department of Health (DoH) in April and May 2018.  The burning issue for MPs was progress made on the National Health Insurance (NHI).

DoH published the NHI White (Policy) Paper in June 2017.  The White Paper lays the foundation for moving South Africa towards universal health coverage (UHC) through the implementation of the NHI and establishment of a unified health system.  NHI is defined as financing system that will make sure that all citizens are provided with essential healthcare regardless of their employment status.  The implementation of NHI is part of government’s broader programme of action as outlined in the National Development Plan (NDP).

The key focus of the NHI is to create a single, publicly owned and administered strategic purchaser that will actively purchase healthcare services on behalf of the entire population from suitably accredited public and private providers.  Though the white paper clearly intends that medical schemes continue to offer complementary cover to fill gaps in the NHI offering, precise details on the future of medical schemes under NHI are unclear.

Preparatory activities on NHI are aimed at strengthening of the health system and service delivery platform.  This includes implementation of re-engineering of Primary Health Care (PHC) and the Operation Phakisa Ideal Clinic Realisation Programme to improve performance and quality of health services in the PHC facilities.

Burning questions from MPs was around preparatory steps for the NHI, in particular, PHC and when the DoH intends referring the NHI Bill to Parliament.  In light of the general elections in April 2019, Parliament will have a shorter siting period.  The NA will close in mid-June to return in August and the National Council of Provinces (NCOP) will close end of June and return in early July.  In addition, as elections take place next year Parliament will likely close in early March 2019.  MPs correctly emphasised that Parliament is constitutionally obligated to follow various steps in the legislative process.  This is further exacerbated by the President’s announcement in the State of the Nation Address (SoNA), that the NHI Bill would be processed in Parliament this year.  Referral of the bill would place the committee under severe pressure to finalising the bill before the end of the Fifth Parliament.

MPs emphasised that they are frustrated because they have been asking the same questions since being appointed to the committee in 2014, however, with very little progress from the DoH.  The MPs also highlighted that it seems that health in the country is deteriorating and explained that in their constituencies, people still have to wait in long queues to obtain medical treatment.  MPs questioned whether they should approve the funds allocated to the departments.  How are they as MPs to ask people to vote for them when nothing has changed?

The response from the DoH was that it was merely a transferring agent.  DoH transfers about R198 billion to provincial DoHs.  Although, the DoH transfers the funds, it does not have the power to instruct provincial DoHs as to how they can spend the funds, nor does it have the powers to withhold funds.  It added that there are certain constitutional issues that must be addressed in the NHI Bill before it can be referred to Parliament

The MoH in his response to the select committee confirmed that he has to take responsibility for issues that occur in the provinces even though he does not have authority to act in the provincial DoH decisions.  The Life Esidimeni[1] issue is a perfect example.  He has no authority in the approving of contracts of service providers, however, he is held responsible. 

The NHI White Paper implies changes to the existing system of intergovernmental funding arrangements.  The pooling of funds is likely to impact the autonomy of provinces to formulate their budgets and spend the funds in terms their provincial needs but in line with the National Health Act, 2003[2].  Further, statements made by the MoH, imply that the constitutional issues pertain to the concurrent jurisdictions between national and provincial spheres of government, provided for in Schedule four of the Constitution.

The High-Level Panel led by former President Kgalema Motlanthe, recommended that Parliament sets up an independent task team of all relevant players in the public and private sectors to evaluate whether there should be legislation passed regarding voluntary or mandatory membership of medical schemes, for the implementation of the NHI to ensure that high-quality, affordable health care is delivered to all South Africans, regardless of race.

Rigorous public participation[3] is essential in this process.  Although, section 27 of the Constitution provides for the right to health, section 25 provides for the right to association.  I should be able to choose which medical aid I belong to.  An independent task team could go long way in brining stakeholders together to discuss the NHI.  This inclusive stakeholder engagement would not only create an opportunity for government to persuade relevant stakeholders but also for government to obtain inputs that can assist it in identifying challenges with regards to the present health system’s state of readiness for the NHI.  In adopting the Constitution, South Africa deliberately moved away from the former apartheid method of centralising power.  We must therefore be vigilant and act with caution to proposals amending the Constitution or the framework of the three spheres of government.

Zelna Jansen

Chief Executive

Zelna Jansen Consultancy


[1] The Life Healthcare Esidimeni Scandal involved the deaths of 143 people at psychiatric facilities in the Gauteng province of South Africa from causes including starvation and neglect. It is named for Life Esidimeni, the private healthcare provider from which patients were removed by the state.

[2] This Act aims to realise the rights set out in the Constitution by providing a framework for a structured and quality uniform health system in South Africa. It outlines the laws that govern national, provincial and local government with regard to health services. The Act clarifies the State’s duty to do what it can to address the right to have access to health care services. It recognises that no person may be refused emergency medical treatment and that everyone has the right to an environment that is not harmful to their health.


[3] Public access to and involvement in National Assembly

59. (1) The National Assembly must—

(a) facilitate public involvement in the legislative and other processes of the Assembly and its committees; and

(b) conduct its business in an open manner, and hold its sittings, and those of its committees, in public, but reasonable measures may be taken—

(i) to regulate public access, including access of the media, to the Assembly and its committees; and

(ii) to provide for the searching of any person and, where appropriate, the refusal of entry to, or the removal of, any person.