The South African Medical Association welcomes the opportunity to submit comments on the NHI Bill on behalf of our membership of medical doctors working in public and private healthcare sectors in South Africa. SAMA has been and remains supportive of the progressive realisation of Universal Health Coverage for people in South Africa. SAMA can, unfortunately, not support the NHI Bill in the form that it has been ascended to Parliament. In 2018, in response to the Draft NHI Bill, SAMA raised many issues with the contents of the Bill, which have regrettably not been addressed in the 2019 Bill. SAMA believes that the establishment of an office of the NHI is an important step forward in taking the vision for the NHI forward, but we are extremely concerned that other elements of the Bill, which will be signed into law as an Act, are premature and have not been based on good available evidence for acceptability or implementation. Such considerations include proposed organisational structures for the health care sector, which have not been piloted anywhere, to our knowledge.
Payment mechanisms have also not been designed with the best available evidence in mind, and we are concerned that there will be a substantial challenge should these not function adequately out once they have been signed into law. SAMA has long highlighted the shortcomings in terms of quality of care addressed by the NHI Policy, NHI Draft Bill and now the 2019 Bill.
We remain concerned that there are no definitions of quality of care to be delivered under an NHI-funded healthcare system. The considerations of immigrants, although improved from the 2018 Bill, will unfortunately not address the concerns of our membership. Doctors at the service level do not discriminate based on citizenship or legal status on the need for health care services, and it is unethical for them to do so. The provisions relating to asylum seekers and illegal immigrants will be impossible for doctors to implement.
Human resources for healthcare are already strained in the South African context, and the current economic, social and political conditions in the country are resulting in an exodus of trained health professionals from the country. South Africa does not have the considered Human Resources for Health strategy, and previous attempts to develop one have been sadly lacking. SAMA’s doctors in both the public and private sectors work long hours, and in many instances in the public sector are exposed to unsafe working conditions, poor management of their skills and time and gruelling expectations of clinical work, studies and teaching responsibilities.
SAMA membership has also voiced concerns about issues such as cover for medicolegal claims, which is currently afforded by the Provinces, but for which a place is unclear in the future envisaged system. Additionally, employment arrangements and benefits are no longer clear, given that the Provinces will be marginalised in their role, and will no longer be the employers of health care workers.
Most of the reimbursement functions under the NHI are envisaged to function on the basis of reimbursement contracts to be signed between the National Health Insurance Fund and health care providers or between intermediate structures like the District Health management offices and some form of organisation of health care practitioners. It is not clear, where the Fund contracts with hospitals, whether doctors will be employed by these hospitals, or whether they will be contract workers.
It is also not clear what the expectations of contracts in primary care will be, nor how these will involve doctors in capitation arrangements. None of these contracting mechanisms have yet been tested, yet the government is on the brink of turning in them into the law of the land. In order for practices to survive, they need a steady source of cash flow. In the Medical schemes environment, claims have to be paid within 30 days. However, there are no such requirements for the NHI Fund. We are aware of significantly long payment periods for suppliers in the public sector at present, which has in the past threatened the ability of suppliers to continue to supply services and goods to the public sector.
The Bill also proposes significant changes to other pieces of legislation which will, among other things:
- Remove the responsibility of employers to cover the healthcare costs of workers injured on duty. SAMA is concerned that this may take away some of the incentives to ensure a safe working environment.
- Fundamentally change the pricing regimen for medicines and medical devices and in-vitro diagnostics. The proposed changes effectively do away with the Single Exit Price, which operates in the private sector, and the tender prices which operate in the public sector. There is no clear replacement for these two systems.
- Make significant changes to the National Health Act, which will alter the delivery functions of healthcare, changing from the current provincial system to a District managed system. This without testing how well this could work in the country.
SAMA has made a number of recommendations, which we believe may address some of these challenges for the NHI Bill itself. We continue to engage with the policy proposals and envisioned improvements to the health system being pursued through various forums in the country