NHI: Giving minister too much power among Bill’s flaws

Corruption, accountability and too much power given to the minister, with very little parliamentary oversight, have emerged as the biggest public concerns about the National Health Insurance (NHI) Bill.

Also, Solidarity Doctors’ Network board member, Dr Angelique Coetzee, believes the perception that once in force, the general public will access the highest quality of healthcare offered by the private sector could be an illusion.

She said it was important to note that the current NHI Bill was actually a funding model, with scant details and no clear guidelines of what was to be funded.

“So we are all fighting about a funding model, but at the end of the day, there are not clear guidelines how this will be done,” Coetzee said.

The NHI Bill’s goal is universal quality healthcare for everyone, rich and poor, as enshrined in the constitution. It aims to do this through the creation of one public fund to meet the health needs of the entire population, not just for a selected few.

Red flags

South Africans will no longer be required to contribute directly to a medical health scheme to get quality healthcare, with the NHI funded from general taxes, contributions of people earning above a set amount, and contributions from employees to the fund.

But Coetzee said she did not see this happening.

“The perception out there is, in my opinion, that people will maybe get more or less the same services that they get in the private sector as if they were on medical scheme, and I do not think that is going to happen. So all of that is a huge concern to us and we need clarity on this,” she said.

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Coetzee said there were also other red flags in the Bill, pointing out very little parliamentary oversight, lack of transparency on how exactly the NHI will work and the enormous power given to the minister of health.

“There is too much power in the hands of the minister. So he will have the power to appoint people to the different committees, oversight committees, and that’s a problem as well. We have seen how it went all wrong with [cadre deployment] corruption,” she added.

The health department has said that the Covid-19 pandemic has contributed to delays in Parliament debating the NHI Bill, but that it was currently being debated, clause by clause.

Enormous power given to minister

Whilst in full support of NHI, civil society organisation Active Citizens Forum, pointed out some concerns with the Bill, including constitutional and governance issues, the role of medical schemes as well as financing.

For instance, the organisation said in its submissions, the central feature of the governance of the fund was its relationship with Parliament and executive.

The organisation’s Dr Bonginkosi Shozi explained that the Bill establishes the NHI fund as “an autonomous public entity, as contained in Schedule 3A to the Public Finance Management Act”, however, its governing board is “accountable” to the minister.

Shozi pointed out that the board, its CEO, and its chairperson are all appointed by the minister, with little direction or oversight, which amounts to micro-management by the minister and undermined the independence of the fnd.

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The organisation also submitted that the Benefits Advisory Committee, one of the three Ministerial Advisory Committees, described as an “advisory committee of the fund” was, in fact, appointed by the minister (after consultation with the board) and by notice in the Gazette.

Constitutional scrutiny

Its role is to determine and review healthcare service benefits and types of services to be reimbursed at each level of care. It will also provide detailed and cost-effective treatment guidelines; and in consultation with the minister and the board, the health service benefits provided by the fund.

Shozi said the NHI was too critical an initiative to risk failure and Parliament, for its part, has a historic duty to ensure that the legislation on which the NHI is founded will stand constitutional scrutiny, and works in the best interests of all people in South Africa.

In June 2022, the Gauteng North High Court found that sections 36 to 40 of the National Health Act were unconstitutional as they referred to the Act’s provisions for issuing health establishments with a “certificate of need”.

These sections force doctors to apply for permission before they can open a practice in an area, with health professionals arguing that this gave the state power to stop them from working.