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Health Department disowns instruction on turning away foreigners

South Africa's national Health Department has withdrawn its instruction to provinces to charge foreign patients the maximum rate, saying the directive should never have been issued, reports Business Day. Provincial health departments received a letter from the department in mid-January instructing them to ensure all non-South African patients pay the full rate for services. The only exception would be refugees with valid documents, who would get discounted fees if they had low income.

The report says government hospitals and clinics charge patients according to the uniform patient fee schedule, which has different rates depending on a patient’s income, but makes no distinction between South African citizens and foreigners. Patients from the poorest households get free services, those on an annual household income of R70,000-R250,000 pay reduced fees, while those with an income of more than R250,000 pay in full.

The Health Department’s deputy director-general for National Health Insurance (NHI), Anban Pillay, said in the report that the letter sent to the provincial health departments was drawn up by a junior official who did not have the authority to introduce changes. It was rescinded on Saturday after the Western Cape Health Department and journalists started asking questions, he said.

The report says Western Cape Health spokesperson Marika Champion confirmed the circular was withdrawn. The Western Cape had not implemented the new policy directive, she said. “We felt our systems were not ready, and asked for areas of policy clarification,” she said.

The report says, according to Pillay, the Gauteng Health Department appeared to be the only one that wrote to health-care facilities instructing them to charge all foreign nationals at the maximum rate for health services, including emergency care. The national Health Department does not have figures for the number of foreign patients using government hospitals, but about a fifth of patients enrolled on its chronic-medicine service were non-South Africans, he said.

Pillay said the silence of current regulations for the schedule on nationality had created confusion about rates foreigners should pay. The national Health Department was drafting regulations to clarify the situation and spell out that all patients using state health-care facilities should be charged according to a means test, regardless of their nationality, he said.

Gauteng Health MEC Gwen Ramokgopa said in the report that the province aligned itself with national policies and withdrew its directive to public health facilities to charge foreigners the maximum rate. “I would like to dispel the (myth) that the circular that was issued by the Gauteng Health Department said foreign patients will not be treated. It was saying, in line with the national circular that has now been withdrawn, that they would be billed fully for the expenses. It never said first get the money before you treat,” she said.

Ramokgopa said foreigners, just like South Africans, should be billed according to the means test in the schedule. “We understand the concern of foreigners who would not be able to afford the full cost of services,” she is quoted in the report as saying.


A Sunday Times report notes that according to the directive from the Gauteng Health, issued two weeks ago, foreign nationals would have been forced to pay to use overburdened state hospitals, including for emergency treatment. The report says Gauteng Health head Mkhululi Lukhele had already written to hospitals telling them to start charging foreigners. "All non-South African citizens should be classified as full-paying patients, except refugees with valid documents who will be classified according to a means test," his memo said. "The non-South African citizens … must pay for all health care including emergency treatment, confinement (maternity) and basic health services. The cost of services rendered must be paid upfront or on discharge."

But the report quotes Precious Matsoso, director-general of the national Health Department as saying that the circular had been issued by a junior official and was "not approved". "I didn't issue it. It is unlawful. If it is not issued by me, it can't be implemented by the provinces. It will be withdrawn on Monday," she said. "This was brought to my attention on Friday. The Western Cape Health Department approached me and asked how must they implement it because it was not signed by me. They wanted clarity and didn't implement it. I called the deputy DG (Anban Pillay) directly and asked why a junior official issued it."

The report says Western Cape Health spokesperson Colleen Smart confirmed her department was "in discussions" with the national department on how to implement the circular, and had asked it to communicate its intentions to "relevant organisations and the broader public".

KwaZulu-Natal Health spokesperson Ncumisa Mafunda said in the report that her department had also received the instructions to implement a new tariff schedule for "non-South Africans".

Pillay said confusion may have been caused by the drafting of new regulations on how hospitals should bill foreigners and locals based on their income.

Constitutional law expert Pierre de Vos, from the University of Cape Town, said in the report that any attempt to treat locals and foreigners differently would be unconstitutional. "There is case law in which the Constitutional Court sets out that the rights to health, and not to be discriminated against, applies to everyone in SA," he said. "If they make this distinction (between South Africans and foreigners) they are discriminating and are probably infringing on the right to health care. As it stands, they have just issued a circular that is clearly unconstitutional. If this was to be challenged in court, they (the health department) will probably lose."

The report quotes another expert in constitutional law, Phephelaphi Dube, as saying: "Making foreigners pay for public health care will limit the ability of particularly the most vulnerable foreigners to access health care, which in turn will negatively affect other rights such as life and dignity."

Ngqabutho Mabhena, a representative of the African Diaspora Forum non-profit organisation, said the group – which campaigns against xenophobia – learnt of the directive on Friday and had already heard of some hospitals charging foreigners. "Our people have been facing a number of challenges in the health system and there are hospitals that we are told are charging up to R5,000 a patient if they want the services," he said.

The report says there were close to 2m Zimbabweans in South Africa. "Not all of them are working and they depend on public health. We also have other people from Mozambique and Lesotho who are here in big numbers. This decision can affect a large number of people," Mabhena said.

Sharon Ekambaram, head of Lawyers for Human Rights' refugee and migrant programme, said in the report that being denied access to health care was a "common experience for foreign nationals".

Francois Venter, deputy executive director of the Wits Reproductive Health Institute, described the circular as "health xenophobia" and an attack on the poor.

However, according to the report, Health minister Aaron Motsoaledi told a National Education, Health & Allied Workers Union conference in November last year that foreigners were placing a strain on public hospitals. "The weight that foreign nationals are bringing to the country has got nothing to do with xenophobia … it's a reality. Our hospitals are full," he said. "When (foreign nationals are admitted in large numbers) they cause overcrowding, infection control starts failing."

[link url=""]Business Day report[/link]

[link url=""]Sunday Times report[/link]

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