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Mkhize says a 'hard fight' ahead to improve SA's 'low quality ‘ healthcare

NurseParliament has called for public submissions on the “constitutionally aligned” National Health Insurance (NHI) Bill, writes  Legalbrief Policy Watch. Conceding that government “will need to invest strongly” in raising the standard of public healthcare services and facilities, Health Minister Zweli Mkhize said these are at “such a low level of quality” that his department will “have to fight hard” to improve them.

Parliament’s portfolio committee on health has called for public submissions on the National Health Insurance (NHI) Bill, which contains the first concrete proposals for realising the government’s plans for achieving universal health coverage. Business Live reports that it proposes extensive reforms to the way healthcare is financed and provided, with a central NHI fund that will purchase services on behalf of the entire population.

The report says the Bill has already overcome its first hurdle, after the Democratic Alliance (DA) asked parliament to seek urgent legal advice on its constitutionality. Last week the state attorney assured the committee that the bill was not at odds with the constitution, despite its proposed changes to the role of provincial health departments.

Once the bill has been passed by the National Assembly, it will be considered by the National Council of Provinces, which is also expected to conduct public hearings.


The Bill is constitutional, state law advisors told the committee. Acting chief state law adviser Ayesha Johaar said the Bill had been certified as “constitutionally aligned” last month, notes a News24 report. Johaar added section 27 of the Constitution obliged the state to take reasonable measures to give effect to the right to health care, adding South Africa was party to international agreements with which it must comply.

The report says the DA has questioned the Bill's constitutionality. DA leader Mmusi Maimane wrote to National Assembly Speaker Thandi Modise to urgently request that she instruct parliamentary legal services to obtain a legal opinion on the Bill before it came before the health committee. Maimane also asked the DA's legal team for an opinion on whether it was constitutional. The party is questioning the Bill's legal validity as it seemingly takes away provinces' constitutionally enshrined right to handle health services.

“We are satisfied that the Bill does not infringe on any of the universal rights in the Bill of Rights,’ Johaar said. She added she was satisfied that Parliament would not violate the rule of law in processing the Bill.


DA doubts remain, however, with the party’s shadow Health Minister, Siviwe Gwarube, a member of the committee, saying she did not accept Johaar’s position on the Bill. "A legal opinion is just that – an opinion," she is quoted as saying in a Business Day report.

Health Minister Zweli Mkhize and his officials briefed MPs on the Bill’s provisions, which include establishing a central National Health Insurance fund to purchase services on behalf of the entire population that will be free at the point of care. In response to MPs’ questions on financial implications of the NHI, Mkhize said there was close consultation with the Treasury on its costs. Mkhize said the Bill’s provisions on its funding sources – including redirecting funds allocated to provincial health departments, scrapping medical-scheme tax credits, instituting a payroll tax, and a surcharge on income – did not step on the Finance Minister’s toes.

Measures such as these would be formalised in a money Bill that would be tabled by the Finance Minister, he said. “We have not transgressed, and it is not wrong to have it (in the Bill),” he said. Health department technical adviser on NHI Aquina Thulare said it was expected the fund would spend no more than 3% of its budget on administration.


Mkhize said that government would handle the implementation of the NHI cautiously and had no intention of bankrupting the country. An IoL report says he told MPs that the measure was in line with "the principle of social solidarity" by which South Africans took care of each other. He said it was evident that many of the fears voiced regarding the Bill were engendered by the state capture scandal and its impact on utilities like Eskom.

But, the report says, he sought to give assurances that that a new national health service would be based on successful models implemented in other countries and cleanly run. "It has made South Africans very nervous, even of things that are procedurally correct. It is actually very unfortunate in this instance because this structure we are using has been benchmarked against many other jurisdictions.

"And I think we must commit that we must work to ensure proper governance and proper administration, because that is what we owe that to our people… We do accept that there is a real concern about corruption."


Universal health care is a global movement, it is not South Africa moving on its own, Mkhize told the committee, according to report in The Citizen. Presidential adviser on health Olive Shisana concurred. "It (universal health care) is a global issue, it is not a South African issue." She said countries like Canada, the Nordic countries, the UK, Taiwan and Spain have single-payer healthcare systems. "SA is not unique." Mkhize, Shisana and a large delegation from the health department of were briefing the committee on the Bill.

Mkhize said he often heard the NHI's critics saying South Africa should have universal health care, just not now. “All countries that instituted national health insurance are in a better economic state now than when they started.” Mkhize acknowledged there was concern about South Africa’s economy. “I think we have dilly-dallied long enough. We cannot afford not to implement the NHI.”

The report says he also played down concerns about corruption, saying measures would be put in place to prevent this. The NHI will provide the same benefits registered South Africans will receive to permanent residents and refugees, while asylum seekers and illegal migrants will only be covered for emergencies. The children of asylum seekers and illegal migrants will receive basic health services, though.


The health committee chair Sibongiseni Dhlomo refused his administrative staff permission to circulate the Office of the State Law Advisor’s (SLA’s) opinion on the constitutionality of the Bill to members of the public. This despite it having been read out in a packed venue – before Mkhize proceeded with his briefing.

Why Dhlomo adopted this stance is not clear, reports Pam Saxby for Legalbrief Policy Watch. Saxby notes that Johaar is confident that the Bill is “constitutionally sound” and in keeping not only with sections 27 and 146(2), but also with sections 3 and 25 of the 2003 National Health Act. She says although Johaar’s presence at the meeting was apparently requested at very short notice, the document was nevertheless given to committee staff in good time – yet members only received copies during the afternoon session, by which time Johaar had left.

While the Minister and his team provided a raft of in-theory examples of how NHI implementation challenges will be overcome, how well they will work in practice remains to be seen, writes Saxby. Conceding that government “will need to invest strongly” in raising the standard of public healthcare services and facilities, the Minister said these are at “such a low level of quality” that his department will “have to fight hard” to improve them. The role of medical schemes under NHI will be spelled out in regulations, while funding proposals will be the focus of a separate money Bill.


There are serious gaps in the Bill that the health minister would have to address if he wants the country’s buy-in and the that the question many ask, is: is he equipped – and willing – to do this? Bhekisisa reports that in the light of the past month’s substantial criticism, also from those who support the principle of social solidarity that the NHI is built on, Mkhize will require the ability to consult – and act on input. The report says Mkhize is a politically powerful man. Influential enough, according to Section27’s former head, Mark Heywood, to do “exactly what (former health minister Aaron Motsoaledi) couldn’t do”: he’s got the political authority within the ANC to ‘crack the whip on health MECs, to phone premiers and say, ‘sort your shit out’”.

But, the Bhekisisa report says, given Mkhize’s history and standing in the ruling party, will he be able to put public health above his own political interests when it comes to the NHI? Will he move decisively against those in the ANC who may act improperly within the context of the NHI, even if it means losing significant political support? In other words, will he replicate his behaviour in dispensing ARVs in KwaZulu-Natal, against Mbeki’s policies?


Deputy Minister of Health, Joe Phaahla, insists that those objecting to the NHI system do so because of their fear of the unknown. According to a Cape Argus report, Phaahla told MPs in Parliament that in its current form, the healthcare system in the country was unsustainable and that the NHI would fix the defects. He called on all stakeholders to support the plan as it would overhaul the provision of healthcare.

He said those objecting to the NHI did so because they feared not knowing how exactly plan the would be handled. “This is a disruptive intervention of those us in the upper side, the 15% who can access private healthcare,” said Phaahla. Phaahla also denied that the government would need more cash for the implementation of the NHI.

The Health Department denied the pilot sites for the NHI had failed. The deputy director-general in the department, Anbhan Pillay, said the pilot projects had been placed in 11 districts across the country, and lessons had been learnt from a report that emerged out of the project.

Global leaders known as the Elders arrived in South Africa this week in support of the National Health Insurance (NHI), reports Business Day. Gro Harlem Brundtland, former prime minister of Norway in 1981, 1986/1989, and 1990/1996, will be in the country to promote the health insurance initiative. Brundtland was also the director-general of the World Health Organisation from 1998 to 2003. Also in the country is Ricardo Lagos, the former president of Chile.

The report says the Elders have been campaigning for universal health coverage throughout the world since 2016 and will come out in support of NHI. An advisory ahead of the visit said the gesture of confidence in the NHI by the Elders is a “much needed affirmation in a country that is just grappling with the idea since the bill was recently introduced to parliament”.

Meanwhile, on Twitter, reports Medicalbrief, Brundtland came under scorn for asserting, in the context of promoting NHI, that SA had similar income levels to Ireland. Prominent lawyer Richard Spoor tweeted: “This is not true average SA income is less than 1/3 of the average income in Ireland. Outsiders who know nothing about our country, much less our government, giving unhelpful advice.”


[link url=""]Business Live report[/link]
[link url=""]News24 report[/link]
[link url=""]Business Day report[/link]
[link url=""]IoL report[/link]
[link url=""]The Citizen report[/link]
[link url=""]Legalbrief Policy Watch report[/link]
[link url=""]Bhekisisa report[/link]
[link url=""]Cape Argus report (subscription needed)[/link]
[link url=""]Business Day report[/link]

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