Concerns over corruption and whether or not foreign nationals would be covered under South Africa's proposed National Health Insurance (NHI) system were some of the issues raised by healthcare groups, trade unions, and the public who recently took part in the Nelson Mandela Bay leg of public hearings into the NHI (National Health Insurance) Bill.
The Eastern Cape legislature held its public hearings from 10 to 13 October in all six of the province's district municipalities. The Bill is currently with the National Council of Provinces (NCOP) after the National Assembly voted in favour of the Bill in June. 205 MPLs voted in favour to 125 against. The process of public hearings is anticipated to be concluded before the end of the year. Based on provincial mandates, the Bill will then be voted on in the NCOP.
'Under the bus'
Thobela Mdledle, the Eastern Cape Legislature Senior Legal Advisor, introduced the NHI Bill at a public hearing on 13 October at Soweto on Sea Hall in Gqeberha, stating that it takes us a step closer to fulfilling the constitutional obligation to provide adequate healthcare to all.
"The legislature is pleased with the number of people who attended the Nelson Mandela Bay hearing. Our target was 100, but we managed to attract more than 400," Nozibele Nyalambisa, the Eastern Cape Legislature Health Committee chair, told Spotlight after the hearing.
Nyalambisa said that the Department of Health's poor financial performance is the main cause of mixed feelings about NHI. Yet, "despite strong dissent from labour unions," she said, "most people supported the Bill."
"We are under the bus when it comes to budgeting issues," she said, "and we are looking for whatever funds we can get from National Treasury to give us some relief. In addition to the shortage of ambulances, the department is unable to hire additional staff."
"The Department of Transport does not purchase ambulances based on the terrain they are in; they just buy the same ambulance whether it is in a rural or urban area. Occasionally, the rough roads led to ambulance breakdowns, so those ambulances had to be serviced in KwaZulu Natal," she said. "These are some of the problems we face in the province, and we don't have to mince our words when discussing them."
Concerns about corruption
Several speakers at the hearing expressed concerns over the potential for corruption under NHI. Nomonde Fanele, a nurse and chairperson of the National Union of Public Service and Allied Workers in Nelson Mandela Bay, called on the government to clean up corruption in the Department of Health before the Bill is implemented.
"We understand that the government wants our opinion on this Bill, but it seems that the government has already made up its mind about this NHI. This is just a pathetic excuse, and we know that when elections are near our government tends to implement new things. This pains us as people who are working in healthcare because these things are not implemented properly, and they lead to fights between us and healthcare users," Fanele said.
"Before this NHI government needed to clean its own system of corruption because clinics don't have medication because of corruption. Now the government wants us to say yes to this NHI Bill while the system is still corrupted. We are living under the tendering system, government issues a tender even for Panado. Even after we go out of this public hearing, we will hear that the government has passed this while we are opposing it," Fanele added.
Velisile Mbuyeni, former board member of Sizwe Hosmed (a medical aid scheme), reminded attendees of the high levels of corruption during the height of the COVID-19 pandemic. "I don't support the Bill since so many things are happening in our country, like corruption," said Mbuyeni.
"According to them, people who have medical aid will be covered, but I'm not clear how this will work," he said. "As part of our medical aid, we already receive benefits that are better than what the government is currently providing."
Benny Macholo, an activist with an organisation called Dithaba Tsa Afrika, said that funding NHI by introducing new taxes would be a problem. "People are not working, and we are not ready for additional tax and the company tax also won't work. We need to find our own NHI and not bring a model of South Korea and try to plug it here because their unemployment rate is totally different from ours. Those are some of the areas that the government should consider," he said.
He was also outspoken about the risk of political interference.
"There must be no interference from the Minister of Health, the minister should provide a guideline for the NHI board. The CEO, chairperson, and deputy chairperson must be appointed by the board, not by a minister. This is to put measures in place to tighten money that is coming from the government," he said. "I believe we should have a committee that deals with corruption and oversight of money that is coming from the treasurer and other relevant departments. The committee needs to consist of people from civic, faith organisations, and labour unions to assist in terms of oversight because the government can't oversight itself."
Inclusion of foreign nationals
Another hot topic at the hearing was the extent to which foreign nationals would be covered under NHI.
According to Mdledle, the NHI will benefit all South African citizens, permanent residents, refugees, inmates, and all children. This includes certain individual foreigners determined by the Minister of Home Affairs, after consultation with the Minister of Health and the Minister of Finance, by notice in the Gazette. An asylum seeker or "illegal foreigner" will only be entitled to emergency medical services and services for notifiable conditions of public health concern, said Mdledle.
She stated that all children - including children of asylum seekers or illegal migrants are entitled to basic healthcare services. According to Mdledle, a foreigner visiting South Africa must have travel insurance to receive healthcare services under their relevant travel insurance contract policy. Those who do not have a travel insurance contract or policy are only entitled to emergency medical services and services for notifiable conditions of public health concern.
Macholo took the stance that there needs to be tight measurers on foreign nationals, including tightening South Africa's borders, to avoid the potential for what he called the abuse of the country's resources by foreign nationals. He was not the only speaker to express views along these lines.
'Addresses the needs of the poor'
Despite the various criticisms and concerns, there were also several positive views expressed on how the NHI Bill could improve access to healthcare services. Buyelwa Mafaya, a local councillor, said it is her belief that NHI is a blessing in disguise for those who cannot afford medical aid.
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"Our views on this Bill are important to us, so we are glad the government took the initiative to invite us to share them. This is in line with the Constitution, which states that people have a right to good quality healthcare," Mafaya said. "It is important to note that people are not equal in terms of their ability to afford medical aid. While some can afford it, others are not fortunate enough to have access to it. Therefore, the National Health Insurance (NHI) will assist in providing good healthcare for all. We support this Bill because it addresses the needs of the poor and aims to make healthcare easily accessible for them."
NHI was also one of the hot topics at the 2023 Public Health Association of South Africa (PHASA) Conference held in Nelson Mandela Bay in August. Some of the attendees supported the Bill, while others raised concerns around issues like governance and the potential for corruption. Dr Nicholas Crisp, who leads the NHI project in the National Department of Health, said at the time that Universal Health Coverage (UHC) is non-negotiable for everyone in the country and that the NHI is the chosen path to achieve UHC.
While NHI was a key focus of that conference, it was however overshadowed by fears over the further freezing of posts in the healthcare sector, following a circular on the need for public sector cost-containment. While the Nelson Mandela Bay leg of the NHI hearings weren't similarly overshadowed by the province's financial and human resource concerns, there were certainly strong echoes in comments such as that from Nyalambisa that the province is "under the bus" when it comes to budgeting issues.
