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NHI Summary Updates

NHI Bill Daily Analysis – Introduction

The revised NHI Bill was published on 8 August 2019. The South African Private Practitioners’ Forum will be sharing an analysis of the NHI Bill with members, highlighting issues of importance and concern.


Funding – Day 1

“PREAMBLE

RECOGNISING

– the socio-economic injustices, imbalances and inequities of the past;

– the need to heal the divisions of the past and to establish a society based on democratic values, social justice and fundamental human rights; and

– the need to improve the quality of life of all citizens and to free the potential of each person;

BEARING IN MIND THAT

– in terms of section 27(2) of the Constitution the State must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of the right of access to health care services;

Purpose of Act

  1. The purpose of this Act is to establish and maintain a National Health Insurance Fund in the Republic funded through mandatory prepayment that aims to achieve sustainable and affordable universal access to quality health care services by—

 (b) ensuring the sustainability of funding for health care services within the Republic;”

Analysis:

The fact that the South African NHI Bill is published in order to “achieve sustainable and affordable universal access to quality health care services”, without any costing of the model having been published in the 10 years since the inception of the scheme, is disingenuous at best and a gross failure of due diligence at worst. It is concerning that attempts are being made to implement NHI without the government providing any clarity on what the initiative might cost and how it will be funded in the current economic climate. Once again we refer to the attempts of Ireland to implement NHI which were scrapped 4 years after a White Paper was published. The costing of the model proved unaffordable for Ireland “now or ever” and the Irish NHI was scrapped, with alternatives now being considered. Implementing this NHI model in an environment which is not able to afford a very comprehensive NHI service basket, will lead to the majority of South Africans having access to less comprehensive health services than is currently the case in both the Public and Private Sectors. This would not be the progressive realisation of healthcare that is demanded by Section 27(2) of the South African Constitution, as quoted in the NHI Bill pre-amble.


Application of the Act – Day 2

“3. (1) This Act applies to all health establishments, excluding military health services and establishments.

(2) This Act does not apply to members of—

(a) the National Defence Force; and

(b) the State Security Agency.

(3) If any conflict, relating to the matters dealt with in this Act, arises between this Act and the provisions of any other law, except the Constitution and the Public Finance Management Act or any Act expressly amending this Act, the provisions of this Act prevail.

(4) The Act does not in any way amend, change or affect the funding and functions of any organs of state in respect of health care services until legislation contemplated in sections 77 and 214, read with section 227, of the Constitution and any other relevant legislation have been enacted or amended.”

Analysis:

Although the NHI Bill does not apply to members of the military, there is no indication of the practicalities of these military members being excluded from surcharges on personal tax to fund NHI. The further implications of Section 3(3) of the Bill is that the NHI Act will supersede any and all other legislation, excluding the PMFA and the Constitution. This could have an impact on the consumer rights of the users of NHI, as the Consumer Protection Act might not apply in all instances. The role of provinces in delivering healthcare and appropriation of the equitable share of funding from provinces to the NHI is likely to face constitutional challenges once implemented, or proposed for implementation.


Competition Act Exclusion  – Day 3

Application of Act

  1. (5) The Competition Act, 1998 (Act No. 89 of 1998), is not applicable to any transactions concluded in terms of this Act.

Analysis:

Excluding all NHI related Transactions from Competition Law could end up having the effect of driving up prices in the NHI environment. This deprives the medical sector of the benefit of competition; investigations and prosecutions by the Competition authorities, which are some of SA’s most efficient admin bodies. It does leave the door open for bidders for NHI tenders to collude and drive up prices. Price discrimination and price exploitation could also happen as a result of this.  Small players could also be pushed out of the market by larger players, with no recourse available to them. This exclusion would create the opportunity of competitors in the NHI market, or provider groupings, to threaten mass withdrawal of their services from NHI if tariffs do not suit them and therefore provide an opportunity to increase tariffs by using this as a negotiating tactic, which will not fall foul of competition law.


Coverage – Day 4

Population coverage

  1. (1) The Fund, in consultation with the Minister, must purchase health care services,

determined by the Benefits Advisory Committee, on behalf of—

(a) South African citizens;

(b) permanent residents;

(c) refugees;

(d) inmates as provided for in section 12 of the Correctional Services Act, 1998 (Act No. 111 of 1998); and

(e) certain categories or individual foreigners determined by the Minister of Home Affairs, after consultation with the Minister and the Minister of Finance, by notice in the Gazette.

(2) An asylum seeker or illegal foreigner is only entitled to—

(a) emergency medical services; and

(b) services for notifiable conditions of public health concern.

(3) All children, including children of asylum seekers or illegal migrants, are entitled to basic health care services as provided for in section 28(1)(c) of the Constitution.

(4) A person seeking health care services from an accredited health care service

provider or health establishment must be registered as a user of the Fund as provided for in section 5, and must present proof of such registration to the health care service provider or health  establishment in order to secure the health care service benefits to which he or she is entitled.

Analysis:

Section 27(1)a of the Constitution dictates that “everyone has the right to have access to health care services, including reproductive health care;” it does not specify “Every South African Citizen, permanent resident, refugee and inmate” has the right to access health care. The exclusion of certain people who are present in South Africa through illegal means might not pass Constitutional muster. Illegal foreigners who are entitled to services for notifiable conditions of public concern, might encounter difficulties in having such conditions diagnosed and will also encounter difficulties in registering for the NHI fund in order to access services for such notifiable conditions, even if diagnosed outside the NHI funding environment. The registration requirements could prove problematic for such foreigners without documentation and the NHI fund would have to record that the individual is only entitled to services for notifiable conditions. There would also have to be a separate service basket for children of foreigners, which contains the basic health care services referred to in 4(3) and a indication that they only qualify for this basket. This is already creating different tiers of access to services in the NHI, which is going to create an administrative problem.


Supersession – Day 5

3 “(3) If any conflict, relating to the matters dealt with in this Act, arises between this Act and the provisions of any other law, except the Constitution and the Public Finance Management Act or any Act expressly amending this Act, the provisions of this Act prevail.”

Analysis:

This clause makes the Act extremely overpowering in the healthcare sphere. It would supersede the Children’s Act, POPI Act, Consumer Protection Act, the Health Professions Act, Medical Schemes Act and even the Health Act itself. This could have a radical impact on consumer rights in this environment, but could also affect the way the Healthcare professionals are expected to keep to ethical medical practice in such an environment.


Registration of Users – Day 6

Registration as users

  1. (1) A person who is eligible to receive health care services in accordance with section 4 must register as a user with the Fund at an accredited health care service provider or health establishment.
  2. (5) When applying for registration as a user, the person concerned must provide his or her biometrics and such other information as may be prescribed, including fingerprints, photographs, proof of habitual place of residence and—

(a) an identity card as defined in the Identification Act, 1997 (Act No. 68 of 1997);

(b) an original birth certificate; or

(c) a refugee identity card issued in terms of the Refugees Act.

(7) Unaccredited health establishments whose particulars are published by the Minister in the Gazette must, on behalf of the Fund, maintain a register of all users containing such details as may be prescribed.

Analysis:

The implication of 5(1) may be that a qualifying user does not have the option to opt out of registration with the NHI, but could also mean that registrations will only happen at health care service providers or facilities. The inclusion of Biometrics and Photos to the registration process would require that each practice that renders services to NHI would need access to the equipment required to complete this registration process and that reception staff at practices would be required to complete such registrations. It is unclear whether practices will be supplied with the equipment or whether they will have to purchase such equipment. Every practice will also require an active internet connection for this process. Practices that opt out of rendering services to NHI would still be required to keep a register of users of the services at the practice, even if cash patients want to remain anonymous. The practice could be in contravention of the law if an unregistered foreigner or any person receives services at a practice and refuses to provide particulars as required by this register.


User Rights – Day 7

  1. Without derogating from any other right or entitlement granted under this Act or under any other law, a user of health care services purchased by the Fund is entitled, within the State’s available and appropriated resources—

6(b) to information relating to the Fund and health care service benefits available to users;

6(d) not to be refused access to health care services on unreasonable grounds;

6(f) to access health care services within a reasonable time period;

6(o) to purchase health care services that are not covered by the Fund through a complementary voluntary medical insurance scheme registered in terms of the Medical Schemes Act, any other private health insurance scheme or out of pocket payments, as the case may be.

Analysis:

Reference to “Appropriated resources” is highly concerning in the current environment where appropriation without compensation is being debated at parliamentary level.

The communication implications of realising 6(b) would require a massive communications infrastructure capacity that would need to be created to manage the communication needs of 57 million uninformed users of the system.

A further concern is the capacity of the state to make a determination on reasonable and unreasonable grounds for denial of care.

An additional issue is what benchmarks will be used to determine a reasonable waiting time for services? The OECD average waiting time for a Cataract is 120 days, but Estonia, with a single payer NHI system has a four year waiting period for such surgery. Who will determine the norm in South Africa and what recourse will a user have if waiting times exceed such a set benchmark?


Health Care Services Coverage – Day 8

  1. (1) Subject to the provisions of this Act, the Fund, in consultation with the Minister, must purchase health care services, determined by the Benefits Advisory Committee, for the benefit of users.

(2) Subject to subsection (4)—

(a) a user must receive the health care services that he or she is entitled to under this Act from a health care service provider or health establishment at which the user had registered for the purposes of receiving those health care services;

Analysis:

The DDG of NHI, Dr Anban Pillay said “the cover the government will provide will be determined by the economy, which dictates what the state can afford”. He said “when the economy does badly, this would affect the budget allocation, which may impact on the services that will be covered. This will then impact on the services that schemes will cover as complementary cover.” This is the clearest indication that the Government will reduce the service basket based on the available budget. If this is the case, it would not be progressive realisation of access to healthcare, as the Constitution dictates. If members of public currently using the state have access to a smaller basket of services than currently available in the state, it is regressive in nature. There is also the aspect of Medical scheme members who could see drugs which are currently funded by Medical schemes not being funded in NHI and whether this is progressive realisation of access to healthcare.  


Transfer of Users – Day 9

7.2(c) should a health care service provider or health establishment contemplated in paragraph (a) or (b) not be able to provide the necessary health care services, the health care service provider or health establishment in question must transfer the user concerned to another appropriate health care service provider or health establishment that is capable of providing the necessary health care services in such manner and on such terms as may be prescribed;

Analysis:

This clause could place the onus on the practice to transfer patients that arrive at the facility requiring inappropriate services. Should a male patient, for instance, arrive at a gynaecology practice seeking services for a headache, the practice would be required to transfer the patient to an appropriate facility. There is no further expansion on whether ambulance services could be utilised for such transfers, or whether there will be any coverage of costs if the practice does not have its own patient transport available, yet remains responsible for the transfer. In the absence of prescribed terms, this clause remains problematic.


Referral Chain – Day 10

7.2 (d) a user—

(i) must first access health care services at a primary health care level as the entry into the health system;

(ii) must adhere to the referral pathways prescribed for health care service providers or health establishments; and

(iii) is not entitled to health care services purchased by the Fund if he or she fails to adhere to the prescribed referral pathways;

Analysis:

This clause, when read in conjunction with the definition of “Complementary cover”, could indicate that Medical Schemes may cover services available within the NHI basket of care, in certain circumstances. If the NHI does not pay for a service because of skipping a referral chain, a Medical Scheme may pay for this. Based on this clause, Medical Schemes may be able to cover all services available in the NHI, except basic primary care. Further to this, if one seeks primary care from a non-contracted Healthcare professional, that would also not be reimbursable by the fund and would also qualify for complementary cover by a medical scheme.


Central Hospitals – Day 11

(f) in order to ensure the seamless provision of health care services at the hospital level—

(iii) the management of central hospitals must be semi-autonomous with certain decision-making powers, including control over financial management, human resource management, minor infrastructure, technology, planning and full revenue retention delegated by the national government; and

(iv) central hospitals must establish cost centres responsible for managing business activities and determine the cost drivers at the level where the activities are directed and controlled.

Analysis:

In this instance, the Central Hospital would therefore need to be able to contract independently with the NHI Fund. Central hospitals are not seen as juristic persons and are not able to contract with any party in the current healthcare system. Contracting happens at a provincial level. Legislation such as the Public Finance Management Act, read in conjunction with the Constitution, is problematic when it comes to the creation of trading accounts and other mechanisms whereby health departments of provincial governments can generate and use funds that do not form part of their equitable share raised nationally to fulfil their constitutional obligations. The same would apply to such Central Hospitals as independent contracting bodies. Such Hospitals would need to be registered as Trading Entities under the Public Finance Management Act and would probably have to be proclaimed as National Government Business Enterprises or Public Entities. This a complex procedure and employees are no longer seen as state employees and the entity would have to be accountable to parliament.


Treatment Exclusions – Day 12

7(4) Treatment must not be funded if a health care service provider demonstrates that—

(a) no medical necessity exists for the health care service in question;

(b) no cost-effective intervention exists for the health care service as determined by a health technology assessment; or

(c) the health care product or treatment is not included in the Formulary, except in circumstances where a complementary list has been approved by the Minister.

 Analysis:

‘‘health care service provider’’ means a natural or juristic person in the public or private sector providing health care services in terms of any law;’ according to the NHI Bill. This implies that a healthcare professional employed by the Fund may not deny such funding and places to the onus on practitioners in government and state to provide reasons why their patient treatment should not be funded by the NHI Fund. It also raises questions as to how traditional healers will be included for funding in NHI, as the Gauteng Health MEC recently alluded, when there is an absence of scientific evidence for such interventions


Foreigners on Medical Schemes – Day 13

8 (2) A person or user, as the case may be, must pay for health care services rendered directly, through a voluntary medical insurance scheme or through any other private insurance scheme, if that person or user—

(a) is not entitled to health care services purchased by the Fund in terms of the provisions of this Act;

(b) fails to comply with referral pathways prescribed by a health care service provider or health establishment;

(c) seeks services that are not deemed medically necessary by the Benefits Advisory Committee; or

(d) seeks treatment that is not included in the Formulary.

Analysis:

Once again implies Schemes can fund services when referral chain is skipped, or out-of-formulary drugs or uncovered services are utilised. It also indicates that foreigners, who are not allowed to register with the NHI Fund to access services, can join Medical Schemes to get full funding of all healthcare treatment they require. Rights for South Africans to join Medical Schemes to access funding all their healthcare needs are not expressed in such certainty under the NHI Act.


NHI Fund Establishment – Day 14

  1. The National Health Insurance Fund is hereby established as an autonomous public

entity, as contained in Schedule 3A to the Public Finance Management Act.

Analysis:

Other entities in this schedule include the Compensation Fund, Lotteries Board, National Laboratories service, CMS and Road Accident Fund. As the Minister of Health recently pointed out, such entities find it very difficult to borrow money from markets or banks. This makes the funding shortages a direct government problem, as any funding shortfalls would have to be funded through tax funded government bail-outs, or else service provision could grind to a halt all across they system. There is currently no indication that the NHI Fund would contain a pool of reserves, similar to Medical Schemes, to assist in periods of excessive service related claims and government would have to step in with additional funding, or alternatively service provision might be halted or severely downscaled.


State Contracting – Day 15

  1. (1) To achieve the purpose of this Act, the Fund must—

(d) enter into contracts with accredited health care service providers based on the health care needs of users;

Analysis:

‘‘health care service provider’’ means a natural or juristic person in the public or private sector providing health care services in terms of any law; Public Hospitals and Clinics are not Juristic persons and can therefore not contract with NHI Fund, until registered as Public Entities under the Public Finance Management Act.


Timely Payments – Day 16

10(e) prioritise the timely reimbursement of health care services to achieve equity;

10(f) establish mechanisms and issue directives for the regular, appropriate and timeous payment of health care service providers, health establishments and suppliers;

2) The Fund must perform its functions in the most cost-effective and efficient manner possible and in accordance with the values and principles mentioned in section 195 of the Constitution and the provisions of the Public Finance Management Act.

Analysis:

It is concerning that “timely” is not defined in the NHI Bill. The Medical Schemes Act specifies that accounts submitted to schemes need to be paid within 30 days. Scheme systems are therefore set up to accommodate this legal requirement. If the government is serious about implementing this NHI system, payment time needs to be stipulated in the NHI Act, so that NHI Fund systems can be aligned with this requirement. The current payment chaos at the Compensation Fund is an illustration of what can happen when administrative process are not held to account as far as stipulating when payments need to be made. The use of the word “timely” gives too much discretion to the Fund and can harm those providing services to the fund with payments that do not happen in regular manner.  Practice expenses and salaries need to be paid monthly and the ability of practices to meet practice expenses cannot be jeopardised by delayed payment for services by this single payer of such services.


Purchasing Services – Day 17

11 (2) The Fund may enter into a contract for the procurement and supply of specific health care services, medicines, health goods and health related products with an accredited health care service provider, health establishment or supplier, and must—

(a) purchase such services of sufficient quantity and quality to meet the needs of users;

(e) negotiate the lowest possible price for goods and health care services without compromising the interests of users or violating the provisions of this Act or any other applicable law.

Analysis:

If state healthcare facilities do not radically improve the quality of their services prior to the implementation of NHI, the NHI fund will not have sufficient supply of quality or quantity of services to fulfil its mandate, as it will not be able to contract with such facilities. It is therefore an imperative that public healthcare facilities in sufficient numbers meet the contracting and accreditations criteria prior to implementation. It is interesting that it indicates the fund will negotiate prices, as the indication is that there will be a Health Care Benefits Pricing Committee which advises the fund on pricing of services. There are references to a national pricing regimen in other clauses, which indicates that this committee will not only advise on prices but will be setting the prices as well.


Removing Hospitals from Provinces – Day 18

32 (2) Subject to the transitional provisions provided for in section 57, the Minister may introduce in Parliament proposed amendments to the National Health Act for the purpose of centralising the funding of health care services as required by this Act, and in such cases the Minister may—

32(2) (a) delegate to provinces as management agents, for the purposes of provision of health care services, and in those cases the Fund must contract with sections within the province such as provincial tertiary, regional and emergency medical services;

32(2) (b) designate provincial tertiary and regional hospitals or groups of hospitals as autonomous legal entities accountable to the Minister through regulation;

35 (2) The Fund must transfer funds directly to accredited and contracted central, provincial, regional, specialised and district hospitals based on a global budget or Diagnosis Related Groups.

Analysis:

This is the strongest indication that the NHI Fund will contract directly with services currently located in the province in a direct manner. All such service providers would have to be registered as public entities in order to contract directly with the fund. The requirements of the Public Services Act are that feasibility studies must be done in each instance:

“7A (1) An executive authority may only request the establishment of a government component in terms of section 7 (5) (c) or (d) if the prescribed feasibility study is conducted and its findings recommend the establishment of such component.”

Should a facility not be of sufficient quality to contract with the NHI Fund, the feasibility study would not be able to recommend such a move, as the facility will have no income stream if unable to contract with the NHI Fund and will have to remain in the province to access the provincial equitable share to keep employing staff and run the facility. The designation of Public Entity cannot be made by the Minister of Health, it must be made by the Minister of Public Service on request of the Provincial Premier and following the feasibility study.


Governance – Day 19 

4. (1) The Fund, in consultation with the Minister, must purchase health care services,

5. (6) The Minister, in consultation with the Minister of Home Affairs, may prescribe any further requirements for registration of foreign nationals

7.(2)(f) in order to ensure the seamless provision of healthcare services at the hospital level— (i) the Minister must, by regulation, designate central hospitals as national government components

10. (3) The Fund performs its functions in accordance with health policies approved by the Minister.

13. (1) The Board consists of not more than 11 persons appointed by the Minister who are not employed by the Fund and one member who represents the Minister.
13. (3) An ad hoc advisory panel appointed by the Minister must—
(a) conduct public interviews of shortlisted candidates; and
(b) forward their recommendations to the Minister for approval.
13. (8) The Minister may remove a Board member if that person
13. (9) (a) Subject to paragraph (b), the Minister may dissolve the Board on good cause

14. (1) The Minister must appoint a Chairperson from amongst the members of the Board as contemplated in section 13(1).

15. (1) The Board must fulfil the functions of an accounting authority as required by the Public Finance Management Act and is accountable to the Minister.
15. (4) For the purposes of subsection (1), the Board—
(d) must inform the Minister of any advice it gives to the Chief Executive Officer.

17. The Board must determine its own procedures in consultation with the Minister.

18. The Fund may remunerate a Board member and compensate him or her for expenses as determined by the Minister

19. (2) The Board must— (b) forward their recommendations to the Minister for approval by Cabinet.
19. (3) The Minister must, within 30 days from the date of appointment of the Chief Executive Officer, notify Parliament of the final appointment

25. (2) The membership of the Benefits Advisory Committee, appointed by the Minister, must consist of persons with technical expertise in medicine, public health, health economics, epidemiology, and the rights of patients, and one member must represent the Minister.
25. (6) The Minister must appoint the chairperson from amongst the members of the Committee.

26. (1) The Minister must, after consultation with the Board and by notice in the Gazette, establish a Healthcare Benefits Pricing Committee as one of the advisory committees of the Fund,

27. The Minister must, after consultation with the Board and by notice in the Gazette, appoint a Stakeholder Advisory Committee

29. When establishing a committee under this Chapter, the Minister must determine
by notice in the Gazette— (a) its composition, functions and working procedures;

31. (2) The Minister must clearly delineate in appropriate legislation the respective roles and responsibilities of the Fund and the national and provincial Departments,

38. (5) The Office of Health Products Procurement must support the review of the Formulary annually, or more regularly if required, to take into account changes in the burden of disease, product availability, price changes and disease management for approval by the Minister.

41. (1) The Fund, in consultation with the Minister, must determine the nature of provider payment mechanisms and adopt additional mechanisms.
41. (4) the Minister may make regulations to— (b) determine mechanisms for the payment of an individual health worker and health care provider;

44. (1) An Appeal Tribunal is hereby established, consisting of five persons appointed by the Minister

48. The revenue sources for the Fund consist of—
(d) any money paid erroneously to the Fund which, in the opinion of the Minister, cannot be refunded;

52. Subject to the Public Finance Management Act— (a) the Minister may assign any duty and delegate any power imposed or conferred upon him or her by this Act, except the power to make regulations, to any person in the employ of the Fund;

Analysis:

The Governance framework of the fund is extremely concerning, especially viewed in the light of the rampant state capture at Transnet and Eskom, which had these same governance structures in place.

The Minister appoints the Board, Board Chair, CEO, Benefits Advisory committee and its chair, Pricing Committee and its Chair, Stakeholder Committee and its chair and has the power to remove any of these Committees and appointees. The Minister may also confer these powers to any person employed by the Fund.

There is too little oversight of the power provided to the minister and the risk for patronage in such as system, should a Minister prove to have questionable morality, can be devastating to the South African Healthcare system. This is especially worrying, as the budget for the NHI Fund is likely to be twice that of Eskom.


More Governance – Day 20

55. (1) Without derogating from the powers conferred on the Minister by the Constitution and the National Health Act or any other applicable law, the Minister may, after consultation with the Fund and the National Health Council contemplated in section 22 of the National Health Act, make regulations regarding—
(a) the legal relationship between the Fund and the various categories of health establishments, healthcare service providers or suppliers as provided for in the National Health Act;
(b) payment mechanisms to be employed by the Fund
(c) the budget of the Fund,
(e) clinical information and diagnostic and procedure codes to be submitted and used by healthcare service providers, health establishments or suppliers for reimbursement and reporting purposes to the Fund;
(g) the registration of users of the Fund in terms of section 5;
(h) the accreditation of healthcare service providers, health establishments or suppliers;
(i) the functions and powers of a District Health Management Office;
(j) the functions and powers of a Contracting Unit for Primary Health Care Services;
(k) the relationship between the Fund and the Office of Health Standards
Compliance;
(m) the relationship between public and private health establishments, and the optional contracting in of private healthcare service providers;
(n) the relationship between the Fund and medical schemes registered in terms of the Medical Schemes Act and other private health insurance schemes;
(o) the development and maintenance of the Formulary;
(p) investigations to be conducted by the Fund or complaints against the Fund in order to give effect to the provisions of Chapter 8;
(q) appeals against decisions of the Fund in order to give effect to the provisions of Chapter 8;
(r) the manner in which health care service providers, health establishments and suppliers must report to the Fund in respect of health care services
(t) all fees payable by or to the Fund;
(u) subject to the Public Finance Management Act, the nature and level of reserves to be kept within the Fund;
(v) subject to the Public Finance Management Act, the manner in which money within the Fund must be invested;
(w) all practices and procedures to be followed by a healthcare service provider, health establishment or supplier in relation to the Fund;
(x) the scope and nature of prescribed healthcare services and programmes and the manner in, and extent to which, they must be funded;
(z) the proceedings and other related matters of the Appeal Tribunal;
(zA) any matter that may or must be prescribed in terms of this Act; and
(zB) any ancillary or incidental administrative or procedural matter that may be necessary for the proper implementation or administration of this Act.

Analysis:

While the content of the NHI Act requires extensive public consultation, the Regulations do not have a similar burden of consultation. Many of the issues which are proclaimable by Regulation should have been included in the Act, where the Minister has less discretion on the content thereof.

The reserve levels of the fund, being a good example. A more comprehensive set of accompanying Regulations referred to in Section 55 should have been published alongside the Act, so that the public could engage with the legislation in totality.

This would have been indicative of proper planning by Government and the total absence of even draft regulations on certain aspects, indicates that the Legislation was rushed and not properly thought through.


Specialist Payments – Day 22

41. (3) (b) In the case of specialist and hospital services, payments must be all-inclusive and based on the performance of the healthcare service provider, health establishment or supplier of health goods, as the case may be.

Analysis:

All Inclusive fees in a hospital environment implies an employment relationship between the Hospital and the Specialist, as well as employment of all involved allied healthcare professionals.

Current HPCSA Regulations do not allow for employment of doctors and healthcare professionals. HPCSA regulations would therefore need to be changed to allow for such a relationship.

One of the major absences is any indication of payment for specialist services outside of the hospital environment. Mental healthcare patients need to be followed up by psychiatrists outside hospital and treatment of eye conditions which require intravitreal injection also needs to happen in a specialist space, outside of the hospital environment. There is no reimbursement mechanism mentioned for such services.

WHO research shows performance based payments are limited to in-hospital services and primary care initiatives at present. This is highly concerning.

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