The portfolio committee on health heard presentations on the National Health Insurance Bill (the Bill) from 117 individuals and organisations. This information was collated by the Parliamentary Monitoring Group and analysed by researchers from the South African Medical Research Council (SAMRC), Clinton Health Access Initiative, and the universities of the Western Cape and Cape Town. 

This paper describes concerns expressed to the portfolio committee about coverage and access to healthcare.

Chapter 2 of the Bill sets out the rules regarding access to the healthcare services covered by the National Health Insurance (NHI) fund, including who is eligible for fund cover, the requirements for eligible individuals to register as users, the rights of users belonging to the fund, the health services and costs covered by the fund and the underlying conditions for that cover. Respondents recorded concerns on the proposed rules across all the sections.

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Eligibility

Section 4 of the Bill sets out the rules on who would be eligible for cover by the fund. The rules limit cover for asylum seekers and “foreigners”. Many respondents including the Children’s Institute, Rural Rehab of South Africa and the Psychology Society of South Africa were concerned by this limitation (previously addressed here).

The Federated Employers’ Mutual Assurance Company pointed out that the definition of an employee eligible for benefits in terms of the Compensation for Occupational Injuries and Diseases Act (COIDA) was wider than that proposed for the NHI, and recommended that “all users (employees) who would have been injured or diseased in the course and scope of employment within the country, and particularly in relation to occupational injuries and diseases” should be eligible for NHI benefits.

Registration

Section 5 of the Bill sets out the rules for eligible individuals to register with the fund. The requirement for users to register at an “accredited healthcare service provider or health establishment” and to provide biometrics, fingerprints, photographs, proof of place of residence and ID card, original birth certificate or refugee card, was considered a barrier to access by many respondents.

The Public Health Association of South Africa (PHASA), the SAMRC and the Psychology Society of South Africa felt the proposed registration requirements would deny access to care to users without complete documentation. The Society of Private Nurse Practitioners of SA  said there was no recognition of children or other persons without valid birth certificates, and that excluded children would be at risk. 

The People’s Health Movement was concerned that registration requirements would exacerbate inequality. The uneven geographic distribution of clinics would make registration difficult for rural populations, the elderly and disabled people. The Cancer Association of South Africa warned that registration should be efficient to prevent “unnecessary waiting periods”. 

PHASA recommended that “explicit provisions (should) be made in the NHI Bill for how users without documentation would be registered in the system and retain their right to access healthcare services despite not having documentation”. The South African Human Rights Commission felt the NHI should consider other forms of identification. 

The Active Citizens Movement felt children should be able to benefit from universal healthcare, regardless of age and, where the assistance of a parent or guardian is unavailable, children should be able to register as users in an alternative way. The SAMRC recommended that a clause be added to enable users not in their geographical area of registration to register. 

Referral pathways

Section 7 of the Bill requires users to attend NHI-registered providers and adhere to prescribed referral pathways or be liable for the cost of care.

Several respondents considered the prescribed referral pathways to conflict with the Patient Rights Charter. The Genetic Alliance noted that the charter makes provision for the right of patients to choose their own healthcare provider or health facility. The Professional Provident Society felt referral pathway rules would prevent people from continuing a relationship with their doctor of choice. The Commission for Gender Equality was concerned that the referral pathways were “prejudicial to pregnant women who prefer to engage their regular gynaecologists or obstetrician and skip a general practitioner”.

Some felt the continuity, quality and efficiency of care was at risk. 

The Genetic Alliance argued that the proposed referral pathways were “not viable … and fail to deal with the practical issue of continuation of care by [an] existing, treating, healthcare practitioner.” The Educational Psychology Association questioned whether the referral pathway would work for long-standing patients in need of chronic services and MSD was concerned that “for patients with complex conditions, access delayed may be access denied”. The Cancer Association of South Africa was concerned there would be unnecessary waiting periods. 

The prescribed referral network could limit access to care.

The South African Disability Alliance said there were no clear guidelines on how persons with disabilities from rural areas and their families would be assisted when referred to one of the 10 state hospitals, nor was there recognition of their need for transport and accommodation. Stellenbosch University and the South African Committee of Deans indicated the risk of limited coverage and/or increased costs for users who have to travel to other facilities because the facility they are meant to access is not accredited. 

Can the referral pathways be made to work? 

The Council for Health Service Accreditation of Southern Africa called for mechanisms to be put in place to safeguard patients transferred outside the pathways for specific reasons, with some degree of choice available to patients in consultation with the referring doctor. Patients should not be refused treatment under this section on financial grounds, and there needs to be an appeal mechanism.

The South African Speech-Language Hearing Association called for the referral pathways to be user friendly, to include all health providers and establishments, to provide for up-and-down referrals from primary healthcare to tertiary care, and to involve clinicians in creating the pathways. 

Recognising the uneven development of protocols across the country, the Actuarial Society of South Africa proposed that “referral pathways and protocols are crucial to ensure sustainability” and that they “should be clearly defined to apply equitably, should be evidence-based and subject to regular updating”. 

The Progressive Professionals Forum was concerned about portability and asked that the Bill provide clarity on how users could access services when they are unable to access the healthcare providers or facilities with which they have registered. 

Preferential access 

The lobbying for differential or preferential access for specific groups was a prominent theme at the hearings. The South African Association of Hospital and Institutional Pharmacies argued that “the elderly should be regarded as a separate target group just as children, refugees and inmates are mentioned specifically”. Priority should be given to South African Police Service members, said Polmed; to people with disabilities, said Rural Rehab of South Africa and the South African Orthotic and Prosthetic Association; to cancer patients, said the Cancer Association of South Africa; to mental health services for children and adolescents and for improved access to forensic mental health services, said the Psychology Society of South Africa. 

Portfolio committee response? 

Access and equity are the most quoted aspirational features of the proposed NHI Bill. Therefore ensuring the Bill can deliver on these is critical. 

The portfolio committee on health heard how the Bill could profoundly limit access and equity through administrative barriers, rigid referral pathway rules and potential conflict with human rights legislation. The committee has been challenged to ensure the proposed rules on eligibility, registration, and prescribed referral pathways for access to care are viable and fair. 

This task is further complicated by the lobbying for preferential treatment for specific groups, which was a recurrent theme at the hearings. DM/MC

This is the fifth article in our series about different issues dealt with in public submissions to Parliament on the NHI bill. See Part 1, Part 2, Part 3 and Part 4.

Geetesh Solanki is Specialist Scientist at the Health Systems Research Unit at the SAMRC; an Honorary Research Associate in the Health Economics Unit, University of Cape Town and Principal Consultant at NMG Consultants and Actuaries. Neil Myburgh is Professor in the Department of Community Dentistry, Faculty of Dentistry and WHO Collaborating Centre for Oral Health at UWC. Stephanie Wild is a postgraduate student enrolled for an MPhil in Public Law at the University of Cape Town. Judith Cornell is former director of Institutional Development and Planning at the Nelson Mandela School of Public Governance at the University of Cape Town. Vishal Brijlal is a Senior Director at the Clinton Health Access Initiative.

The opinions expressed are those of the authors and do not necessarily reflect the views of their institutions.