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In defence of the NHI Bill process – There was unprecedented public engagement, says parliament’s health chair

In defence of the NHI Bill process – There was unprecedented public engagement, says parliament’s health chair
Dr Kenneth Jacobs played a pivotal role in overseeing public deliberations around the National Health Insurance Bill, which was signed into law in May. (Photo: Parliament)

The chairperson of the National Assembly’s Portfolio Committee on Health, Dr Kenneth Jacobs, played a pivotal role in deliberations on the National Health Insurance Bill. Spotlight’s Biénne Huisman asked him about some criticisms of the NHI and about his plans for life after Parliament.

A week before South Africa’s sixth democratic Parliament drew to a close on 21 May, chairperson of its Portfolio Committee on Health, Dr Kenneth Jacobs, watched President Cyril Ramaphosa sign the National Health Insurance (NHI) Bill into law at the Union Buildings in Pretoria.

Back in Cape Town, Jacobs tells Spotlight the NHI signing was the culmination of his own work dating back 15 years. He says he started working on public health projects relating to universal health coverage and the NHI in 2009, as a consultant to the National Department of Health.

For him, at the heart of the bill lies fairness: “We should be able to provide all of the people of South Africa the opportunity to access quality healthcare,” he says.

Jacobs entered Parliament as an ANC MP in 2019, and two years later was elected chairperson of the Portfolio Committee on Health after his predecessor, Dr Sibongiseni Dhlomo, became deputy health minister. Committee chairpersons are elected by and from among the members of each committee, meaning the majority party in Parliament has the most influence in selecting chairpersons.

As chairperson, a large part of Jacobs’s job was to hold the country’s executive and the Department of Health to account on behalf of South Africa’s citizens.

Among other tasks, he played a pivotal role in overseeing public deliberations around the NHI Bill, which included 338,891 written submissions and presentations by 133 organisations. These included political parties, trade unions, medical aid schemes, health technology organisations, the South African Medical Association and university departments.

“It is never in the history that the committee had such an engagement by the public,” says Jacobs. “So I’ve been very blessed and fortunate to go to Parliament in the final process of the NHI Bill.”

‘Disheartening’ criticism

Both before and after its signing into law, the NHI has been deeply divisive, with several political parties and other role players threatening litigation. One criticism is that, while many people and organisations made submissions to the committee chaired by Jacobs, the final bill did not change substantially from what it was before the public hearings.

Interviewed on the topic, Business Leadership South Africa CEO Busi Mavuso said the government rushed populist policy through Parliament – an electioneering ploy – as the significant public input into the Bill and its socioeconomic ramifications had not been considered.

Jacobs voices his frustration at such criticism of the NHI public participation process, saying it is “disheartening”, adding that criticisms are doled out by South Africans who are “in better financial positions”.

He explains the process of collating so much information: “Well, firstly it’s driven by the chairperson [him]… We appointed a team through parliamentary processes, who looked at the submissions, and interpreted the submissions using computerised systems. It’s thematic – what are the themes, really? These are developed into reports; the reports on all the public hearings, those reports are all available.”

He adds: “So, people who want to write and say all these negative things, they really should go and access these documents and see what the submissions were.”

‘It’s attractive to make people insecure’

Another aspect of the NHI over which many have expressed concern is the potential for corruption, particularly in light of massive healthcare corruption at the height of the Covid-19 pandemic and more recent alleged corruption at Tembisa Hospital in Gauteng. Here criticism ranges from a simple distrust in government to run such funds, to more nuanced criticisms of aspects of the Bill that critics say increases the risk of corruption – such as the minister of health’s expansive powers and accountability to Cabinet rather than to Parliament.

In an interview following the signing of the Bill, the DA chief whip who was also a health portfolio committee member, Siviwe Gwarube, said: “The NHI will not address the underlying issues in our healthcare system; it is financially unfeasible, an election gimmick, and will burden South Africans with increased taxes.” She added: “The potential for corruption is staggering, and the flawed parliamentary process further erodes public trust.”

Asked about fears that money might disappear from centralised NHI coffers – to be governed by a board appointed by the minister of health – and accountability to prevent such, Jacobs says: “I think that people are putting the cart before the horse. You must remember this will be an entity [with tender procedures], and then who is supposed to appoint them [board members] in any case? Somebody has to have the responsibility. Why can that not be the minister, for example? But remember that it will be a transparent process, the same as the appointment, I think, as what we do with the appointment of judges.”

The NHI fund will be a schedule 3A entity, similar to, among others, the Road Accident Fund, the National Lotteries Commission, the National Laboratory Service, the Office of Health Standards Compliance, the Competition Commission and the Council for Medical Schemes.

Jacobs says checks will be provided by the country’s forensic investigation agency, the Special Investigating Unit (SIU). “And there are many ways to put checks and balances into place,” he says, “we talk [in the Bill] about the interventions which can be made, or the investigations which can be made by the SIU and other law enforcement agencies.”

Shortly after taking over as health committee chairperson, Jacobs told Spotlight that rooting out corruption in the health sector was a priority. At the time, he stressed the importance of safety nets for whistle-blowers, and of establishing systems to enforce accountability. Around the time of his appointment in 2021, whistle-blower Babita Deokaran was murdered for exposing R1-billion worth of allegedly irregular tenders issued at Tembisa Hospital in Gauteng.

Asked about these particular earlier priorities, Jacobs responds: “I have no answer on that, I don’t think I want to talk about corruption now.” Upon reflection, he adds: “Of course corruption is important. Losses to the fiscus is important; people doing wrong is important. People need to be brought to book, be held accountable for doing wrong.”

Later in the interview, when the issue of corruption comes up again, he says that corruption has decreased in South Africa: “I think we’ve advanced quite a bit from the time when corruption was more rife. I think nowadays you hardly hear about these things and it’s because unprecedented intensive programmes were put in place to address these issues of corruption and fraud. I really think what they [critics] are doing is fearmongering, telling people that you need to be frightened, and I’m going to say again, those who are telling others to feel frightened are in a better financial position. So it’s attractive to make people insecure.”

Money for NHI?

Another common argument against implementing the NHI is that it is not affordable. The government’s spending on health has declined in real terms for much of the past decade and the South African economy is struggling by most measures.

Asked about crippling budget cuts in the health sector as it stands, and questions around the NHI’s affordability, Jacobs says South Africa has insufficient central funds because of unemployment, and that the country needs more jobs and more workers to increase its tax base.

“My personal view is that we need to understand why there’s a budget problem,” he says. “So where is government supposed to get money? Who are supposed to contribute? Those who are employed. And look at our employment rate – is it government’s responsibility? No, the emphasis is wrong. It is businesses’ responsibility.

“When people have employment they can contribute to the coffer… and I’m going to keep on saying, the narrative is in the wrong place. We need to say to South Africans: ‘Don’t all of us have a responsibility?’ Those who have the economy in their hands and those who don’t have the economy in their hands, all [have] the responsibility to drive our country forward.”

How to drive South African healthcare forward remains contested. Several organisations representing healthcare workers, such as the South African Medical Association, do not support the NHI Act in its current form. Others, including the South African Medical Association Trade Union, welcome it.

Meanwhile, Jacobs expresses empathy for his clinician colleagues: “As a medical doctor, I have absolute respect for all of my colleagues. I would like you to write it. I understand the conditions under which our medical and or health personnel have to function. And I don’t think that National Health Insurance will be a negative thing for healthcare professionals.”

‘Why should there be people who profit from the ill health of other people?’

Another concern in some quarters is that the NHI will over time squeeze out medical aid schemes and leave people with no alternative to health services provided through the NHI. This is because, according to Section 33 of the NHI Act, medical schemes will not be allowed to cover services that are already covered by the NHI fund.

Asked about the future of medical aid schemes in South Africa, Jacobs says: “What is the medical aid system? It’s a profit-driven system by people who are in business. Is it correct that there are people who make profit off the lives of people, and the health of people? I don’t think that is correct.” (Note: Medical schemes are nonprofit entities while medical scheme administrators are for-profit.)

He adds: “What is wrong with having one single system, in which everybody has access to the same healthcare? Why do we need to keep exclusionary rights for some people, based on them having a better income than others? I think that’s the bottom line on the answer of the medical aid. Whether medical aid will stop functioning or not, I think that’s not the question to ask. The question is why should there be people who profit from the ill health of other people?”

‘From policy to practice’

Given that he won’t be returning to Parliament, Jacobs hopes to resume public health consulting work for the Department of Health.

“I have a project which is very dear to me,” he says. “I want to start an institute for health governance, and it’s called ‘from policy to practice’. It’s on health governance, universal health coverage… and will be instrumental in influencing dialogue.

“So, I can’t wait to stay active in the health sector, but not being restricted in that I’m no longer a member of Parliament, not feeling that there’s some sort of conflict.”

Jacobs will now move from the Acacia Park Parliamentary Village on Cape Town’s northern fringes back to his family home in Wellington.

He says that they will soon have seven public health doctors in his family – that is, when his son completes medical school at Stellenbosch University. His daughter recently finished medical school and is contracted as a doctor at a clinic in Khayelitsha.

Originally from Gqeberha, Jacobs holds a Bachelor of Medicine and Bachelor of Surgery degree from Stellenbosch University where he also obtained a Master of Medicine degree in family medicine. He went on to obtain a Master of Science degree in sports medicine from the University of Pretoria. In earlier years, he served as a physician to the Stormers and Springbok rugby teams.

In the previous interview with Spotlight, Jacobs relayed how his formative years were tough. His family were forcibly evicted from sea-facing South End, in what was then Port Elizabeth, and moved to Gelvandale in the city’s northern suburbs. His father worked in a shoe factory, but lost his job when Jacobs was in Grade 10.

“South End was like Port Elizabeth’s District Six,” said Jacobs in that interview. “So yes, honestly, that was something that had a huge impact on me. I decided then that I would not allow somebody to suppress or oppress me and I think it is probably why I just kept on studying and improving.”

At 65, Jacobs exudes ambition and enthusiasm. Wrapping up, he quotes an Afrikaans aphorism: “Die mens wik maar God beskik” (Humanity proposes, God disposes). DM

This article was published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.

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Comments - Please in order to comment.

  • Graeme J says:

    Why doesn’t the DoH fix what it has broken, the existing public health system?

  • J W says:

    What an evil snake. You have laid the paving for the destruction of our healthcare sector and our economy. The NHS and Canadian healthcare systems are horribly broken and those countries have far more money.

    • Louis Botha says:

      Cyril stated that they are creating a Rolls Royce. Why must I pay for everybody to have a Rolls Royce when a VW Polo will do. The problem is that with all the tax money allocated to healthcare, they have created a failure. There is no VW Polo. They should rather focus on fixing the Polo. Let the people who want to pay for their own Rolls Royce continue to do so

  • Middle aged Mike says:

    “For him, at the heart of the bill lies fairness: “We should be able to provide all of the people of South Africa the opportunity to access quality healthcare,” he says.”

    Rubbish. Like everything else that the filthy ANC gets behind it’s about stealing. That’s why the existing state provided health care is in the shambles it’s in and that hasn’t caused slippery cyril and his minions to lose any sleep over it being ‘unfair’.

  • Louis Botha says:

    NHI takes away the right to personally insure by way of a medical aid your ability to send your wife and small children to a private facility for ANY service covered by NHI. NHI does not address the mess at some public hospitals, those where there is no linen, food or clean floors, but plenty of skinny jeans.

  • Sergei Rostov says:

    What nonsense. Piles and piles of submissions but was anybody listening? Not a single change to the intial Bill. Was there nothing at all of value in the piles of submissions?

    • Louis Botha says:

      Yes, It is not public participation if you meticulacely record all submissions, from professionals and their organisations, and then ignore the contents thereof

      • Johns No says:

        I, the taxpayer expected to pay for it all was never consulted. The consulted the private sector and some organisations… were YOU, fellow taxpayer, consulted? I never got the memo.

        In any case, how do we know they have 340k contributions? What are those contributions? How many were considered? How many were tossed?

        It’s just “take my word for it”. Even THAT process has no transparency or checks and balances. So how do you even start a program intended to respect taxpayers when you can’t even respect the taxpayers to begin with?

        Even now in all the media hubbub about NHI, taxpayers get a passing reference! It’s always “the poor”, “the private sector”, “equity”, “fairness” and no one ask the central question: What happens to taxpayers who have financial commitments to 5-20 year loans? If you take more of their disposable income to fund a program that they already got taxed for?

  • Fred BH says:

    This guy says the unemployment problem is not a government failing, it’s a private sector failing. Wot? He doesn’t realise that for business to thrive the government has to have business-friendly policies. This government interferes in free enterprise to an excessive extent, and after 30 years of increasing unemployment you’d think they’d have realised it’s not working, and would look for a better affirmative action model.
    Making South Africa an attractive investment destination is entirely within the ambit of government. Sadly, you’d have to be an idiot to put any money into South Africa as things stand.

  • David McCormick says:

    Very slick answer regarding the source of budget for NHI – “Its businesses problem”. Not true, its also Governments problem.
    The examples of lost employment opportunities due to Government maladministration are so numerous that the only way to avoid becoming depressed is to bury one’s head into the NHI placebo.
    The Goverment has squandered or stolen our taxes, destroyed income-creating entities by not maintaining Government assests, and installed cadres who have permitted the pillage of State Owned Entities, and created policies that increase the risks to starting new businesses in South Africa.
    Dr Jacobs, as part of your function, please update us on the real issues at Charlotte Maxeke Hospital – have vacancies been filled? Has security been improved so copper piping is no longer stolen? Has the fire damaged section been repaired? Is there sufficient linen for the beds? Is the hospital being cleaned? Are controls in place to prevent the theft of food?
    Only once the Department of Health can maintain their own assets should NHI be considered.

  • Robert Gornal says:

    What a load of absolute rubbish. Not a word about how bad are the current state run hospitals. It must be pleasing to live in a dream world all on your own, but in reality his political party has overseen the destruction of the health system and the NHI will not be any different, if it ever gets off the ground.

  • Colin Braude says:

    “As chairperson, a large part of Jacobs’s job was to hold the country’s executive and the Department of Health to account on behalf of South Africa’s citizens.”

    This cretin cannot explain why his oversight has left the existing health system, once world-class and attracting learner doctors and patients from 1st-world countries, has been allowed to deteriorate and keep rotting.

    He is out of touch with his medical colleagues (who all work to earn money → “profit”, as does Dr Jacobs who enjoys his parliamentary salary) as the psychotic Nicholas Crisp.

    As an ANC cadre, he should be demanding that his colleagues fix school education, which would (a) fix the anemic economy he is moaning about (b) contribute far more to wellness than any hospital ever could.

    • Mike Grace says:

      So true and he did not do the large part of his job, holding the executive and the dept of health to account because he was too busy fiddling with NHI.

  • Fanie Rajesh Ngabiso says:

    The problem is not the idea – it is the inability to implement.

  • Rob Wilson says:

    Such naive claptrap. All the NHI is now is a legislated wishlist. It has no proper plan, no substance and no hope of implementation while our state services are mired in ideology and rent seekers. Its going to need a lot more than money.

  • Trevor Gray says:

    A man out of touch with reality! Fix the entrenched corruption first! improve hospitals one by one. Only then will you be considered. You were parachuted into parliament for the sole purpose of ramming through this insidious abomination. Now you go back to a suitably cushy job? Will you use govt hospitals?

  • Simon Davis says:

    “Jobs isn’t the government’s responsibility – it’s business.” What a joke. The government strangles businesses with their ideological beliefs. Hiring anyone is something you do as a last resort because of the complete nightmare of trying to fire anyone – even those guilty of outright theft. The whole process is impossible for small or medium businesses – and designed to appease unions – who I might add don’t give a damn about the unemployed since they don’t pay union dues. And let’s not forget BEE, the most well meaning and unproductive policy of all that pretends that we have educated people in every demographic to fill every role. We don’t because education is the same shambles as everything else. Until the government gets serious about policies that actually make businesses want to hire, we will continue to have the bare minimum employed with nobody new paying any taxes. The ANC’s lack of accountability is simply breathtaking. May they get 20% of the vote next time.

  • Graeme Norval says:

    Reading Dr Jacobs’ answers to the questions posed to him makes me despair that a qualified medical doctor seems so incapable of thinking practically about such a patently unworkable system, choosing instead to spout reductive axioms like “isn’t it better for all South Africans to have access” or “why should people profit from others’ ill-health”?

  • M M says:

    Not even an “opinion piece”, just words, waffle and a glaring avoidance of reality. He does not seem able to argue from a factual base – no stats, no budgetary base – just socialist claptrap.
    So my question to the good Doctor is: Do you share your house, your car and your fridge with the less fortunate ? I’ll bet you enjoy a better standard of living than around 90 % of South Africans. Should you ?

  • Geoff Coles says:

    I am assuming Dr Jacobs is retiring. That’s a good thing as he doesn’t seem to have much answer beyond ‘We want and we need’

  • Rudd van Deventer says:

    Dr Jacobs said “It is never in the history that the committee had such an engagement by the public,” He is not wrong! Lots of input and many people spent a lot of time contributing to previous proposals.
    This is not the problem!
    The problem is that nearly all of the contributions were ignored by the committee, making their efforts worthless. Till Dr Jacobs learns to listen he is a sock puppet.

  • Alan Paterson says:

    The health care for all preamble is of course correct but done to death. What irritates me most about Dr Jacobs is his total lack of insight into his own profession. Within his portfolio he should have done the research and understood that the issues plaguing, for example, the UK NHS, relate to three issues – remuneration and quality of life for the understaffed medical professionals and waiting lists for the patients. He should also remember that medicine is a labour intensive discipline. For two essentially similar population numbers the NHS has nearly 140,000 NHS doctors (and identified as understaffed) while we have maybe 35,000 (we don’t know how many are already gone but retain their SA registration). UK qualifies over 8,000 doctors annually against just over 2,000 in SA. Furthermore at his age he should have identified the deterioration of our public heath sector over the past 30 years. And spent his time in the ANC trying to uplift it. His comment “I don’t think that National Health Insurance will be a negative thing for healthcare professionals” could well be correct – many will simply up and leave. Our waiting lists, which are even present for our current private practitioners, would ultimately be insurmountable. Finally, while he now starting his institute for health governance I wonder if he will retain the medical aid coverage that he enjoyed in government,

  • Andrew Lowry says:

    I wonder how much his pension is worth

  • Random Comment says:

    Hellbent on destroying the only medical system that works in the entire Africa.
    Anti-democratic; anti-human rights; unconstitutional, misguided; or just plain stupidity…the worst kind of jobsworth politician with delusions of grandeur.

    WAR IS PEACE; FREEDOM IS SLAVERY; IGNORANCE IS STRENGTH; & CRITICISM IS DISHEARTENING

  • jcdville stormers says:

    He is talking theoretical claptrap

  • Gavin Hillyard says:

    Dear Dr Jacobs. If you think it is fair that the minority should fund the healthcare costs of the majority, then I say to you you have a skewed idea of fairness. Instead of this disastrous and ill- conceived NHI idea, the government should leave medical aids to provide cover for those who can afford it and concentrate their energies on making the public health system work. Medical aids don’t cost the government anything. It would be difficult to refute the argument that everything the government touches goes south – why should this be any different? More likely it is a scheme to loot the reserves of medical aids, prudently built up over decades. By your logic, because it is only fair, everyone should have a Mercedes, and a house in the suburbs. You need a reality check doctor and some lessons in logic methinks.

  • Gavin Hillyard says:

    Man proposes -God disposes

  • Johns No says:

    “We should be able to provide all of the people of South Africa the opportunity to access quality healthcare”.

    75% of the money goes to salaries. Is there a profitable company that can operate like that?

    I read the list of entities he says they engaged with aggressively to produced 340,000 contributions. I was hoping to see the taxpayer mentioned… but nope, no such luck.

    It’s as if this gentleman is completely unaware that his entire pipe-dream requires that taxpayers who have bank loans, mortgages and school fees all of which need to be paid have to be dispossessed of the money they calculated to be for that purpose for the next 5-20 odd years of their lives. That increasing taxes will leave them with a massive financial problem that may see them having to surrender properties, cars or even leaving school.

    Govt perks make one blind to reality.

    He talks about transparency, SIU, tender processes, “checks and balances”… I ask: Do we not have these now? How many cadres are in jail for corruption so far? . And transparency: When’s the last time any of you had access to monitor tender adjudication? We only hear about tender debacles after the money is gone! And even then, the ANC will run defence to protect the cadres involved!

    Cut the salary bill to 35%. Jail the corrupt. Fix what you broke first… then ask the TAXPAYER for input as the funder. OUTA should be the head of the board that monitors any NHI fund’s use… not one (wo)man with unchecked powers to steal.

  • Bob Fraser says:

    Bob F – June 4th 2024 at 06:39
    Dr Kenneth Jacobs has everything reason to be proud of himself and his family all of whom have obviously acquired a very good education in what may must have been trying circumstances. Whilst I now have a better understanding of the NHI I cannot accept that the government can be trusted to control the large amount of money required to fund NHI when they have completely destroyed SAA, Eskom, Transnet etc. In far so as private medical aid is concerned the president and South African cabinet ministers have always had access to the very best medical facilities available in the country. Some, like you know who, even travelled to China for treatment as South African doctors and hospitals were not considered good enough. Imagine ten or fifteen years down the line a person requires urgent major surgery but there are no hospital beds available. That person is placed on a waiting list of which can be months or years. Will this apply to the president or cabinet member? No, no. Send him to China or Russia. Expense is nothing.

  • Louis Fourie says:

    When signing the bill Ramaphosa admitted that public comments were not taken into consideration. Adherence to the public consultation process is measured by the extent to which valid comments are not just considered, but adopted, and by ignoring all the very valid comments about the lack of detail, constitutionality, false and incorrect data and assumptions and hosts of other points, all you’ve done is set up expensive litigation that the state will lose. There is exactly 0% chance that the NHI bill in its current form will be implemented.

    • Gavin Hillyard says:

      Hopefully more capable people will be running the country soon Louis, and they will cancel this ill-considered and destructive initiative. But in any event as you say there is no chance that the scheme will be implemented as is.

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