WCG urges President Ramaphosa to refer NHI Bill back to National Assembly

The Western Cape Government (WCG) urges President Ramaphosa to refer the National Health Insurance (NHI) Bill back to National Assembly for reconsideration 

Following the passing of the National Health Insurance (NHI) Bill in the National Council of Provinces (NCOP), Premier Alan Winde and Minister of Health and Wellness, Dr Nomafrench Mbombo, will be writing to President Cyril Ramaphosa to urge him not to sign the Bill into law.

When pieces of legislation are passed in both Houses of Parliament, it is sent to the President for assent. However, the President is empowered to send legislation back to the National Assembly for further consideration should he have any reservations regarding its constitutionality.

The President can use this crucial mechanism to ensure that the major practical and constitutional concerns surrounding the NHI Bill are properly tended to.

According to 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. While our health system has progressed towards greater coverage after 1994, many structural issues remain which necessitate the need for proper health care reform in South Africa.

This is why we, as a provincial government, wholly subscribe to the objectives of Universal Health Coverage (UHC) and for the development of a mechanism that allows for greater allocation of resources from both public and private sectors so that the health needs of the population can be equitably addressed and financial hardship is removed at the point of contact. This is what the NHI Bill intends to achieve.

However, the current iteration of the Bill will only change how money is spent without addressing the challenges which the health system is facing. As such, we strongly believe that it will not achieve the UHC which our residents deserve and that it requires substantial amendment. 
 

Insufficient consultation

Since its inception, the development of the NHI Bill has been marred by haste and, more importantly, a lack of consultation with all stakeholders. When the Bill was first introduced, it was rushed through Cabinet before the National Health Council – a platform constituted by the National Minister, MECs and HODs of all provinces – had an opportunity to deliberate the matter.

Beyond this, public input on the NHI Bill has been grossly inadequate and therefore it contravenes the constitutional duty of the NCOP and provincial legislatures to facilitate public participation. When noting those that were submitted by public and private stakeholders, it becomes apparent that the Select Committee did not consider and respond to the comments it received but rather relied on what the National Department summarised and provided to the committee. 
 

Constitutionality concerns and fragmentation of care

As it stands, the NHI Bill conflicts with the provision of the Health Act of 1977 and the concurrency of Health as prescribed by the Constitution.

If the NHI Bill is implemented in its current form, central hospitals will become a national government competency with the NHI Fund directly contracting with regional and large hospitals. Additionally, District Health Management Offices will be created as well as Primary Healthcare Contracting Units in our communities. In doing so, our services will become fragmented and will introduce challenges to delivering coordinated healthcare packages. We believe the Bill does not provide a sufficient rationale for this decision.

As such, provinces’ roles in the healthcare system will be significantly reduced in comparison to its current mandates. The Bill also states that provinces would be management agents in the NHI system, in which clarity regarding responsibilities have not been disclosed. 
 

Issues of funding

Provinces will see their equitable shares and conditional grants redirected towards financing the NHI Fund, a process that has already begun. With provincial health departments having experienced a constrained fiscal climate for consecutive financial years and an unprecedented budget cut for the current financial year 2023/24, the total impact of the NHI Bill on our ability to deliver services is unknown at this point.

As provinces face immense fiscal constraint ahead of the new financial year, it is beyond comprehension that the national government is willing to sponsor an unaffordable piece of legislation when South Africa’s health departments will likely be experiencing decreased funding over the next few years.

Minister Dr Nomafrench Mbombo added: “The attainment of UHC is not only guided by the Constitution but is a critical goal of the Healthcare 2030 plan in the Western Cape. As a province, we are actively working towards transforming the healthcare system so that it can offer the right healthcare at the right place, at the right time and at the right price.

For us to truly achieve UHC, the entire health system – public, private, civil society, communities and various stakeholders that include sectors like government departments and academia to name a few – need to be capacitated and coordinated going forward with provinces playing a stewardship role. The whole of society approach is needed to ensure that we leave no one behind. The Bill will force the system to operate in silos which will prevent our health sectors from strengthening the health system as a collective and its ability to tackle social determinants of health as well.”

Premier Alan Winde concluded: “Not only is the bill in its current form unconstitutional but NHI will prove to be unaffordable and impractical. How can we be assured that NHI will be protected from corruption, maladministration and incompetence, all the hallmarks of national government. National government should fix the economy first, before embarking on NHI. The bill is vague and as with so much other legislation drawn up at a national level lacks policy certainty. Not only will we have to precariously navigate our way through catastrophic budget cuts, but now national government appears to be steamrolling ahead with NHI. We have on multiple occasions raised our concerns over this bill and its constitutionality. And in the face of this catastrophic fiscal crisis we have to ask, how will we fund this?