Where are we in the National Health Insurance legislative process and what happens next?

On Wednesday, MPs in Parliament’s Portfolio Committee on Health sat for the 25th day of public hearings on the National Health Insurance Bill. This leg of the public hearings started on 18 May 2021 with about 135 stakeholders who indicated they wanted to make oral submissions.

Committee chairperson Dr Kenneth Jacobs said seven stakeholders had withdrawn from the process, stating that their written submissions were sufficient. Those who have already presented include civil society organisations such as SECTION27 and the Womxn and Democracy Initiative, academics and researchers, statutory entities such as the South African Health Products Regulatory Authority and the Competition Commission as well as professional health bodies such as the Public Health Association of South Africa and the South African Medical Association.

How we got here

While debates about healthcare reform in South Africa have a long history, the current NHI Bill process arguably started with a Green Paper published in 2011. In 2015, the first White Paper was published, followed by a second White Paper in 2017. In 2019, the bill was tabled in Parliament and MPs criss-crossed the country for public hearings in various communities.

Where we are

According to Jacobs, the committee received 338,891 written public submissions – of which at least 283,009 were accompanying submissions, including petitions supporting some of the submissions.

Asked about progress in processing the submissions, Jacobs said, “All the public submissions received have been collated and worked through. A team of about 20 parliamentary staff members was recruited to assist with the processing of the public submissions.

“All the shorter submissions (about one page) were captured into metadata, categorised, and thematically analysed into a report. Elaborate submissions, ranging from two to 200 pages, were analysed separately using an analytical tool that captures the name of the submitter and clause-specific comments with suggestions and recommendations thereof.”  

It is not yet clear whether any submissions or related documents were destroyed in the recent fire in Parliament.

Between October 2019 and 24 February 2020, MPs visited 33 municipalities across South Africa’s nine provinces with more than 11,500 people attending these hearings. Jacobs said a total of 961 submissions were made during this leg of the public participation process. This means only about 8.3% of those who attended made submissions.

On the outcomes, Jacobs said 85% (820) of the participants were in support of the NHI Bill, 12% (118) were opposed to the bill, and 2% (23) raised issues unrelated to it.

Asked about the quality of the legislative process so far, some opposition parties raised some concerns. Freedom Front Plus MP Philip van Staden said he was concerned about the low numbers. 

“More people could have gone out to these public meetings if the advertisements for these meetings were adequately advertised not only by Parliament but also by the provinces and local municipalities. Luckily, there will be another opportunity for public submissions when the matter is referred to the National Council of Provinces (NCOP) and the nine legislatures.”

Democratic Alliance MP Siviwe Gwarube raised concern over the manner in which oral submissions were done. 

“The process was deeply politicised and often did not provide an honest reflection to the people of South Africa about what the legislation seeks to do and how it will go about it,” she said.

Spotlight attended some of these hearings and many of them were dominated by concerns about existing health system challenges. Read our coverage here.

According to Jacobs, however: “Health is by its very nature an emotive subject. The public engaged with the legislation from the perspective of their lived experience, and there is no right or wrong answer. It would not be correct to stifle people’s freedom of speech. People are allowed to engage with the issues in the manner they deemed most appropriate.”

Stressing that public hearings are a cornerstone of the democratic lawmaking process, he said: “This is a democratic process and it is not for the committee to police public sentiment.”

Jacobs said where complaints were raised on the level of service received at health facilities, the relevant provincial and national health department officials were there to deal with those. The latest version of the report (on the hearings in provinces) will be referred back to the committee for further consideration. Once agreed upon, it will form part of the overall report on the NHI Bill, he said.

What lies ahead

Some opposition parties made it clear that they do not support the current version of the bill and that it must be panel-beaten into shape. Van Staden told Spotlight it would be scandalous if the process were pushed and manipulated to get the legislation finalised as soon as possible just for ANC political gain. “To be realistic, I don’t think that the NHI Bill will be passed this year.”

Explaining the process in the coming months, Jacobs told Spotlight the committee will further consider all reports stemming from the three components (public hearings in provinces, written submissions, and oral submissions in Parliament) as well as the overall report as part of its broader deliberations on the NHI Bill. He said the committee would also have to schedule a meeting with the National Department of Health as the sponsor of the bill to respond to the public inputs received and to the recommendations.

The exact date for the finalisation of the bill is difficult to predict at this point, as it all depends on the parliamentary legislative processes that follow. The NHI Bill is a section 76 bill, meaning it is legislation that must be approved by both Houses of Parliament. The rules of the National Assembly states that the Portfolio Committee on Health can approve the bill as is or with changes, reject the bill, or recommend a redraft of the bill.

Once this report is adopted by the committee, where the ANC majority is likely to determine the outcome, it will be referred to the National Assembly for consideration and adoption. The bill will then be referred to the NCOP for concurrence where the select committee will have its own public participation process. DM/MC

* For extensive minutes on the NHI hearings in Parliament, follow PMG. 

This article was produced by Spotlight – health journalism in the public interest.