National Health Bill: hearings

Meeting report

HEALTH PORTFOLIO COMMITTEE
19 August, 2003
NATIONAL HEALTH BILL: HEARINGS

Chairperson: Mr L Ngculu (ANC)

Documents handed in:
Age in Action Presentation
South African Catholic Bishops' Conference (SACBC) Presentation
Health Sciences Faculty, UCT's Presentation
SA Dental Association's Presentation
Children's Institute, UCT
Children's Institute, UCT: Presentation
South African National Blood Service (SANBS) & Natal Bioproducts Institute (NBI)
Commission on Gender Equality (CGE)
ANC National Health Secretariat & Committee
Health Systems Trust's Presentation

Documents awaited:
Democratic Nursing Organisation of SA (DENOSA) Presentation
The Rights of Children Project in Education & Kooblal Incorporated Attorneys
South African National NGO Coalition (SANGOCO)

SUMMARY
Numerous submissions were presented at the second day of the Joint meeting of the Portfolio Committee on Health and the Select Committee on Social Services regarding the proposed National Health Bill 32-2003. Each submission prepared a number of recommendations for the Joint Committee to include in the Bill and there was Committee discussion after each presentation.

MINUTES

Age in Action submission
Ms V Kadalie stated that Age in Action welcomed the Bill. The presentation highlighted various concerns with regard to the treatment of the aged in hospitals, in community care and in home residences. Access for the aged to health services was hampered, with residential homes for the frail still largely only accessible to white people. She proposed numerous amendments which are detailed in the attached submission.

Discussion
Dr Cachalia commented that many of the suggestions made by Age in Action would necessitate the co-operation of different departments such as Transport, Health, Welfare and others.

The Minister commended the presentation for being very specific in its observations on the Bill.

The Chairperson stated that the call to define a stroke as a disability should be considered. The Committee would use this constructive submission to guide them in refining the Bill.

South African Catholic Bishops' Conference submission
This presentation by Ms T Mzamane, and Mr M Pothier suggested that the establishment of the National Health Council and the Advisory Committee, along with the Consultative Forum, could constitute a duplication of functions. They asked that more be done to ensure effective consultation amongst the various bodies. Some private healthcare providers, such as church facilities, might not be able to comply with such "high-level requirements".

A distinction should be made between private healthcare providers for profit, and public providers who provided services that were really the state's responsibility. It was often easier for the private, for-profit providers to comply than for the latter providers to do so.

Finally, the SACBC urged the Committee to monitor the progress of the legislation to ensure that its provisions were properly implemented and adhered to.

Discussion

With regard to the non-inclusion of private and non-governmental representatives on the consultative bodies, the Minister explained that some criteria had to be developed.

Mr Pothier responded that the CBC would like to see certain minimum provisions enshrined in the Bill.

The Minister explained that it was necessary for the Advisory Committee to process matters dealt with in the National Council so that the latter could meet for one or two days at a time. The roles of the two bodies needed to be clearly defined to ensure no duplication of functions. There was much unease about the Forum and she assured the CBC that consultation would take place on a continual basis.

The Chairperson commented that, notwithstanding the Minister's comments, the consultative structures would of necessity be carefully studied. There had been submissions that suggested that alternative mechanisms be considered to reach the same objectives.

Democratic Nursing Organisation of South Africa
Mr E Mafolo (DENOSA President) stated that DENOSA supported the main content of the Bill. However, there was insufficient provision for the protection of health workers. They were not specified for inclusion on the Provincial Councils [28(2)], and although they served on hospital boards, they had no voting rights [46(7)(e)].

On the various new structures provided for in the Bill, they were concerned about cost implications. Funds should not be channelled away from patient care and the appointment of more staff to set up structures.

Discussion
Ms Rabinowitz commented that even though some suggested amendments to the Bill seemed rather small, they were nevertheless important. She asked if it was incumbent upon every medical practitioner to provide emergency treatment and who would pay for such treatment. She suggested that DENOSA's proposal with regard to enforced emergency services be endorsed.

The house agreed that all medical practitioners should perform emergency treatments.

Dr Cachalia said that the issue of emergency treatment involved a question of ethics upon which the Health Professions Council should comment. Practitioners who refused to administer emergency treatment should be brought before this Council. Patients arriving at any healthcare establishment should at least be stabilised, whereafter the patient could be sent on to an appropriate establishment.

University of Cape Town's Faculty of Health submission
Prof N Padayachee, Dean of UCT's Faculty of Health welcomed the Bill, and offered numerous comments and suggestions for amendments detailed in the attached submission.

Discussion
Dr Luthuli commented that it was important to stipulate who could provide emergency treatment as anybody who was not a registered professional could not be allowed to do so.

The Director-General explained that the Bill stipulated that "A healthcare provider or health establishment may not refuse emergency treatment". It was quite explicit that non-professionals were not being given the go-ahead to administer emergency treatment.

Dr Jassat felt it was important to provide a definition for "emergency".

Ms Rabinowitz asked for comment on hospitals who refused to admit patients for emergency treatment.

Prof. Padayachee responded that some hospitals close down their outpatient's section by October when they become financially constrained. Hospitals often run out of funds months before the end of the year.

With regard to the non-inclusion of health providers on the Provincial and National Health Councils, the Director-General explained that they were concerned about establishing structures that were too complex. They might now have to reconsider this after incorporating suggestions of the presenters.

South African Dental Association (SADA) submission
Dr N Campbell, Executive Director, stated that SADA had not been consulted in the developmental stages of the Bill. This Bill would have major ramifications and could be part of a trend towards over-regulation of the private sector. SADA asked for exemption from the provisions of Section 41 of the Bill since it claimed the dental profession was already highly regulated.

The Chairperson remarked that the main areas of SADA's submission had been cogent.

Discussion
Ms Rabinowitz observed that SADA had similar sentiments as SAMA to the certificate of need provisions. She asked if they had considered joining with other objectors to oppose the government.

The Chairperson stated that as an extension of Parliament, it was inappropriate for members of the Portfolio Committee to instigate people to action against the state.

Mr Campbell mentioned that SADA incorporated members from all political affiliations. If they did consider joining with other parties for legal action, it would only be for action against Section 41 of the Bill.

Dr Jassat noted that most dental services were focused in urban areas. He asked what suggestions SADA could provide for bringing dental services to rural areas.

Mr Campbell responded that there was a great amount of goodwill in SADA but unfortunately there was a lack of positions in state employment. Dentists would be willing to provide special times of free services. It must be understood, however, that dental equipment is extremely expensive, and carting them to rural areas could prove cumbersome as roads are not good.

The Chairperson asked Mr Campbell to explain Point 8 on page 7 of SADA's submission.

Mr Campbell responded that the dental profession was unique in the health industry. Dentists must invest in expensive equipment. Their radiographic machines are subject to be maintained well. If licensing measures were to be imposed, he suggested using a "carrot" rather than a 'stick" approach and provide incentives.

Health Systems Trust submission
Dr P Barron submitted that the Health Systems Trust supports the Bill, with the exception of some suggested changes. Government and management structures in the Bill were not as clear as they should be. The HST recommended the election of Provincial Health Managers and said that the councils should be made up of these provincial and local health managers.

Ms Rabinowitz commented that the HST had made some excellent proposals. However, it would be helpful if they could suggest actual wordings for amendments.

Dr Barron felt that the law advisers might be better able to provide guidance on how to include those proposals in a manner that would be acceptable.

UCT Children's Institute submission

Their recommendations included: legislation of minimum level of free health care for children under 6 and for pregnant and lactating women, as well as primary level care for those not on medical aid. Secondly, enriched current structures in the interest of children. Thirdly, legislation of statutory establishment of the Maternal, Child and Women's Health Directorate at all levels. Fourthly, to specify specific child health services to be rendered in Chapter 3, 4 and particularly 5 at the national, provincial and district levels.

Discussion
The Chairperson said that some proposals had huge budgetary implications, such as free medical care for all uninsured people.

Dr Maylene Shung King (Children's Institute) said that the free health care for children had been in existence for the past nine years and free primary level health services for the past four years. These provisions needed to be legislated.

The Chairperson said that there might be cost considerations down the line as the situation changed and improvements took place. There might be the need in the future to review abuse of the system. It is difficult in practice to find a legislation that encompasses all issues of rights of children.

Dr Chetty said this issue had been raised previously and it was difficult to know where to draw the line.

Dr Maylene Shung King said that the National Health Bill (NHB) is rather vague and children's rights had been included and excluded over the years. The NHB should at least include a principle of ensuring children's issues are considered at all times, aside from gender health issues. She suggested that the drafters of the NHB and the Children's Bill come to some consensus on the issue.

The Rights of Children Project in Education & Kooblal Incorporated Attorneys submission
The presenters proposed that every healthcare provider inform each patient or their agent of their health condition. Many users do not understand the language and terminology used. Mr Wohrnitz said that Section 12 made no reference to dissemination of information regarding the rights and duties of users. He proposed that all providers be made roleplayers in this process.

Discussion
Dr Luthuli inquired whether there were there cost implications associated with agents.

Mr Wohrnitz said that the word "agent" was used in a general sense and there ought to be no cost implications. The proposal is to allow a user to bring another party with him to a practitioner. Attorneys had noticed that some providers service/stabilise to a certain point but do not complete treatment. When lawyers tried to proceed further they were denied access simply because they did not have the legislative authority to investigate on behalf of their clients. The idea was to ensure that their clients got appropriate medical treatment at whatever medical facility they chose.

The Chairperson said that it was a difficult issue to answer. The proposal was a completely new issue unrelated to this particular area.

There was a general agreement with the proposal to add clause "g" to the Section 12 that reads: "g) the rights and duties of - the user, - the healthcare provider, as per the section of Chapter 2 of the Bill". 12(g) is applicable to all healthcare providers and health establishments.

South African National NGO Coalition (SANGOCO) submission

SANGOCO recommended that the principle of equity be clearly expressed to encompass all spheres of government in light of the differing capacities and resources of provinces and municipalities. The schedule of definitions should clarify the following terms: "private health establishment" and "national health system". There were also recommendations to include some additional terms listed in the document attached.

A recommendation was presented that Chapter 1, Section 3, be amended to include both the responsibility of the Minister and the National Department of Health as in other legislation of this kind. The Ombudsman should be independent of the Forum of statutory Health Professional Councils. The Bill should locate regulation, guidelines and resourcing at the national level to ensure uniform healthcare delivery across the country. Ms Farred expressed hope for the speedy promulgation of this Act so that the 1977 Health Bill was repealed by the tenth year of democracy in South Africa.

Discussion
The Chairperson asked whether SANGOCO wanted to put the one provision dealing with local government legislation as part of the national system.

Ms Farred said that they were more concerned about the earlier provisions like the equity, access to services. All of those should be at a national level.

The Minister said they needed to think very carefully about which ones to elevate to national level so as not to crowd the legislation.

Dr Rabinowitz asked with regard to the definitions, if it would be possible to reach a situation where each association could decide on the appropriate minimum responsibility in an emergency service.

Ms Farred said that they would be concerned about the subjectiveness of some of the definitions it was left to providers. There are examples of overservicing in the private sector as well as underservicing.

Dr Chetty suggested a possible framework around the issue of definitions that is created from a legal standpoint. If a word appears just a few times, then there is no real need to define it in the schedule. She was concerned that a simple definition could provoke legal discourse.

South African National Blood Service (SANBS) & Natal Bioproducts Institute (NBI)
The presenters asked for support for a single blood transfusion licence that would ensure safety, quality, sustainability and availability. They expressed concern that the link seemingly established between blood transfusion and blood fractionation services is unwarranted and should be removed. Other areas of concern were plasma, plasma pools, pharmaceutical companies and the Pharmacy Act. They shared a number of recommendations on issues concerning blood transfusion service and proposed an amendment to the definition of "blood products".

Discussion
Dr Jassat commented that both plasma and pexils were blood products.

Prof Heyns (SANBS) said that the qualifications of the people would do blood fractionation were totally different from people who deal with blood transfusions. The product and its distribution were different.

Dr Chetty said that she did not see the reason to revisit the definitions of blood and blood products. It was however problematic that, on the one hand, there was a non-profit body that had to follow various guidelines of safety and efficacy, and on the other hand, there was a full-profit company that derived blood products. She raised the question of whether a single licence holder could do both functions.

Prof Heyns said that those Section 21 organisations were not for profit, including NBI.

Dr Luthuli asked the presenters for clarification on perceived conflicts in the legislation.

Prof Heyns said that the unit operating in terms of the Pharmacy Act should be a separate entity. The area that it is managed and operated is completely different from the proposal in terms of blood transfusion.

ANC National Health Secretariat & Committee submission
The ANC supported the UWC recommendations on equity in the Preamble, but also saw the need for more equity in health care financing between the public and private sectors. The rights of health providers were not specifically mentioned at all. Municipal health services in the Bill did not include some preventive elements. The Bill should move to an active redistribution plan to ensure equity in the rural-urban, doctor-nurse and inter-provincial equity divides. There was a need to prevent the super-specialisation of doctors in favour of generalists who could be utilised at secondary and primary levels.

Discussion
The Minister complimented the ANC representative for a good presentation and there were no questions from the MPs (the written submission was not supplied).

Commission on Gender Equality (CGE) submission
The special needs of geriatrics and the accessibility of health services in rural areas were highlighted. Older persons were affected by numerous problems such as inadequate transport, no proper consultation or examination, and receiving incorrect medication. Gender norms, discriminatory legislation and social values tended to negatively impact on women, leaving a huge power and resource imbalance between men and women. Other concerns included the right to equality as defined by the Constitutional Court and its understanding of the State's obligation to adopt measures to prevent unfair discrimination and to adopt measures to promote equality. The CGE also discussed topics of international standards regarding the right to health availability, acceptability, quality and accessibility for vulnerable and marginalised groups, as well as emergency medical treatment.

Discussion
The Chairperson asked about ethical conduct and how doctors could check for domestic abuse when presented with suspiciously injured patients.

Dr Cachalia said that the Older Persons Bill also obliged any health provider to report any physical or domestic violence to the Director-General of Social Development.

The Minister said that there was a provision in the Domestic Violence Act that if persons are being beaten and they do not report, they themselves could be interrogated. She suggested that rather than bringing everything into this one Act, they should refer to other cross-referenced legislation.

Ms Williams (CGE) said that the proposal was aimed at referring the person in need to counselling.

Dr Chetty asked about disclosure of HIV status (Section 19 - Duties of users). At times health workers required such information for appropriate treatment and she asked the CGE for recommendations on how to balance this with the potential harm of stigmatisation.

Ms Williams said there should be a confidentiality clause about not disclosing information to another party. She was not sure if such ethical behaviours were currently legislated for medical practitioners.

The meeting was adjourned.