BRIEFING DOCUMENT: BRIEF TO SENIOR COUNSEL FOR FORMAL LEGAL OPINION

POTENTIAL CONSTITUTIONAL ISSUES ARISING FROM THE PROPOSED NHI IN SOUTH AFRICA

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DISCLAIMER

Views expressed in this report do not necessarily represent the views of the Inclusive Society Institute or those of their respective Board or Council members or Members.

Authors: Percept & Daryl Swanepoel

Graphic Design: Nini van der Walt

SETTING THE SCENE FOR THE ROUNDTABLE DISCUSSION ON THE CONSTITUTIONALITY OF NHI 

The Inclusive Society Institute hosted an online roundtable on the constitutionality of the National Health Insurance Bill on 19 May 2020. The roundtable formed part of the institute’s broader research into achieving universal healthcare coverage. It was facilitated by Prof Dirk Kotze, with several legal experts, and industry representatives, participating. Each of the potentially problematic constitutional issues identified in relation to the NHI Bill were examined. This report sets out the main issues identified during the roundtable.

The primary focus of the Inclusive Society Institute, and to a large degree the dialogue around the table on the day, was to work on and promote a more inclusive society, as the institute’s name suggests. There is much upheaval being made in South Africa’s national discourse about various present-day issues, much of which it is not positive. The institute has been established to create a platform where this discord can be presented and discussed, in an attempt to find some middle ground in dealing with the pressing issues the country is confronted with.

The question of the National Health Insurance is one of these stumbling blocks. Different stakeholders have gotten fixed on certain potentially fundamental points of disagreement around National Health Insurance. This poses the risk of a number of possible constitutional challenges. The purpose of this report is therefore to logically set out these potential areas of constitutional concern, introduce new information and perspectives and, in doing so, develop a brief that could potentially serve to obtain legal advice and certainty with regard to the constitutionality of the legislation being put forward.

CONTENT

Setting the Scene for the Roundtable Discussion on the Constitutionality of NHI

  1. Introduction
  2. Potential constitutionality and other legal issues identified with the NHI Bill during a desktop review
  3. Discussion of constitutionality issues at a roundtable of constitutional and legal experts
  4. Request for legal clarification

References

1. INTRODUCTION 

Various commentators and the media have raised the possibility of taking legal action against the NHI Bill in its current form (Cohen, 2019; Mokone, 2019). Although not all submissions on the Bill are in the public domain, some have highlighted various potential legal issues with the Bill (e.g. Van den Heever, 2019).

Given these concerns, the Inclusive Society Institute commissioned a desktop review of potential constitutionality and other legal issues with the NHI Bill. This review was published in the ISI’s report on an NHI Roundtable which took place in Johannesburg during December 2019 (Inclusive Society Institute, 2020). Following the NHI roundtable, the ISI hosted an online roundtable on the constitutionality of the NHI Bill on 19 May 2020. The roundtable was facilitated by Prof Dirk Kotze, and several legal experts, as well as industry representatives, participated. Each of the potentially problematic constitutional issues with the NHI Bill were discussed and debated.

In this brief to Senior Legal Counsel, various concerns with the constitutionality of the NHI Bill as identified through the desktop review are presented first. This is followed by a summary of views on each of these identified issues that were discussed at the Constitutionality Roundtable. The brief is concluded by asking for further legal interpretation and clarification on the legal muster of each of the potential issues.

2. POTENTIAL CONSTITUTIONALITY AND OTHER LEGAL ISSUES IDENTIFIED WITH THE NHI BILL DURING A DESKTOP REVIEW 

The text below has been taken verbatim from the Inclusive Society Institute’s report on the NHI Roundtable (Inclusive Society Institute, 2020).

Whilst state law advisor Ayesha Johaar confirmed that the Bill had been certified as being aligned with the Constitution (Gerber, 2019), the desktop study revealed various constitutional concerns from a broad spectrum of organisations.

Section 18 of the Bill of Rights: the right to freedom of association

The first argument relates to Section 18 of the Bill of Rights, which guarantees every person the right to freedom of association. Some in the legal fraternity argue that by being compelled to associate oneself with the NHI, one’s right to decide with whom to associate – either the NHI or a medical scheme – may be unfairly and unduly limited (Botha, 2019; Kirby, 2019; Van Staden, 2019).

Section 12(2)(b): The constitutional right to bodily and physical integrity

It is further argued that the freedom to choose healthcare services may well be intertwined with the constitutional right to bodily and psychological integrity entrenched in Section 12(2)(b) of the Constitution. This right guarantees all people control over their own bodies (Anonymous, 2019; Botha, 2019).

Section 25: The right to property

Another argument relates to Section 25 of the Constitution. In essence, the Bill does away with a medical scheme’s ability to provide and charge for services rendered under the NHI regime. This, it is argued, may constitute an “unlawful infringement of a medical scheme’s right to property”, which is specifically prohibited by Section 25 of the Bill of Rights (Kirby, 2016).

Section 27(1): Infringement on the right to access to healthcare

Whilst state law advisor Johaar argues that Section 27 of the Constitution, along with the Republic’s responsibilities in terms of international treaties, imposes a duty on the state to take reasonable measures to give effect to the right to healthcare, (Gerber, 2019), others rely on the Constitutional Court ruling in Government of the Republic of South Africa v Grootboom 2001 (1) SA 46 (CC) to support their argument that the current NHI Bill may in fact infringe on their Section 27(1) right to access to healthcare. In Grootboom, the court ruled that “the positive rights in the Bill of Rights – those rights that entitle South Africans to services from government, such as housing, healthcare, education, etc. – are themselves also negative rights. Whilst government is expected to progressively make possible the right to healthcare, government may not hinder South Africans from themselves giving effect to this right” (Van Staden, 2019). Yet, even though government may therefore not prevent citizens from providing their own healthcare, the NHI Bill does not include an “opt-out clause”, and clause 33 relegates medical schemes to offering only “complementary cover to services not reimbursable by the Fund” (Van Staden, 2019).

Section 22: Impact on an individual’s right to freedom of trade, occupation and profession

Another area of potential conflict touched on during the roundtable is the potential impact on an individual’s right to freedom of trade, occupation and profession guaranteed in Section 22 of the Constitution. Here too the Constitutional Court has provided guidance, this time in Affordable Medicines Trust v Minister of Health 2006 (3) SA 247 (CC), where it held that “there are two components to this right: it is the right to choose a profession and the right to practice the chosen profession”. The court concluded that where a law regulating a profession has a negative impact on citizens’ choice of profession, the statute must be subjected to the rationality test. Some in civil society question whether the NHI Bill in its current form will indeed pass such a test, particularly given its lack of evidence of public purpose as well as the legislature’s failure thus far to present proper financial feasibility studies (Anonymous, 2019; Botha, 2019; Van den Heever, 2019). This is despite the state law advisor’s insistence that “the bill’s provisions connected rationally with constitutional obligations” (Gerber, 2019).

Exclusion of applicability of the Competition Act

In a similar vein, the civil society organisations Section27 and TAC have questioned the Bill’s specific exclusion of applicability of the Competition Act 89 of 1998. Excluding the NHI from the scope of the Competition Act, they believe, is not in the interest of health or of the NHI Fund (Section27 and TAC, 2019).

Section 36: Rights may only be limited to the extent that limitations are reasonable and justifiable

There is also a suggestion that the Bill may fall short of the limitations clause contained in Section 36 of the Constitution, which states that “the rights in the Bill of Rights may be limited only to the extent that the limitation is reasonable and justifiable in an open and democratic society based on human dignity, equality and freedom, taking into account all relevant factors, including … (d) the relation between the limitation and its purpose [and] (e) less restrictive means to achieve the purpose” (RSA, 1996). Proponents of this argument emphasise the lack of published evidence to prove that the NHI is indeed necessary to achieve universal access to healthcare, claiming that there are numerous other approaches that could be implemented that would be less restrictive than Section 33 of the Bill (Anonymous, 2019; Van den Heever, 2019).

Vagueness and non-specific nature of the Bill

Finally, both the initial NHI roundtable and the subsequent desktop study have found that the vagueness of many aspects of the legislation, including the costing and funding model, and the unpredictability of the legislation’s intended outcomes, may constitute sufficient grounds for a constitutional argument. In its founding provisions, the Constitution affirms that the state is founded on, among others, the value of the “supremacy of the constitution and the rule of law” (RSA, 1996). The rule of law suggests that legislation should be clear, unambiguous and provide reasonable certainty and sufficient information to enable those affected by it to respond in an informed manner. This notion was supported in the Constitutional Court ruling in Van der Walt v Metcash Trading Ltd 2002 (4) SA 317 (CC). Here, the court stated an absence of arbitrary power and unpredictability as essential elements of its understanding of the rule of law (Venter, 2011). Furthermore, in Affordable Medicines Trust, the court held that legislation should “indicate with reasonable certainty to those who are bound by it what is required of them so that they may regulate their conduct accordingly” (Constitutional Court, 2005).

3. DISCUSSION OF CONSTITUTIONALITY ISSUES AT A ROUNDTABLE OF CONSTITUTIONAL AND LEGAL EXPERTS 

An online roundtable on the constitutionality of the NHI Bill was hosted on 19 May 2020 via Google Meetup. At the start of the roundtable, participants were reminded that the aim of the discussion was to test whether the previously identified constitutionality issues have merit. Participants were also encouraged to put forth any other legal issues that may need to be considered.

The questions that participants at the roundtable had to address were: (1) whether the policy is compatible with constitutional principles; and (2) whether it will also promote the principles of the constitution. The roundtable provided a platform to facilitate robust discussion and debate and not to necessarily establish consensus. Consensus on whether concern for each of the potential constitutionality issues was warranted, was rarely achieved.

Below we discuss the various sections of the Constitution where the NHI Bill may be in conflict or infringe on rights as well as participants’ views on each of these possible areas of concern. While some sections raised no concern, with others there was clearer consensus amongst participants of the potentially problematic interaction between the NHI Bill and the Constitution. There was quite a lot of consensus about both Section 22 (right to trade, occupation and profession) and the irrationality argument with regards to NHI which has bearing on the relationship between the NHI Bill and Section 36 of the Constitution.

Potential infringement of the NHI Bill on part (a) of Section 27(1):

“Everyone has the right to have access to health care services, including reproductive health care;”

Section 27(1) of the Constitution deals with the right to health and healthcare, including reproductive healthcare. The state must provide resources to allow for progressive achievement of these rights and no one must be refused medical treatment.

While there is an obligation in terms of Section 27 to provide essential health services, this does not preclude an individual from making their own arrangements for access to healthcare. The fact that there is an obligation to provide access to essential health service implies both a positive and a negative right: the obligation to provide (positive) and also the responsibility to ensure that the obligation does not infringe on the right of people to provide for themselves. It was mentioned that as part of this obligation, it is important that the South African government does not take regressive steps in terms of healthcare provision, that is in an attempt to provide more care to some, take away care from others.

Essential health services have not been defined in either the Bill, or by the courts. The term is lacking clear definitional content. A basic benefit package has not been set out in the NHI Bill and it is therefore not possible for the Court to pronounce on whether the health services to be provided by NHI can be considered essential or not.

The major stumbling block, however, in terms of NHI is with regards to “available resources”. In NHI discussions and arguments it is generally assumed that available resources include the money spent in the private sector (4% of GDP) as well as the public sector. There’s an assumption that the equivalent private sector amount can be raised in taxes and redistributed to the whole population. This lack of definition with reference to available resources is what creates the impasse around reaching agreement on NHI between critical stakeholders. Generally there are thought to be three groups of stakeholders with regards to the resourcing of NHI: (1) those who argue ‘let’s work with the public funds available’, (2) those who say ‘let’s pool everything, both public and private resources’, (3) and stakeholders who argue for the creation of new resources through new taxes, fund raising, etcetera. Ultimately, the main mechanism to access resources in the private health sector would be the tax system. Changes to the tax system to allow for resource pooling from existing private healthcare sector expenditure would be constrained by the design of the tax system, making it difficult to match tax revenue to be collected to the full amount as currently spent on private healthcare. The lack of an NHI financing paper which stakeholders had thought would be released in parallel to the NHI Bill has not assisted with providing clarity on the likely financing mechanisms.

During the discussion it was argued that the right to health does not have definite content. The courts have generally not pronounced on resource availability in the hard sense. It will be interesting to see in which direction the positive and negative rights associated with Section 27 are weighed, that is do the negative or positive rights have a heavier weight attached to them.

The questions being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill relative to Section 27 of the Constitution have legal merit?
  • Given available case law and legal precedent, do positive or negative rights have heavier weight?

Potential infringement of the NHI Bill on Section 18:

“Everyone has the right to freedom of association.”

Section 33 of the NHI Bill (National Department of Health, 2019) currently confines the role of medical schemes (the existing private healthcare funding market) to complementary cover once NHI has been fully achieved:

“Once National Health Insurance has been fully implemented as determined by the Minister through regulations in the Gazette, medical schemes may only offer complementary cover to services not reimbursable by the Fund.”

Given that medical schemes will be limited to complementary cover only, there is potentially an infringement on the right to freedom of association. Citizens who want healthcare access will be compelled to be associated with NHI1. In this context, it was argued that having a choice in terms of a medical scheme as alternative to public or NHI healthcare is a freedom of association. The NHI policy therefore potentially violates the right to freedom of association. A few questions emerged from this debate: Is there a need to create a limitation on private funders in order to increase capacity in public health sector? And more importantly, can one choose a preferred practitioner? It is important to take note that the NHI Bill does not prohibit out-of-pocket payment for private healthcare –it is individuals right to private insurance that is limited, not the right to private care.

Legal experts argued that this line of reasoning is a tenuous one (a “tortured argument”). Section 18’s conception of the right to freedom of association relates more to the protection of liberty and protecting participatory democracy rather than choice in the market. The right of association has to do with the right to form groups with common interest, to associate with those we want to in public, etc.

In this context, one of the experts voiced the concern that there is a danger of conflating the practical difficulties of questions with the crisp details the roundtable aimed to discuss. What the roundtable discussion was meant to answer remained unclear: Is the Bill constitutional, yes or no? Nothing in the Bill states that South Africans cannot belong to a medical aid scheme once NHI is implemented – it was argued that Section 33 of the Bill is forward looking and will only limit medical schemes to complementary cover once full NHI has been achieved. A counter argument to this (also made in other discussions) is that the implications of the Bill once fully implemented, rather than simply the current implications, should be considered.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill relative to Section 18 of the Constitution have legal merit?

Potential infringement of the NHI Bill on Section 12(2)(b):

“Everyone has the right to bodily and psychological integrity, which includes the right to security in and control over their body;”

It is argued that the freedom to choose healthcare services may well be intertwined with the constitutional right to bodily and psychological integrity entrenched in Section 12(2)(b) of the Constitution. This right guarantees all people control over their own bodies.

In debating the validity of this line of argument, it was stated that we need to be cautious of adopting a consumerist view of healthcare and avoid information asymmetries such as moral hazard and adverse selection. because the patient may not always know what’s best for them. It is usual for health systems to have referral pathways, or to select contracted providers on the basis of quality of services provided. A strength of the Bill is the referral pathway and reference to the need for evidence in the way care is delivered. Who is best equipped to make the expert medical judgements? Following the line of argument around consumers needing to choose their providers potentially leads to a minefield discussion about who is best equipped to make difficult health decisions.

It was asked whether this line of argument may only become relevant in the long term. However, arguments around the envisaged endpoint of NHI need to be considered. It was argued that if the public health system is going to determine who your doctor will be and you’re not comfortable with it, then it becomes problematic (especially given that medical schemes will eventually be limited to complementary cover only). While participants noted not being able to choose your own doctor as a concern with the NHI Bill, this is already the status quo for many medical scheme products. Medical schemes also impose doctor and hospital networks. The NHI Bill also does not prohibit out-of-pocket payment for private care.

Measuring the Bill relative to this section also raises the issue of whether NHI will be a funding or a servicing mechanism. The service provision aspect of NHI may ultimately limit what is possible in this regard.

Section 8 of the NHI Bill states that if you do not follow the referral pathways set out by NHI, you need to pay for these services on an out-of-pocket basis. A question was raised about whether this could potentially be viewed as punitive and therefore undermining to the right to bodily and physical integrity. The public health sector currently follows strict referral pathways – patients are not allowed to access tertiary care without having followed appropriate referral pathways from the primary healthcare level.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill relative to Section 12(2)(b): of the Constitution have legal merit?

Potential infringement of the NHI Bill on Section 22:

“Every citizen has the right to choose their trade, occupation or profession freely. The practice of a trade, occupation or profession may be regulated by law.“

The facilitator introduced the discussion on this section by asking whether there are limitations in the Bill that prevent the right to (a) trade as a healthcare practitioner and (b) enter into the health sector. Will practitioner options to freedom of trade, occupation and profession be limited?

One set of opinions that were offered is that the answer to the above questions is very much dependent on how NHI will be implemented – there is not a problem in the legal construct but in the practical implications and implementation. If NHI rates (used for contracting with GPs and other specialists) are reasonable, it may not impact freedom of trade. Potential constitutionality issues arising with this section are rooted in execution. How will we protect the system as it stands? Does a right arise from the status quo? How do we protect current rights?

Some legal experts believed the way the Bill is currently drafted does not create any conflict with Section 22 of the Constitution. They said there is nothing in the Bill that suggests that someone who wants to be a doctor and work in the private sector can’t work there. They expressed the opinion that the Bill, as currently constituted, was written as mainly a funding bill that may have some service design implications.

There was, however, disagreement between experts. Some experts felt this particular section of the Constitution had more force with regards to the Bill than previous sections highlighted in this report. In thinking about restrictions on trade, the whole healthcare profession (not limited to the private sector) should be considered. Professions cut across both sectors and NHI may imply restrictions on the ability to trade freely and work for an employer of choice.

Again, it was recommended that the Bill should be reviewed in terms of the current situation (what is currently being proposed) and what the realisation of these proposals are likely to look like. The Bill does not set out the future details of the private sector but mainly focuses on the public sector. Which assumptions underlie what the private sector is envisaged to look like? The Bill should be more forthcoming with private sector aspects of the health sector. The lack of details on the private sector leads to varied interpretations of the Bill: in some cases it refers to the private sector or where there isn’t sufficient infrastructure it mentions purchasing and obtaining infrastructure from the private sector. It was argued that the lack of clarity around the private sector in the NHI Bill has created much uncertainty and speculation about what the future is likely to look like.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill relative to Section 22 of the Constitution have legal merit?

Potential infringement of the NHI Bill on Section 25:

The right to property

The Bill does away with a medical scheme’s ability to provide and charge for services rendered under the NHI regime through Section 33 (cited earlier). This, it is argued, may constitute an “unlawful infringement of a medical scheme’s right to property”, which is specifically prohibited by Section 25 of the Bill of Rights (Kirby, 2016).

There was consensus amongst participants that stating that the NHI infringes on the right to property is a weak argument. While the NHI Bill may revoke the right of medical schemes to render financing for comprehensive health services, there is nothing in the Bill to suggest that it will appropriate the assets of medical schemes. However, the bill is suggesting that medical schemes will no longer be able to provide to their clients base the full suite of medical scheme products. Furthermore, the state has the right to appropriate service delivery in certain areas, for example housing. This does not, however, preclude the private sector from also providing housing.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill relative to Section 25 of the Constitution have legal merit?
  • Would the diminishing of the right of medical schemes to provide products to their clients/members not imply an expropriation of assets?

Issue about the NHI Bill’s specific exclusion of applicability of the Competition Act of 1998

The NHI Bill (National Department of Health, 2019) excludes the NHI Fund and related activities from the ambit of the Competition Act:

“S3(5): The Competition Act, 1998 (Act No. 89 of 1998), is not applicable to any transactions concluded in terms of this Act.”

While participants thought this will be helpful for the functioning of the private health sector by enabling collective price bargaining, this section in the Bill needs to be made clearer. More specifically, it needs to clearly stipulate the rationale for why the exclusion is required. Participants argued that many of the problems in the healthcare sector, including the absence of proper pricing guidance, were caused by the Competition Act and the section which excludes the Bill from the Competition Act was merely intended to address this shortcoming. Roundtable participants concluded that in principle the NHI Bill’s exclusion from the ambit of the Competition Act was a non-issue.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill’s exclusion of applicability of the Competition Act have legal merit?

Potential infringement of the NHI Bill on Section 36:

“The rights in the Bill of Rights may be limited only in terms of law of general application to the extent that the limitation is reasonable and justifiable in an open and democratic society based on human dignity, equality and freedom, taking into account all relevant factors, including…”

There is a suggestion that the Bill may fall short of the limitations clause contained in Section 36 of the Constitution, which states that “the rights in the Bill of Rights may be limited only to the extent that the limitation is reasonable and justifiable in an open and democratic society based on human dignity, equality and freedom, taking into account all relevant factors, including … (d) the relation between the limitation and its purpose [and] (e) less restrictive means to achieve the purpose”.

It was mentioned that there are major concerns around the Bill’s ability to meet the requirements of rationality and being justifiable, given the potential infringements on rights. A restriction of rights needs to be clearly substantiated. How does NHI set out to achieve health systems objectives?

The limitations in this section cannot be abused. In weighing whether there are less restrictive means to achieve the purpose, limitations have to be understood relative to those in other open, democratic societies. However, ultimately the limitation clause can work in both directions – limitations to public and private sector. Rights are not absolute and can be limited/infringed.

To the extent that proposals are currently linked to dates (Chapter 9 of NHI Bill) and that the Minister can determine that the NHI is fully implemented, there are irrational elements contained in the Bill. It was argued that the implementation of NHI should be linked to clear, measurable milestones which should be referred to in the Bill (rationality argument). There was a strong opinion in the group that if a landing point cannot be found for the implementation issue, the bill can be rationally challenged.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill relative to Section 36 of the Constitution have legal merit?

General issue: Vagueness and non-specific nature of the Bill

The discussion on the Bill’s vagueness was introduced through a question on whether the Bill is so vague that it can challenge the notion of the rule of law. Is there a legal precedent that could show the way in terms of the specificity required in a bill to allow for implementation? It was agreed that there will always be an element of uncertainty. But the question still remained: What is the legal test for certainty and predictability?

Administrative law could provide a lens/solution to this question. Ultimately, the policies and implementation approaches may matter more than the law itself. For the NHI project to be successful, concerns about the vagueness of the law, and therefore potentially also the vagueness of supporting implementation policy, have to be internalised to the system (Section 33, Rights of Just Administrative Action). There are standards to this, but their application makes a huge difference.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about the NHI Bill’s vagueness and non-specific nature have legal merit?

Emerging issue: Intergovernmental relations in the Bill

A further area of concern with the Bill is that it does not clearly deal with the issue of inter-governmental relations; in particular, with provincial competence and the split in service delivery responsibilities between the various levels of government – national, provincial and municipal. It is not clear what the immediate implications are.

The most relevant Section of the NHI Bill (National Department of Health, 2019) is in Section 32:

S32(2) Subject to the transitional provisions provided for in section 57, the Minister may introduce in Parliament proposed amendments to the National Health Act for the purpose of centralising the funding of health care services as required by this Act, and in such cases the Minister may—

(a) delegate to provinces as management agents, for the purposes of provision of health care services, and in those cases the Fund must contract with sections within the province such as provincial tertiary, regional and emergency medical services;” This type of intervention into a distributed function will have real implications for constitutionally allocated responsibilities, specifically also around procurement (Section 217).

During the discussion, it was mentioned that at NEDLAC the NHI discussion is that, in principle, funding following function. Amendments will have to be made to the National Health Act to change the provincial functions. The idea is that government will amend inter-governmental responsibilities in the Health Act. The Department of Health is arguing that the level at which services are delivered does not have to be re-specified in the Constitution itself if it be amended in the National Health Act. However, this will depend on whether the National Health Act is itself constitutional.

Ultimately, concerns around inter-governmental relations at the level of service delivery respond to the issue of whether the Bill is primarily focused on financing, service delivery or both. While NHI is presented as a financing model, the Bill goes much further and has significant implications for health service delivery.

The question(s) being posed to Counsel from this section include:

  • Given the information presented on the NHI Bill in this section and from the roundtable report (earlier section), do concerns about how the NHI Bill deals with inter-provincial relations have legal merit?

4. REQUEST FOR LEGAL CLARIFICATION 

We end this brief with a request for legal clarification on the above potential constitutional and legal issues raised by the NHI Bill. In particular, this is a brief for interested and concerned Senior Counsel to provide opinions on the issues and questioned raised in this document.

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1: There are parallels to this in other parts of the economy: the formally employed are compelled to contribute to the Unemployment Insurance Fund (UIF) and via fuel levies to the Road Accident Fund (RAF). This does not, however, preclude individuals from taking out private insurance for the same risks covered by these public funds. 

This Report has been published by the Inclusive Society Institute.

The Inclusive Society Institute (ISI) is an autonomous and independent institution that functions separately from any other entity. It is founded for the purpose of supporting and further deepening multi-party democracy.

The ISI’s work is motivated by its desire to achieve non-racialism, non-sexism, social justice and cohesion, economic development and equality in South Africa, through a value system that embodies the social and national democratic principles associated with a developmental state. It recognises that a well-functioning democracy requires well-functioning political formations that are suitably equipped and capacitated. It further acknowledges that South Africa is inextricably linked to the ever transforming and interdependent global world, which necessitates international and multilateral cooperation. As such, the ISI also seeks to achieve its ideals at a global level through cooperation with like-minded parties and organs of civil society who share its basic values.

Whilst the institute undertakes research through the lens of social and national democratic values and principles, it is pragmatic, not dogmatic, in its approach.

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