Notice: Data extracts from NHI Bill

This page lists selected extracts related to data, information, transparency and M&E related to the National Health Insurance (NHI) Bill tabled in August 2019.

CHAPTER 2: ACCESS TO HEALTH CARE SERVICES

Population coverage

(4) A person seeking health care services from an accredited health care service provider or health establishment must be registered as a user of the Fund as provided for in section 5, and must present proof of such registration to the health care service provider or health establishment in order to secure the health care service benefits to which he or she is entitled.

Registration as users

(1) A person who is eligible to receive health care services in accordance with section 4 must register as a user with the Fund at an accredited health care service provider or health establishment.

(5) When applying for registration as a user, the person concerned must provide his or her biometrics and such other information as may be prescribed, including fingerprints, photographs, proof of habitual place of residence and—

(a) an identity card as defined in the Identification Act, 1997 (Act No. 68 of 1997);

(b) an original birth certificate; or

(c) a refugee identity card issued in terms of the Refugees Act.

(7) Unaccredited health establishments whose particulars are published by the Minister in the Gazette must, on behalf of the Fund, maintain a register of all users containing such details as may be prescribed.

(8) A user seeking health care services purchased for his or her benefit by the Fund from an accredited health care service provider or health establishment must present proof of registration to that health care service provider or health establishment when seeking those health care services.

Rights of users

6. Without derogating from any other right or entitlement granted under this Act or under any other law, a user of health care services purchased by the Fund is entitled, within the State’s available and appropriated resources—

(b) to information relating to the Fund and health care service benefits available to users;

(c) to access any information or records relating to his or her health kept by the Fund, as provided for in the Promotion of Access to Information Act, in order to exercise or protect his or her rights;

(m) to the protection of his or her rights to privacy and confidentiality, in accordance with the Protection of Personal Information Act, 2013 (Act No. 4 of 2013), in so far as he or she must grant written approval for the disclosure of personal information in the possession of or accessible to the Fund, unless the information—

(i) is shared among health care service providers for the lawful purpose of serving the interests of users; or

(ii) is utilised by the Fund for any other lawful purpose related or incidental to the functions of the Fund;

(n) to have access to information on the funding of health care services in the Republic;

Health care services coverage

(d) a user— (i) must first access health care services at a primary health care level as the entry into the health system; (ii) must adhere to the referral pathways prescribed for health care service providers or health establishments; and (iii) is not entitled to health care services purchased by the Fund if he or she fails to adhere to the prescribed referral pathways;

CHAPTER 3: NATIONAL HEALTH INSURANCE FUND

Functions of Fund

(1) To achieve the purpose of this Act, the Fund must—

(b) pool the allocated resources in order to actively purchase and procure health care services, medicines, health goods and health related products from health care service providers, health establishments and suppliers that are certified and accredited in accordance with the provisions of this Act, the National Health Act and the Public Finance Management Act;

(g) determine payment rates annually for health care service providers, health establishments and suppliers in the prescribed manner and in accordance with the provisions of this Act;

(i) collate utilisation data and implement information management systems to assist in monitoring the quality and standard of health care services, medicines, health goods and health related products purchased by the Fund;

(j) develop and maintain a service and performance profile of all accredited and contracted health care service providers, health establishments and suppliers;

(k) ensure that health care service providers, health establishments and suppliers are paid in accordance with the quality and value of the service provided at every level of care;

(l) monitor the registration, license or accreditation status, as the case may be, of health care service providers, health establishments and suppliers;

(m) account to the Minister on the performance of its functions and the exercise of its powers;

(n) undertake internal audit and risk management;

(o) undertake research, monitoring and evaluation of the impact of the Fund on national health outcomes;

(p) liaise and exchange information with the Department, statutory professional councils, other government departments and organs of state as and when appropriate or necessary in order to achieve the purpose outlined in section 2;

(q) maintain a national database on the demographic and epidemiological profile of the population;

Powers of Fund

(1) In order to achieve the purpose of the Act and to perform the functions outlined in section 10, the Fund may—

(i) identify, develop, promote and facilitate the implementation of best practices in respect of—

(iv) receiving and collate all required data from providers for the efficient running of the Fund;

(j) undertake or sponsor health research and appropriate programmes or projects designed to facilitate universal access to health care services;

(l) obtain from, or exchange information with, any other public entity or organ of state;

CHAPTER 4: BOARD OF FUND

Constitution and composition of Board

(2) Before the Board members contemplated in subsection (1) are appointed, the Minister must issue in the Gazette a call for the public nomination of candidates to serve on the Board.

(3) An ad hoc advisory panel appointed by the Minister must—

(a) conduct public interviews of shortlisted candidates; and

(b) forward their recommendations to the Minister for approval.

(4) The Minister must, within 30 days from the date of confirmation of the appointment of a Board member, give notice of the appointment in the Gazette.

(5) A Board member is appointed for a term not exceeding five years, which is renewable only once, and must—

(e) not have any personal or professional interest in the Fund or the health sector that would interfere with the performance in good faith of his or her duties as a Board member.

CHAPTER 5: CHIEF EXECUTIVE OFFICER

(3) The Minister must, within 30 days from the date of appointment of the Chief Executive Officer, notify Parliament of the final appointment and give notice of the appointment in the Gazette.

Responsibilities

20. (1) The Chief Executive Officer as administrative head of the Fund—

(d) must report to the Board on a quarterly basis and to Parliament on an annual basis.

(3) Subject to the direction of the Board, the Chief Executive Officer must establish the following units in order to ensure the efficient and effective functioning of the Fund:

(h) Performance Monitoring;

(5) The Chief Executive Officer must submit to the Board an annual report of the activities of the Fund during a financial year as outlined in section 51

CHAPTER 7: ADVISORY COMMITTEES ESTABLISHED BY MINISTER

Disclosure of interests

28. A member of a committee established by the Minister in terms of this Act who has a personal or financial interest in any matter on which such committee gives advice, must disclose that interest when that matter is discussed and be recused during the discussion.

CHAPTER 8: GENERAL PROVISIONS APPLICABLE TO OPERATION OF FUND

Role of Department

32. (1) The functions of the Department are outlined in the National Health Act and the Constitution, and include—

(a) issuing and promoting guidelines for norms and standards related to health matters;

National Health Information System

34. (1) The Fund must contribute to the development and maintenance of the national health information system as contemplated in section 74 of the National Health Act through the Information Platform established in terms of section 40.

(2) Subject to the provisions of the National Archives and Record Services of South Africa, 1996 (Act No. 43 of 1996), the Protection of Personal Information Act, 2013 (Act No. 4 of 2013), and the Promotion of Access to Information Act, data must be accurate and accessible to the Department and the Fund, or to any other stakeholder legally entitled to such information.

(3) Health workers, health care service providers and persons in charge of health establishments must comply with the provisions in the National Health Act relating to access to health records and the protection of health records.

Contracting Unit for Primary Health Care

(2) A Contracting Unit for Primary Health Care must be comprised of a district hospital, clinics or community health centres and ward-based outreach teams and private providers organised in horizontal networks within a specified geographical sub-district area, and must assist the Fund to—

(a) identify health care service needs in terms of the demographic and epidemiological profile of a particular sub-district;

(b) identify accredited public and private health care service providers at primary care facilities;

(e) access information on the disease profile in a particular sub-district that would inform the design of the health care service benefits for that sub-district;

Office of Health Products Procurement

(3) The Office of Health Products Procurement must—

(a) determine the selection of health related products to be procured;

(b) develop a national health products list;

(g) establish mechanisms to monitor and evaluate the risks inherent in the public procurement process;

(4) The Office of Health Products Procurement must support the Benefits Advisory Committee in the development and maintenance of the Formulary, comprised of the Essential Medicine List and Essential Equipment List as well as a list of health related products used in the delivery of health care services as approved by the Minister in consultation with the National Health Council and the Fund.

(5) The Office of Health Products Procurement must support the review of the Formulary annually, or more regularly if required, to take into account changes in the burden of disease, product availability, price changes and disease management for approval by the Minister.

(6) An accredited health care service provider and health establishment must procure according to the Formulary, and suppliers listed in the Formulary must deliver directly to the accredited and contracted health service provider and health establishment.

Accreditation of service providers

(2) In order to be accredited by the Fund, a health care service provider or health establishment, as the case may be, must—

(a) be in possession of and produce proof of certification by the Office of Health Standards Compliance and proof of registration by a recognised statutory health professional council, as the case may be

(b) meet the needs of users and ensure service provider compliance with prescribed specific performance criteria, including the—

(v) submission of information to the national health information system to ensure portability and continuity of health care services in the Republic and performance monitoring and evaluation;

(5) In order to be accredited and reimbursed by the Fund, a health care service provider or health establishment must submit information to the Fund for recording on the Health Patient Registration System, including—

(a) national identity number or permit and visa details issued by the Department of Home Affairs, as the case may be;

(b) diagnosis and procedure codes using the prescribed coding systems;

(c) details of treatment administered including medicines dispensed and equipment used;

(d) diagnostic tests ordered;

(e) length of stay of an inpatient in a hospital facility;

(f) facility to which a user is referred if relevant;

(g) reasons for non-provision or rationing of treatment, if any; and

(h) any other information deemed necessary by the Minister in consultation with the Fund for the monitoring and evaluation of national health outcomes.

(6) The performance of an accredited health care service provider or health establishment must be monitored and evaluated in accordance with this Act and appropriate sanctions must be applied where there is deviation from contractual obligations as per the law.

(11) The Fund may issue directives relating to the listing and publication of accredited health care service providers and health establishments.

Information platform of Fund

(1) The Fund must establish an information platform to enable it to make informed decisions on population health needs assessment, financing, purchasing, patient registration, service provider contracting and reimbursement, utilisation patterns, performance management, setting the parameters for the procurement of health goods, and fraud and risk management.

(2) Health care service providers and health establishments must submit such information as may be prescribed to the Fund, taking into consideration the provisions of the Protection of Personal Information Act, 2013 (Act No. 4 of 2013).

(3) The information in subsection (2) may be used by the Fund to—

(a) monitor health care service utilisation and expenditure patterns relative to plans and budgets;

(b) plan and budget for the purchasing of quality personal health care services based on need;

(c) monitor adherence to standard treatment guidelines, including prescribing from the Formulary;

(d) monitor the appropriateness and effectiveness of referral networks prescribed by health care service providers and health establishments;

(e) provide an overall assessment of the performance of health care service providers, health establishments and suppliers; and

(f) determine the payment mechanisms and rates for personal health care services.

(4) Information concerning a user, including information relating to his or her health status, treatment or stay in a health establishment is confidential and no third party may disclose information contemplated in subsection (2), unless—

(a) the user consents to such disclosure in writing;

(b) the information is shared among health care service providers for the lawful purpose of serving the interests of users;

(c) the information is required by an accredited health care service provider, health establishment, supplier or researchers for the lawful purpose of improving health care practices and policy, but not for commercial purposes;

(d) the information is utilised by the Fund for any other lawful purpose related to the efficient and effective functioning of the Fund;

(e) a court order or any law requires such disclosure; or

(f) failure to disclosure the information represents a serious threat to public health.

(5) The information architecture must include a fraud and risk management mechanism.

(6) In order to fulfil the requirements for dissemination of information and the keeping of records, the information platform must facilitate—

(a) the implementation of the objects and the effective management of the Fund; and

(b) portability and continuity of health care services available to users subject to the provisions of this Act.

CHAPTER 10: FINANCIAL MATTERS

Auditing

50. The Auditor-General must audit the accounts and financial records of the Fund annually as outlined in the Public Audit Act, 2004 (Act No. 25 of 2004).

Annual reports

51. (1) As the accounting authority of the Fund, the Board must submit to the Minister and Parliament a report on the activities of the Fund during a financial year as determined by the Public Finance Management Act.

Protection of confidential information

53. Nothing in this Act affects the provisions in any other legislation or law prohibiting or regulating disclosure of personal or other sensitive information accessible to or in possession of the Fund.

Offences and penalties

(1) Any person who—

(e) sells or otherwise discloses information owned by the Fund to a third party without the prior knowledge and written consent of the Fund, is guilty of an offence and liable on conviction in a court of law to a fine not exceeding R100 000.00 or imprisonment for a period not exceeding five years or to both a fine and such imprisonment.

Regulations

55. (1) Without derogating from the powers conferred on the Minister by the Constitution and the National Health Act or any other applicable law, the Minister may, after consultation with the Fund and the National Health Council contemplated in section 22 of the National Health Act, make regulations regarding—

(d) information to be provided to the Fund for the development and maintenance of the national health information system by users, health establishments, health care service providers or suppliers and the format in which such information must be provided;

(e) clinical information and diagnostic and procedure codes to be submitted and used by health care service providers, health establishments or suppliers for reimbursement and reporting purposes to the Fund;

(f) participation by the fund in the national health information system contemplated in section 74 of the National Health Act, including the Health Patient Registration System referred to in section 39;

(g) the registration of users of the Fund in terms of section 5;

(h) the accreditation of health care service providers, health establishments or suppliers;

Transitional arrangements

(4) Objectives that must be achieved in Phase 1 include—

(d) the development of a Health Patient Registration System contemplated in section 5;

(e) the process for the accreditation of health care service providers, which must require that health establishments are inspected and certified by the Office of Health Standards Compliance, health professionals are licensed by their respective statutory bodies and health care service providers comply with criteria for accreditation;