National Health Bill: deliberations

Meeting report

HEALTH PORTFOLIO COMMITTEE
25 August, 2003
NATIONAL HEALTH BILL: DELIBERATIONS

Chairperson: Mr L V Ngculu (ANC)

Documents Handed In:
Summary of all submissions(document waited)
National Health Bill [B32-2003]

SUMMARY
The Health Portfolio Committee deliberated on the amendments suggested previously by the members of the public and various organizations. Some of the aspects that raised a lively discussion included the eligibility for free health services in public health establishments, emergency treatment, consent of user policy and the discharge reports.


MINUTES
National Health Bill [B32-2003]
The Chairperson said that after two days of hearing the different submissions from various presenters it was time to deliberate on the issues raised. He advised the members to take the submitted suggestion under serious consideration when working on the substance of the National Health Bill [B32-2003].

Dr Jassat (ANC) suggested adding words "establish a health system based on decentralized management, principles of equity, efficiency and sound governance" in the section immediately above the preamble.

Preamble
Mrs. S Kalyan (DA) asked to find a better definition of the term "available resources".

Chairperson said to flag "available resources" for further consideration.

Dr Cachalia (ANC) said to insert a word "quality" in front of "health policy" in section "And in order to" of the preamble, bullet 2, and also to insert "equity and efficiency" before "sound governance" under bullet 3 of the same section.

Definitions
"essential health services"
Dr Jassat asked to add a definition of "essential health services". It should read: those services as prescribed by the Minister after consultation with the National Health Council.

The new definition has been accepted.

"basic health care services"
Mrs Kalyan proposed to add this new definition.

The Committee decided not to define that term.

"health care provider"
Mrs Kalyan suggested changing from "a person providing health services in terms of any law" to "a person who operates in terms of any law".

"health worker"
Dr Chetty suggested to change the definition from "a person who provides" to "a person involved in the provision" to make the meaning wider to capture everybody else.

Dr Luthuli (ANC) proposed the same amendment as did Dr Chetty.

Mrs Kalyan's suggestion was to read: people who are providing health services but who are regulated by statutory health professional councils.

Dr Cachalia suggested to instead use the word "health establishment" in order to encompass everybody.

Dr Gous suggested the following: a person who is involved in the process of providing.

Dr Jassat proposed a change from health workers to "health assistants" or "associates" not to confuse them with the providing team.

"informed consent"
Mrs Kalyan suggested adding this new term in reference to children and minors.

Mr Hoon (State Law Adviser) said that the exhibition was used in chapter 2, clause 7, subsection 2 and that it was spelled out in clause 6. It is not used in other parts of the Bill.

"municipal health services"
Dr Cachalia suggested removing "(j) noise control" because it was not a health hazard.

Ms Peurmain said that the suggestion was appropriate as the "noise control" was in fact governed by municipalities.

The Chairperson decided that "(j) noise control" should be retained.

Dr Nel asked whether "(e) communicable disease control" include malaria?

Dr Chetty pointed out that proviso after "(j) noise control" excludes malaria.

"person"
Dr Jassat asked to add this new definition.

His suggestion was turned down.

"primary health care"
Dr Jassat asked to add this new definition that would mean "primary health care service as prescribed", so that it would be more clearly defined.

The Chairperson agreed.

"emergency"
Dr Gous asked to add this new definition due to its subjective meaning.

Ms Peurmain suggested defining emergency in medical terms not to confuse it with the constitutional term. It should be stated according to the professional judgement of a health care provider. The problem was to make sure that not to define the term too narrowly (limiting people's rights) or too widely (inducing cost implications).

"life threatening"
Dr Jassat asked to add this new definition to include it in the definition of an emergency and to make it more clear.

The Chairperson asked the state advisers to come up with their own proposals of these two definitions.

"perverse incentives"
Mrs Kalyan asked to add this new definition as it has been giving the medical profession a bad name. It could be guiding in cases of complaints especially in the presence of two health care sectors: private and public.

Ms Peurmain said that there was a document being prepared by the Health Provisions Council called Multiprofessional Peer Review Committee. The problem that was encountered during the process was that the more precise the definition got, the more holes were found in the definition. She cautioned about the risk of missing some points. Consequently she suggested not defining it.

The Chairperson decided to flag it.

"private health establishment"
Mrs Kalyan asked for clarification of that definition. She suggested differentiating between private establishments operating for profit and the ones operating not for profit. Then the two would operate on different principles.


Chapter 1: Objects of Act, Responsibility for Health and Eligibility for Free Health Services
Clause 2: Objects of Act

Dr Luthuli asked to insert "in an equitable manner" between "provides" and "the population of the Republic…", in 2(a)(ii).

The Chairperson agreed.

Dr Luthuli also asked to insert "protecting" at the beginning of section 2(c).

The Chairperson agreed.

Dr Luthuli asked to delete "within available resources" at the end of section 2(c)(i).

The Chairperson agreed.

Dr Luthuli asked to insert subsection (iv) into section 2(c) that would read: "vulnerable groups such as women, children, older persons and persons with disabilities".

The Chairperson agreed.

Clause 3: Responsibility for health
Dr Cachalia asked to insert "consisting at least of primary health services" after "3(1)(d) ensure the provision of such essential health services".

Mrs Kalyan asked if the Bill would show the difference between basic and primary health services?

The Chairperson said that the minimum expected from the Minister would be to ensure "primary" and not "basic" health services.

Mrs Kalyan said that the primary health care services were prescribed by the Minister.

Mrs Dudley proposed an inclusion of sub-clause "(1)(f) promotion and development of the private health sector as an equal partner in the social economic development plan of the Republic as well as the policies and measures needs to protect promoting improvement and maintain the well being of the population".

The Chairperson asked whether the promotion of the private sector was the responsibility of the government? Must the Minister within the available resources address promotion of the private sector?

Dr Luthuli said that the private sector tends to be left out and hence the Minister should be concerned with the private sector as well, because their work does affect the nation. It should come in when appropriate.

The Chairperson agreed to Mrs Dudley's suggestion.

Dr Cachalia suggested inserting a word "equitably" at the beginning of subsection (1)(e) and to exclude "and available resources" at the end of the sentence.

The Chairperson agreed.

Mrs Kalyan suggested erasing "taking into consideration health needs and available resources"

The Chairperson agreed.

Dr Cachalia asked to insert "equitably" between "must" and "provide" in subsection (2)

The Chairperson agreed.

Clause 4: Eligibility for free health services in public health establishments
Dr Jassat asked to add "and vulnerable groups such as women, children, older persons and persons with disabilities" at the end of the subsection (2)(c).

The Chairperson agreed.

Mrs Kalyan suggested to create a category of all vulnerable groups that would include pregnant women as they too are entitled to free health services. She also asked to consider including all children receiving child support grant as the grant is to be extended over the phase of 3 years to include not only children under the age of 6, but also children up the age of 14 years old.

The Chairperson said that the current policy already includes pregnant women in the vulnerable group.

The Chairperson said that he was not sure whether all those receiving child support grant must be incorporated as the policy progresses to include children under 14. There is a possibility that over time it might extend to 18 years.

Mrs Kalyan said that that the clause should state all children who receive child support grant, and the age limit would extend progressively over the years to include children up to the age of 14. She also said that pregnant women are not included in the vulnerable group.

The Chairperson supported the suggestion to include pregnant women and the disabled.

Dr Jassat said that pregnant women are already covered in subclause (2)(b). He suggested not specifying.

The Chairperson decided not to edit the clause by including the phasing in of the age of children, as the policy keeps on changing and new categories emerge and in effect the Bill would require constant amendments. This aspect would be left to the regulations.

Chapter 2: Rights and Duties of Users and Health Care Providers
Clause 5: Emergency treatment

Mrs Dudley suggested defining the term "health care provider" more specifically as those people might feel vulnerable due to the fact that they might to be expected to give unreasonable emergency treatment when if fact they are outside of the establishment.

Ms Peurmain said that it might be better to leave the subject of emergency medical treatment to the regulations.

Mrs Kalyan suggested to specify what exactly falls within the ambit of a health care provider health care worker.

The chairperson said that the terms "health care provider", "health establishment" and "health worker" were defined with some specific limitations. The question of ambulance services was not specifically mentioned in public or private sector. It remained unclear who was obliged to provide emergency medical treatment. The formulation of clause 5 left a lot of gaps and must be redrafted.

Clause 6: User to have full knowledge
Mrs Kalyan suggested an amendment to subsection (d). She wanted to add at the end "provided that the user is made aware of the consequences of refusal".

Mrs Dudley suggested to add at the end of subsection (d) "in terms of law".

Mrs Baloyi said that it must also take into account "the consequences, implications, risk, and obligations".

The Chairperson suggested that all points (a)-(d) be placed under a newly created subclause (1) and to add subclause (2) that would read: Care must be taken to ensure that information is within the appropriate linguistic and cultural aspects".

Mrs Kalyan supported that proposal under a condition that "wherever it is possible" was added at the end of the sentence.

The Chairperson asked the state advisers to draft a proper proposal of the above amendment.

Clause 7: Consent of user
Dr Nel inquired on subclause (1)(a), that "if a person is not able to give informed consent either in writing or orally, how would he be able to mandate the person in writing to grant consent on his behalf?" He then questioned the necessity of inclusion of that clause.

Ms Peurmain explained that if a person required assistance with drafting such a document he could ask a social worker or a layer for help. There had to be a facilitator or a mediator present. It is required by law that the evidence of a transfer of authority is prepared in writing.

Dr Nel said that subclause (1)(a)(ii) solved the problem of giving consent by a person who cannot write.

Ms Peurmain said that court orders are very expensive for the relatives of elderly people. Also, the law does not automatically allow someone to give consent to another person particularly in the private sector.
That was the reason for inserting that particular provision. The goal was to assist people who are dealing with the elderly or those who do not have a mental capacity or access to the court system due to their poor financial standing.

The Chairperson said that there must be some other legally recognized forms of consent other than in writing.

Ms Peurmain said that unless there was a record of a consent such as a tape recording, there was no way to prove that the consent was given. It is a logistical problem.

Mr Hoon said that there was no need to change the current formulation of the subclause.

The Chairperson decided to retain it.

Mrs Baloyi suggested to add subclause "(1)(f) the providers will take all reasonable and appropriate steps to obtain the users consent".

The Chairperson agreed.

Mrs Kalyan asked for clarification of the term "informed consent" under subclause (2) in terms of the definition and in terms of a person with legal capacity to do so. There is a different definition of a child and of the consent need from a parent acting on its behalf in the Child Care Act. In case of termination of pregnancy there are different limits to a child consenting by herself to have the procedure. If a user is the parent acting on behalf of the child, and the child wants to have the procedure, and the parent disagrees, what implication does that bring?

The Chairperson said that the subsection (2) successfully attempted to explain the term "informed consent". Any case was subject either to that law or the court order.

Clause 10: Discharge reports
Dr Luthuli proposed to divide that clause into three subsections. (1) would include the current provision "A health care provider must provide a user with a discharge report at the time of a discharge of the user an inpatient from a health establishment containing such information as may be prescribed". The additional two would read: "(2) In prescribing the information referred to in subsection (1) the Minister must at least help in regard to (a) the nature of the health service that has been rendered, (b) the prognosis for the user, (c) the need for follow up treatment. (3) A discharge report provided to a user may be viable in the case of outpatients and other users who are not inpatients, but when an inpatient is discharged, the discharge report must be in writing".

Dr Gous asked the representatives of the Department to explain what would the regulation on such a discharge be and why?

Dr Chetty said that previous versions of the clause did not contain much details on that subject. She said that patients were often discharged without receiving the proper information about their health condition and of the necessary treatment. The purpose of the clause was to make sure that that information was in fact provided to the patient. It also allowed for easy referrals between institutions.

Dr Cachalia suggested exclusion the word "inpatient" from the clause.

Dr Gous suggested keeping the word "inpatient" and addition the following phrase "unless a person asks for such a report".

Dr Gous said that it was unclear whether a health care provider would be a private doctor in a private institution or the institution itself. Is it a doctor that signs a discharge and the institution must provide the information or vice versa?

The Chairperson said that the Minister should not be involved in the process proposed in the amendment given by Dr Luthuli.

Ms Peurmain said that the proposed subclause (1) required the Minister to prescribe the minimum information that must be included in the discharge report. It guides the Minister and gives an idea of an intention of a discharge report.

The Chairperson endorsed Dr Luthuli's proposal on section 10 and added "as requested by the patient".

Clause 12: Duty to disseminate information
Dr Rhoda proposed to add "appropriate" before "adequate" and "that is culturally and linguistically accessible" after "information", in the first sentence.

Mrs Kalyan supported the addition of the word "appropriate" but did not agree with the proposed addition of the phrase "that is culturally and linguistically accessible".

The Chairperson decided to follow Mrs Kalyan's suggestion and only endorsed the addition of the word "appropriate".


The meeting was paused for lunch.