MHM Magazine

2 | MENTAL HEALTH MATTERS | 2023 | Issue 4 MHM the NHI Bill. We echo concerns raised by other key stakeholders, like the South African Medical Association and the Hospital Association of South Africa. This includes: 1. The Portfolio Committee for Health passing the bill without any changes or with only minor amendments, thereby largely rejecting the public’s concerns 2. The poor track record of our state’s duty bearers for policy implementation, accountability, and good governance. Government is trying to assure us that the NHI will be a Schedule 3 Public Entity and so will operate as a ‘reputable entity’, unlike Eskom, which is a Schedule 2 Entity. As a reminder, the National Lottery Commission and Unemployment Insurance Scheme are also Schedule 3 Public Entities. These are just two of many Schedule 3 Public Entities that have been riddled with looting, corruption and mismanagement, with negligible, meaningful consequences for offenders (see here, here and here). The NHI being a Schedule 3 Public Entity does not equate to implementation, accountability, and good governance. 3. The lack of clarity about what the government is actively doing right now to address the myriad of issues already facing health systems, including poor service delivery. Former Health Ombudsman Professor Malegapuru Makgoba, described our health system as a ‘dysfunctional mess’. What is the government currently doing to remedy this so that the NHI – funded by taxpayers – will be founded on and build on a functional public sector; one that inspires trust from the public and delivers quality services to all. We have mental health specific concerns: 1. The conditional grant budget line item for mental health needs to be revisited (pg. 58; 8.7). This amount is not congruent with the proposed recommendations from a Mental Health Investment Case Report done in 2021 to sufficiently strengthen mental health services and integration. An adequate conditional grant for mental health is necessary to correct the injustices of the past regarding mental health service allocation and investing in scaling up mental health care in the country. 2. There is no commitment to an explicit priority setting exercise for the NHI packages of care. Currently, the Bill states the Health Minister will ultimately determine health care benefits that will be reimbursed through the NHI Fund, as well as the service coverage. This is a serious concern. If the Minister does not see value in quality mental health services, would this mean no coverage? Furthermore, what if, for example, an outgoing Health Minister saw value in mental health and prioritised it adequately, but an incoming one has a drastically different view? Such decisions cannot be made subjectively by a single person. We advocate that the decisions related to the amounts and types of resources to be made available, eligible populations, and specific rules for allocation are informed by an economic analysis to maximise value and achieve social goals. We recommend that the Department of Health and the Portfolio Committee for Health establish a process with key stakeholders, including persons with mental health conditions, where they review and interrogate these packages and the potential benefits, placing equal consideration on both the burden and disability imposed by diagnosable mental illnesses, our human rights obligations and the socio- demographic conditions which place particular groups at heightened risk of deterioration in their mental health, in and across the country. 3. We are unsure what approach will be used to inform priority setting. We advocate that any priority setting should be informed by a needs- based approach rather than a current service use approach. Considerations around burden of disease, our human rights obligations and treatment gaps should drive the prioritisation of health services and associated budgets. These metrics alone provide good evidence for investing in mental health care. WHAT DOES THIS ALL MEAN? We want to see the right to health – including mental health – realised for all in South Africa. This means supporting UHC. To achieve UHC we need enabling national laws, policies, planning and regulatory frameworks, monitoring mechanisms and dedicated budgets. Mental health services must be integrated into all the aforementioned areas, including in the basic package of essential services. However, our concerns with NHI Bill remain, as outlined above. While debates around the NHI will continue and perhaps even intensify in the lead up to the 2024 elections, this should not stunt the immediate implementation of known, uncontroversial rights-based and evidence-based actions desperately needed to improve health system performance. We continue to advocate for evidence-based, cost-effective mental health services, like those outlined in the Mental Health Policy Framework, which can be implemented today to improve the mental wellbeing of all in South Africa.  There is currently a call for written submissions and enquiries about the NHI Bill with the deadline for the 15th September. If you would like to raise your concerns or voice your opinion, please make a submission at the link: National Health Insurance (NHI) Bill | PMG ( https://pmg.org.za/call-for- comment/1334/ ) References available on request.