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Eyewitness News
6 days ago
- Health
- Eyewitness News
MPs question Motsoaledi spending R9 million to hire 12 counsel to defend NHI
JOHANNESBURG - Members of Parliament (MPs) have questioned Minister of Health Aaron Motsoaledi over the hiring of 12 counsel at a cost of R9 million to defend the National Health Insurance (NHI). But Motsoaledi has defended the expenditure, saying litigation comes at a high cost and the department needs the expertise of senior counsel as it defends its flagship universal healthcare policy. The minister was briefing the National Assembly as part of the social cluster in Parliament on Wednesday. Motsoaledi said his department is facing several lawsuits challenging the NHI as well as the National Health Act. He justified the expenditure, saying litigation in its nature is costly to defend. Some of the organisations taking the department to court include the South African Medical Association (SAMA) and the Board of Healthcare Funders (BHF). "Those who have been involved in litigation will know how expensive senior counsel is. It's not us. So, it's seven cases, seven junior counsel, and five senior counsel." President Cyril Ramaphosa is also facing his own NHI-related legal challenge after the court ruled that his decision to sign the act was reviewable, ordering him to provide the record of his decision. He is appealing the ruling.
Daily Maverick
11-05-2025
- Health
- Daily Maverick
Changes to overtime pay causes Gauteng state doctors to gear up for health department fight
Trade unions, medical associations and universities are raising the alarm that Gauteng budget cuts at the cost of doctors' take-home pay will have dire consequences for public sector health. Meanwhile, the National Minister of Health has convened a committee to review the future of overtime for state doctors. Dysfunction in the Gauteng Department of Health hit home hard for many public sector doctors on 29 April when their overtime payments due for the month went unpaid. The non-payment came without notice and affected medical staff in facilities across the province, according to the South African Medical Association (SAMA). Only by Tuesday, 6 May did some doctors start to see payments reflect in their bank accounts. More payments are expected soon, given that, according to the Basic Conditions of Employment Act, the employer has seven days to settle, said SAMA. As a fixed amount, commuted overtime is predictable supplemental income and for many doctors, it amounts to about a third of their take-home pay. But tensions are rising as this payment blunder follows a protracted row over the department's unilateral decision to cut and change the terms of commuted overtime in the province. Proposals to cut down on commuted overtime come in the light of a very tight provincial health budget. As with most other provincial health departments, Gauteng's health budget has been shrinking in real terms for several years. Threats of protests and legal action The delayed payments and the ongoing review of cuts and changes to commuted overtime pay has led to threats of protests and legal action. SAMA says they will make civil claims for salaries owed, including for interest and legal costs. Registrars and medical officers at Dr George Mukhari Academic Hospital in Ga-Rankuwa collectively wrote to the hospital giving notice of withdrawal of overtime services until the non-payment issue is completely resolved. By 7 May, the head of anaesthesiology at Sefako Makgatho Health Sciences University wrote to the CEO of George Mukhari, informing him that no anaesthesia services would take place at the hospital starting Thursday, 8 May, given the decision by registrars and medical officers to down tools outside of regular work hours. Those that Spotlight spoke to from the medical fraternity have set out a series of concerns. These include resignations; an exodus of doctors, especially specialists from the public sector; plummeting staff morale; negative impacts on the training of doctors as fewer consultants and seniors are available to supervise — which then puts universities' training accreditations at risk. Ultimately, several sources point out, it is the services offered to the public that suffer. Committee appointed By the beginning of April, there appeared to be some walking back by the Gauteng health department of its unilateral cutback proposals after meeting with the South African Medical Association Trade Union (SAMATU). In the same week, a circular was issued announcing that the national health department was conducting a review of its own, instructing provinces to hold off on their plans. Health Minister Dr Aaron Motsoaledi then set up a committee of experts to review certain human resource policies in the public healthcare sector. This includes a review of community service, commuted overtime, remunerative work outside the public service for health professionals, and rural and related allowances. Commuted overtime is a pre-determined amount of overtime that doctors employed by provincial health departments are allowed to work. The amount is historically decided by hospital management and is based on an employee's role, seniority, the department they work in and the amount of overtime they are allowed to safely work. It's a fixed rate of 1.3 times the applicable hourly tariff for a specific work grade. There are five contract options. A is no overtime worked; B is overtime of between four and eight hours a week; C is overtime between nine and 12 hours a week; D is overtime between 13 and 20 hours per week; and an option E is where, on approval, a doctor can be authorised to work more than 20 hours of overtime a week. As a fixed amount, commuted overtime is predictable supplemental income and for many doctors, it amounts to about a third of their take-home pay. The long rumblings to cut their overtime pay has seen doctors being required to motivate why they should remain on contracts that pay for more overtime hours, and junior doctors say they are being pressured to sign option C contracts, which will pay for fewer overtime hours. There are also proposals to change some of the terms relating to overtime, including scrapping overtime payments for doctors who are on call but not physically present at a facility. Many doctors already exceed the maximum hours of their contracts because of the emergency nature of their work, gross understaffing and backlogs at their hospitals. Costly, but essential? The commuted overtime pay model has been contentious for years because it adds up to a sizable chunk of the healthcare budget. According to a spending review conducted in 2022 on behalf of National Treasury, the country's health departments spent R6.9-billion on commuted overtime in 2021. This made up about 70% of the total R9.9-billion spent on all types of overtime. In an editorial published in the South African Medical Journal in April 2025, health sciences academics, associations, and unions slammed the Gauteng health department's handling of pay issues. They argue that the basic salaries of medical professionals in the public health sector are already much lower than what would be considered fair pay. 'COT [commuted overtime] has long served as a critical mechanism to ensure that doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system… The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced,' they wrote. A co-author of the editorial, SAMA CEO Dr Mzulungile Nodikida, told Spotlight: 'Medical doctors in South Africa's public sector are severely underpaid. A study by SAMA has shown that even the annual cost of living adjustments that have been made on the salaries have not matched inflation in the last five years. Commuted overtime has had the effect of masking a deficient salary.' He said the Gauteng health department has shown itself to be an 'unreliable employer', adding that its relationship with doctors remains fractured as a loss of confidence in the department deepens. 'This breach of the most basic employment obligation: timely remuneration, has cascading effects. It jeopardises morale, compromises service delivery, and calls into question the department's commitment to its workforce. Doctors now operate under a cloud of uncertainty, unsure whether they will receive their salaries at month-end. This anxiety permeates every aspect of the employment relationship, from retention efforts to the willingness to engage in additional responsibilities,' said Nodikida. View from the wards Two doctors who spoke to Spotlight independently, from two different Gauteng hospitals, say the commuted overtime pay disaster is yet another symptom of weak human resources and poor management from the department of health. For them, proposals to cut commuted overtime is the department shirking from addressing the staffing crisis; the need to improve human resources systems; and rooting out corruption, maladministration and wasteful expenditure. Both doctors asked not to be named for fear of reprisals. Dr A, who is based at Charlotte Maxeke Johannesburg Academic Hospital, said: 'Instead of having a system in place to record how many hours each doctor is actually working and what overtime that person should be paid, the department pays everyone this commuted overtime fixed sum…. [Y]ou could be a dermatologist or a psychologist and have very few overtime hours, or be a surgeon who is doing a lot of overtime. But you all get paid the same if you're on the same contract option,' she said. 'Right now, in my career, I'm working way more overtime hours than my contract, and I'm not being reimbursed for any of it.' Dr A said the overtime pay cuts and proposed changes will impact her decision to stay in the public sector. 'It used to be the case that you were happy, once specialised, to stay because the overall lump sum of money from your salary and commuted overtime made up a decent pay — not comparable to what you could earn in private — but decent enough to stay,' she said. She said she feels like doctors are now being under-valued and coming under attack by their own employer. 'The message we are getting is that 'if you're not happy, there's the door' — but what the department doesn't understand is that you can't just replace someone with 10 years' experience or someone who has 30 years' experience; it has a huge impact,' she said. 'Our patients are suffering; and every day it's like a game of Survivor. We run multiple clinics in one clinic space at Charlotte Maxeke, but you can't offer a functioning service like that. It's noisy, the computers don't work, and the intercom is going off the whole time. 'The other day, I had a 90-year-old patient have a panic attack in the waiting room. He had been waiting for a while and left his wife, who is blind, in the car. He had to park far from the hospital building because the parking lot from the hospital fire [in April 2021] is still not properly repaired and he was overcome with worry,' she said. Dr B works at Chris Hani Baragwanath Hospital and he said the debacle over doctors' overtime pay has pushed him to the edge. He said doctors are already overworked and disheartened from working within a failing system. He sent photos to Spotlight of theatres and wards in darkness, as power went off at the Soweto hospital for days at the end of April. He said staff bring in their own toilet paper because they're told there's none. Most alarming, he said 'doctors are not getting the training and supervision they need' and regularly perform surgeries and procedures without adequate experience and with no supervision. 'They are overwhelmed, overworked and doing way too many overtime hours that they're not being paid for. Then they go home overtired, eat a pizza and crash, sleep a few hours then do it all over again the next day, and the next day,' he said. 'We, doctors, are literally the ones putting patients' lives at risk,' he said, adding that he is 'surviving on anti-depressants' and has sometimes shut himself away in hospital storerooms crying tears of sheer frustration, exhaustion and exasperation. Dr B does still count the wins though. It's on the days when he clears an impossibly long patient list of children who need procedures done. It's when he and his colleagues decide to push through to make sure no child's procedure gets cancelled. 'Those are the good days — they're just few and far between. And now the department is coming for us by cutting our overtime pay and forcing us to sign contracts to downgrade our overtime pay,' he said. Resignations and impact on training Professor Shabir Madhi is dean of the faculty of Health Sciences at the University of Witwatersrand. He said the proposed cuts and freezing of posts and changes to commuted overtime pay has already resulted in resignations of some senior staff at state hospitals. 'If we don't have the proper consultant staff complement in these hospitals who can provide supervision throughout the day, it compromises our training of specialists as well as of undergraduate students. 'If the Health Professions Council of South Africa were to do an audit and find that there isn't adequate consultant cover and supervision, they could remove the accreditation of the training programmes offered by the universities. 'The medical schools are completely dependent on the Gauteng Department of Health to retain consultants and other categories of staff, and to ensure that staff are allocated time for supervision and training of future medical doctors, including specialists, as well as other academic activities. 'It means decision-making around cuts to overtime pay need to be cognisant of the overall impact that it would have, and not only in how it would assess budget constraints. This situation needs meaningful and informed decision-making,' he said. Dr Phuti Ratshabedi, Gauteng chairperson of SAMATU, said the non-payment of commuted overtime pay in April was a slap in the face from the provincial health department, as the union had a meeting with the department that month and left with the department agreeing to uphold their contractual agreements to leave contracts terms for commuted overtime pay unchanged at least till the end of March 2026 — the end of the financial year. 'What we saw is that the department will promise one thing, and do another. But we will be holding them to what they stated in their own circular or we will look to legal action. 'What we want to see in this review period is that they go after departments [where overtime is not being performed but being paid for] but leave other departments alone — they cannot put everyone under the same blanket. 'If the government is able to bail out over and over things like Eskom and Transnet, how can they not prioritise healthcare — this sets our country way back, and we doctors will no longer be silent about this,' said Ratshabedi. Spotlight sent questions to the Gauteng Department of Health, including on how the payment delay happened; the number of people affected; how the department is addressing the widespread knock-on effects of their proposed commuted overtime cuts; and what amendments they hope will come out of the national review. Despite several reminders, the department did not respond to our questions. DM
Daily Maverick
23-04-2025
- Health
- Daily Maverick
On what grounds are the legal challenges against the contentious NHI Act being fought?
The National Health Insurance Act has been subjected to five legal challenges. Who are the challengers and what are their grievances? The National Health Insurance (NHI) Act has long been a controversial piece of legislation among organisations in the health sector and in the broader arena of public opinion. Since it was signed into law by President Cyril Ramaphosa in May 2024 — shortly before the general election — there has been a spate of legal challenges to the Act seeking amendments to certain sections, and in some cases, an outright withdrawal of the law. There are five legal challenges on the books, led by the South African Medical Association (Sama), the Board of Healthcare Funders (BHF), the Hospital Association of South Africa (Hasa), the South African Private Practitioners Forum (SAPPF) and the trade union Solidarity. What outcomes are these challengers gunning for, and how does the fight over the Act stand to affect the broader agenda of healthcare reform? South African Medical Association The South African Medical Association is the most recent legal challenger to the NHI Act, launching its case against the legislation on 2 April in the Gauteng Division of the High Court in Pretoria. Sama is a non-statutory professional association for public and private sector medical practitioners, registered as a nonprofit company. According to its website, it has more than 11,900 members. At a press conference announcing the legal challenge on 1 April, the association's chairperson, Dr Mvuyisi Mzukwa, described the litigation as the 'most comprehensive constitutional challenge to the National Health Insurance Act to date'. It is contesting multiple provisions in the Act that it states will 'severely prejudice both doctors and patients alike', including the requirements that: Every South African will need to register as an NHI 'user' receiving treatment, a process that raises concerns about access for unregistered individuals; Registration can only occur at an accredited primary healthcare provider, with patients required to seek care at their registered facility first, even if that facility is overloaded or incapable of providing appropriate treatment; and Complaints about poor service delivery will be handled by a single, centralised investigative unit within the NHI Fund's National Office — a mechanism Sama believes will be 'wholly inadequate' to respond to the large scale of grievances in a timely or effective manner. Other concerns raised by Sama include: A lack of clarity in the Act about which services will be covered by NHI; The unclear system for the procurement of medical supplies under NHI, which raises 'serious concerns about supply chain management and stock shortages'; The consequences the Act will have for healthcare professionals, who will be required to meet 'impossible accreditation standards' and work well beyond their normal capacity for less income; and A lack of provisions in the Act to insure private sector doctors against medico-legal claims, despite these doctors operating within NHI protocols. 'Sama is not opposed to the goal of universal health coverage. We strongly believe in equitable, high-quality healthcare for all South Africans. However, the NHI Act risks collapsing our healthcare system rather than strengthening it,' said Mzukwa. Sama is a member of the Universal Healthcare Access Coalition (UHAC), alongside the Progressive Health Forum and the SA Private Practitioners Forum. The collective has been pushing a joint proposal to reform the healthcare system as an alternative to NHI, stating that their plan offers 'pragmatic, scalable and equitable solutions' to enhance healthcare access in South Africa. Dr Aslam Dasoo, a health activist and member of the UHAC steering committee, said the objectives of the NHI could take more than a decade to implement, while the reforms put forward by UHAC were suited to the current needs within the health system. 'Our view is that we completely back [Sama's legal challenge]… All strength to their arm, they must go ahead,' he said. 'If you take the other [legal challenges], they go for specific areas of law… What Sama did, in addition, was to actually look at not just the constitutional problems with this thing, but the health policy problems and the financial implications.' Board of Healthcare Funders The Board of Healthcare Funders, a nonprofit company that represents more than 40 South African medical schemes, launched its legal challenge to the NHI Act on 27 May 2024 in the Gauteng Division of the High Court in Pretoria. The BHF has requested that the court review and set aside Ramaphosa's decision to sign the NHI Act into law, according to its notice of motion. 'While we support the objective of universal health coverage for all and are committed to working with government to progress towards this goal, we hold serious reservations about the NHI Act in its current form,' the BHF told Daily Maverick. Among the concerns raised by BHF are: The 'broad, vague terms' of the Act, which delegates 'excessive decision-making power' to unelected officials without sufficient oversight from Parliament; The failure of the Act to provide a concrete and transparent funding mechanism; The limitation on individuals' ability to choose their healthcare providers and schemes, which BHF describes as an 'impairment of existing constitutional rights'; The government's alleged failure to amend the Act in response to submissions from BHF and other stakeholders during the public consultation process; The Act's potential to reduce access to healthcare by imposing rigid referral pathways that restrict patients' choice, driving health professionals out of the system and 'jeopardising the viability of the private sector'; and The centralisation of authority in the NHI Fund under the minister of health. 'President Ramaphosa signed the NHI Bill in May 2024, bringing it into force as an Act of Parliament. In doing so, he ignored all the well-reasoned arguments made by a range of stakeholders from business, civil society and health interest groups… As there were clear reservations about the constitutionality of the legislation, the President was obligated by law … to refer the Bill back to the National Assembly for reconsideration. He did not do this,' said the BHF. The matter was heard in the high court on 4 and 5 March, with judgment currently reserved. Hospital Association of South Africa The Hospital Association of South Africa (Hasa) represents private hospital organisations, including Mediclinic, Life Healthcare and Netcare. In late February, it lodged papers in the Gauteng Division of the High Court in Pretoria, challenging the NHI Act. Hasa has asked the court to declare the Act unconstitutional and unlawful and set it aside, according to a Business Day report. In particular, it is challenging section 33 of the legislation, which states that once the NHI has been fully implemented, medical schemes will be restricted to providing complementary cover for benefits not covered by the national fund. These restrictions on medical schemes are 'irrational', says Hasa. The private hospital association focused on the financial implications of the NHI Act, stating that the legislation was incoherent, financially unviable and at odds with the Constitution. 'We remain firmly committed to participating constructively while the legal process unfolds. As an organisation, we have always preferred to resolve matters through dialogue, and we believe that effective healthcare solutions are urgently needed and achievable through a reasonable and collaborative approach,' said Melanie da Costa, chairperson of Hasa, in a press statement announcing the association's legal challenge. South African Private Practitioners Forum The South African Private Practitioners Forum (SAPPF) launched its legal challenge against the NHI Act in the Gauteng Division of the High Court in Pretoria on 1 October 2024. It is asking that Ramaphosa's decision to assent to and sign the Act be reviewed and set aside. 'SAPPF argues that President Cyril Ramaphosa failed to adequately scrutinise the constitutionality of the NHI Bill before signing it into law, thereby violating his constitutional duty,' the forum told Daily Maverick. The organisation has also argued that the Act is 'impermissibly vague, leaving both the public and healthcare providers uncertain about access, processes and rights. 'It is irrational and unworkable, lacking critical feasibility studies, budget forecasts, or socioeconomic impact assessments,' it said. The SAPPF has contested the Act on constitutional grounds, stating that it violates the right to dignity; freedom of trade, occupation and profession; and access to healthcare, among others. Solidarity trade union Solidarity trade union represents more than 200,000 members, according to its website. It was the first organisation to launch a legal challenge against the NHI Act, lodging its papers in the Gauteng Division of the High Court in Pretoria in May 2024. It has asked the court to declare the Act to be unconstitutional and invalid. In its founding affidavit, Solidarity stated that the NHI, 'though morally praiseworthy in its intentions', didn't pass constitutional muster. 'The statute, which does not provide for a clear funding model and which leaves the determination of health services to be purchased by the NHI Fund as monopsony buyer to a future endeavour, fails at the first constitutional hurdle. This, because the scheme that is created under the NHI Act is vague,' it said. Solidarity criticised Section 33 of the Act concerning the restriction of medical schemes, stating there was 'no guidance on any criteria' which must be satisfied before the minister of health can enact the restrictions. 'The NHI Act poses a threat to the existing access [to quality health services] of at least some — especially members of medical schemes. The statute's proposed limitation of services provided by medical schemes is inconsistent with the state's duty to respect socioeconomic rights,' said Solidarity. The trade union raised concerns about the concentration of decision-making powers over the NHI to the minister of health and the board of the fund. Department of Health stands firm Health Minister Dr Aaron Motsoaledi has doubled down on his support for the NHI Act in recent months, dismissing many of the criticisms of the legislation as 'elitist' and 'discriminatory'. In a Business Day report, Motsoaledi claimed that the 'nub of Solidarity's complaint is its discomfort with the fact that the majority of the population who now use the public healthcare system will be afforded access to private healthcare providers and facilities under the NHI Act, which are now the exclusive domain of those who are better off'. Speaking before the second meeting of the G20 Health Working Group in March, he told assembled dignitaries that the NHI was designed to 'provide financial protection for all, ensuring that access to quality healthcare is not dependent on one's ability to pay. 'The NHI is a concrete demonstration of our commitment to leaving no one behind, fostering equity and strengthening our health resilience,' he said. When Daily Maverick reached out to the national Department of Health about Sama's legal challenge, spokesperson Foster Mohale said the department had noted the decision of Sama and other organisations to exercise their constitutional right to litigate against the NHI. 'The department will respond accordingly through legal channels for what we believe is part of a transformative agenda to address the legacy of the apartheid system, in providing quality and affordable healthcare for all citizens, regardless of their socioeconomic status,' said Mohale. 'Parliament conducted public hearings countrywide on the NHI Bill as part of a public consultation process where individuals and stakeholders were afforded an opportunity to air their views… Unfortunately, in this case the privileged minority could not decide for the disadvantaged majority who equally deserve a better life. The government has an obligation to remove any barriers to accessing quality and affordable healthcare for all.' With no concrete outcomes to any of the legal challenges against the NHI at this stage, the future of the Act is uncertain. DM
