As South Africa moves closer to implementing the National Health Insurance (NHI), Sections 42 to 44 of the NHI Act, which designates a centralised investigative unit within the NHI Fund as the sole authority for managing all complaints, has become a major point of contention in the recent court challenges against the Act. 

Health professionals and advocacy groups argue that this centralised approach could undermine transparency, compromise the independence of investigations, and erode public trust in the system.

Currently, patients can submit complaints, either verbally or in writing, directly at the health facility. 

Professor Hassan Mahomed, a public health specialist with the Western Cape Department of Health and Stellenbosch University, says that Sections 42 to 44 of the NHI Act provide for the establishment of the Fund’s own internal complaints investigation unit and appeals process, raising concerns that this may function separately from the Office of the Health Ombud.

“The Ombud is part of the Office of Health Standards Compliance (OHSC), which is intended to operate independently of both the Department of Health and the NHI Fund, as established by the National Health Amendment Act of 2013,” he explains.

“What remains unclear is whether a complainant can seek redress through both channels, either simultaneously or in succession. Legally, these structures appear independent of each other, and in theory, the Ombud should be empowered to act independently, particularly in cases where complaints are directed at the NHI Fund itself,” he says.

He says health facilities are often resource-constrained, making it difficult to give patient complaints the attention they require.

“A fundamental issue is the asymmetric power dynamic between vulnerable patients and a powerful health system bureaucracy. As a result, most dissatisfied patients do not report their complaints. It is primarily empowered individuals, or those with particularly serious complaints, who persist in pursuing a resolution,” Mahomed says.

Another route for people to lodge complaints is through the Health Ombudsman. Mahomed says that the Ombud is meant to act independently and help protect patients. 

But the Ombud’s office is also facing severe resource constraints, with staff based in former store rooms without windows, fresh air, or natural light.

The Health Ombud’s 2023/2024 annual report reads:

“The call centre operates in an open space that is prone to noise disruptions, which compromises confidentiality when interviewing complainants. Complaints assessors and investigators also work in an open-plan area, making it difficult to concentrate due to frequent distractions.”

Another avenue for people to lodge complaints is with the HPCSA, which handles complaints against healthcare professionals registered with them. 

Complaints under NHI 

Under the NHI all complaints will be handled solely by the NHI Fund.

Health Ombud Professor Taole Mokoena says his office will collaborate with the NHI Complaints Management unit to avoid duplication, as the office is currently responsible for referring matters related to corruption, fraud, or unprofessional conduct to the appropriate statutory bodies.

The Health Ombud’s role will expand beyond public facilities to include all healthcare providers contracted by the state. Currently, the Health Ombud primarily deals with failures in the public sector. 

“The office will have the authority to investigate complaints related to the NHI Fund, healthcare service providers, establishments, and suppliers. This is because all healthcare services and funding will be centrally managed under the NHI system, and the Health Ombud is tasked with ensuring accountability and upholding the quality and safety of healthcare services,” Mokoena says. 

Mokoena says additional resources will be essential to manage the increased demands that will come with the implementation of the NHI.

Oversight and quality assurance 

Dr Nicholas Crisp, Deputy Director General for the NHI explains that the Fund will function as a government entity responsible for purchasing services on behalf of the population.

“If it becomes apparent that a provider is not delivering quality care, the NHI Fund may initiate an investigation to improve services or, if necessary, terminate the provider’s contract,” he says.

He adds that the NHI Fund will be held accountable for how it handles and resolves complaints from patients or healthcare users. 

“When a complaint is made, it will be referred to the relevant healthcare provider, the Office of Health Standards Compliance, or the Health Ombud, depending on the issue. However, the Fund will keep a record of all complaints to identify any recurring problems with specific providers,” he says. – Health-e News