A fundamental transformation in the South African healthcare system is essential to address the imbalances in the access and utilization of health services and health outcomes.
Many challenges exist in the current healthcare system inter alia:
Inequitable distribution of spend between two tiers namely a large private sector (60%) serving a higher income minority while the public sector (40%) serves the majority of the population.
Since 1994 the public health sector has experienced a stagnation in funding allocation, with a consistent decline in real per capita terms
Inability to effectively treat people with TB. The incidence of adult TB has risen seeing a threefold increase in numbers of infected people from 1996 to 2006
The mal- distribution of human resources is evident, 60% of nurses and 40% of doctors serve 85% of the population in the public health sector.
There is also a severe undersupply of pharmacists in the public sector resulting in many rural areas having inadequate or no access to pharmacy services and hence no access to medications (especially AIDS drugs)
The National Health Insurance (NHI) will enable an integrated, pre-payment-based mechanism that will ensure that all have access to healthcare. The key objective of the NHI is to solve the problems seen with a dual health system and to promote social solidarity by achieving universal coverage. This change is needed urgently due to the lack of achievement of the MDGs (Millennium Development Goals) for health and the stagnation and even deterioration in mortality rates and life expectancy. An additional rationale for introducing an NHI system is that it would provide a mechanism for improving cross-subsidization in the overall health system, whereby funding will be linked to an individual’s ability to pay while benefits will be determined by an individual’s need for care. This will enhance compliance with our constitution (right to access health care services as well as the underlying determinants of health such as the right to clean drinking water, the right to adequate housing, and the right to a clean and safe environment, the right to sufficient food and nutrition and social security)
An NHI Fund will be established within the provisions of the appropriate laws and regulations. The NHI Fund will be responsible for: receiving funds, pooling the resources and purchasing services on behalf of the entire population. The Fund will be publicly administered as a single purchaser with sub-national offices at the provincial level and will negotiate and contract with service providers. This single payer system will be effective in collecting revenue, distributing risks through one large risk pool and offers government a high degree of control over total health expenditure.
Structure
Minister of Health
CEO (Chief Executive Officer)
Executive Management Team with specific technical committees
Technical advisory committee, audit committee, pricing committee, remuneration committee, benefits advisory committee (BAC) and others
The NHI Fund will be advised by a committee comprising of representatives of the relevant government authorities, the health care providers and representatives of civil society.
The Minister of Health will remain responsible for the overseeing the NHI Fund, the development of NHI policy and any amendments that impact the NHI Fund (changes in demography, epidemiology and health technology development)
The Fund however must remain an independent body; the National Department of Health will continue to be the overall steward of the healthcare system and will remain a major provider of services through its national, provincial and district level structures and facilities. In addition the NDoH will continue to provide non-personal services including overall responsibility for infrastructure development for which it receives a budget. Coordinating the development of overall health plans including personal services will remain the responsibility of the NDoH, the purchasing function for personal services will be the NHI Fund’s responsibility (the Fund will contract directly and reimburse both private and public providers) These purchases will be part of a NDoH-approved purchasing plan.
NHI Healthcare Benefits
The NHI Fund will provide primary, secondary and tertiary care. Quaternary care will remain the responsibility of the NDoH.
Primary care and preventative services
Inpatient care
Outpatient care
Emergency care
Prescription drugs
Appropriate technologies for diagnosis and treatment
Rehabilitation
Mental health services
Full scope of dental services (other than cosmetic dentistry)
Substance abuse treatment services
Basic vision care and vision correction (other than laser vision correction for cosmetic purposes)
Hearing services, including the provision of hearing aids.
The EDL will be the basis for pharmaceutical, medical supplies and devices. This will be updated regularly by the BAC. Emphasis will be on primary health care with referral to specialists and in-patient care. Through a defined allocation of funds the NHI will include personal preventative services according to developments in the disease burden of the covered population. The NHI benefits will be comprehensive but will exclude all medically unnecessary services. This exclusion list will be reviewed at appropriate intervals by the BAC.
Public and private healthcare providers will be accredited to provide 1o, 2o, 3o and 4o care. A referral process will be defined for services within and outside the district to assure continuity of care and of cost containment. Private GPs will be encouraged to develop multi-disciplinary practices. The accreditation will be conducted by the National Office of Standards Compliance (OSC) which will report directly to the Minister of Health.
Sources of Revenue and Pooling Functions
The main source of funding will be general taxation and mandatory contribution (at a later stage additional funding e.g. from the Road Accident Fund (RAF), Compensation for Occupational Injuries and Diseases Act (COIDA) will be considered). The mandatory contribution will be progressively structured and collected by SARS. Everyone earning above the income tax threshold (annual adjustment) will make this contribution which will be shared between employer and employee. Additional funding will include the elimination of the current tax-deductions for medical scheme contributions. This will be channeled to the NHI system. Out-of-pocket payments are not seen as funding for the NHI as there will be no charges at the point of service for the insured for the services covered by the NHI. Currently the exact magnitude of the mandatory contribution and that of the general tax funding is still under discussion, however it is agreed that a considerable increase in public funding is essential to meet the financial needs of a publicly funded health system.
Provider Payment Mechanisms: all accredited service providers will be reimbursed on according to a risk-adjusted per capita payment and global budgeting. The annual capitation amount will be linked to target utilization and cost levels. This will apply to all service providers, private and public in all categories of service provision. Recommendations include that the capitation should be linked to an appropriate index such as CPI, the NHI Fund will assist providers to control expenditure through approved formulae and protocols. At all costs an appropriate level of care must be assured and under-servicing must be avoided. High cost care for services excluded from the list of benefits under capitation will be reimbursed from a separate allocation of the NHI. There will be no co-payments or out-of-pocket payments to accredited providers. (this payment will only apply to the non-insured (tourists) or for health services excluded by the NHI).
Allocation of NHI Fund Revenues: The allocation of funding must ensure the provision of care for the services covered by the NHI Fund whilst maintaining improved quality as well as an incentive to recruit and retain qualified health workers.
Registration of the population will be essential to ensure that all eligible citizens have access to the NHI, initially the green, bar-coded or equivalent legal ID will be used and later all will be issued with an NHI card that will contain all the relevant health information. This will ensure portability of health services.
Information systems and quality assurance: the NHI Fund will contribute to an integrated and improved National Health Information System (NHIS) to facilitate an effective implementation of an NHI system and portability. This will support monitoring of coverage in all population sectors, financial and management functions, utilization reviews, quality assurance programmes for health care providers, report generation for health system management and research documentation to support changes as the healthcare needs of the population change.
Promotion of the NHI system: through a transparent communications programme, a proactive social marketing approach will be taken to increase the knowledge and understanding of the NHI Fund’s functions and activities. This will include raising awareness among politicians and community leaders at all levels to enlist their support, develop and maintain a multi-target educational drive using all relevant elements of communication.
The improvement, expansion and revitalization of the public healthcare infrastructure is critical to achieving a successful implementation of the NHI, hence a parallel health systems strengthening plan has been developed to assure infrastructure maintenance, improvement and expansion (capital costs) and service provision (recurrent costs)
This concurrent Health System Strengthening Plan will focus on
General Infrastructure Inventory and Development, all existing public and private facilities will be assessed to determine their capacity for service delivery and to identify gaps for expansion and development.
Quality primary healthcare will be delivered by a revitalized and adequately financed district health system hence the District Health Councils , nationally, will be strengthened by improving political governance, managerial oversight and accountability structures. These offices will manage the flow of funds from the NHI to the providers.
Mechanisms will be created to increase the efficiency of these public health facilities, especially hospitals, to allow them more managerial autonomy and thereby improve decision making and accountability.
A Human Resources Plan for Health will be developed to increase the supply, quality, distribution and retention of health workers in the country.
Quality Improvement Plan: The capacity of SA healthcare to meet the needs of the community it serves has been examined and factors impairing this ability have been identified. A carefully planned, organized, articulated and documented quality improvement and quality assurance plan is required. This plan is described in depth with all the relevant bodies involved.
Phased implementation of the proposed NHI: because this requires substantial transformation in funding and provision aspects a phased approach will be beneficial. Phase 1: wide consultation to get inputs from public and private, stakeholders (labour, community groups, NGOs, civil society) comprehensive review of existing legislation to draft new legislation and the drafting thereof, increase funding of public sector health services from general tax revenue, revitalization of public health infrastructure, introduce quality improvement and quality assurance programmes and the development of a human resources programme.)
