NHI a major health care overhaul
When the private and public healthcare sectors compete with each other, as is the case in South Africa, the one that supports mainly the poor will suffer, argues Dr Anban Pillay, Deputy Director General of the National Health Insurance (NHI).
CABINET recently published the National Health Insurance Bill and the Medical Schemes Amendment Bill for public comment, but discussion about the National Health Insurance (NHI) system is not actually new.
Plans to establish a NHI system for South Africa date back to 1928.
Over the past 90 years, there have been several commissions and committees established by government to design a NHI system for South Africa. Those who are old enough may recall the Collie Committee (1941), Gluckman Commission (1944), Broomberg-Shisana Committee (1995) and Taylor Committee 2002, among others.
So the plans have been a long time in the making.
There are a number of challenges in the current healthcare system (public and private) which warrants a massive reorganisation of the system.
In most healthcare systems across the world, the public and private healthcare systems do not compete with each other to deliver services.
Rather the private healthcare system complements the public healthcare system – which is the main provider of healthcare services. When the two sectors compete with each other for doctors, nurses and other resources, then clearly the sector that supports mainly the poor will suffer.
The public system, which caters mainly for the poor, has a high patient load, limited staff, and old infrastructure which contribute to the decline in the quality of services.
Those who are able to pay more for healthcare services use the private sector, and consequently, there is a migration of health professionals away from the public system into the private sector since health professionals are paid more for relatively less work. The poor have the greatest healthcare needs, however, they have disproportionately fewer health professionals and consequently there are long waiting times and overall poorer quality care.
Clearly, this system cannot continue in its current form and requires significant reform. The National Health Insurance Policy is central to these health reforms. We have chosen to use the term National Health Insurance; however, the term used globally is universal health coverage.
The United Nations has also adopted universal health coverage as one of the sustainable development goals which countries should strive towards by 2030.
South Africa, as a member of the United Nations, has committed itself to the achievement of these goals.
The Green Paper on NHI was initially developed in 2011, and after extensive public engagement, this was revised to the White Paper which was finalised in 2017. The White Paper outlines the policy framework of the NHI. The NHI Bill is effectively a translation of the policy into law.
These bills can be accessed from the website of the National Department of Health. Once public comment has been received, these bills will be revised, before being presented to cabinet for final approval.
After approval by cabinet, these bills will be submitted to Parliament for consideration. The portfolio committee will review these bills as well and will also embark on a process of public consultation before final approval of the bill by the president.
You would note that this process of consultation allows for substantive public engagement on these matters at several stages before finalisation. Implementation of this legislation will only occur after the bills have been signed into law by the president.
The National Health Insurance Bill proposes the establishment of a National Health Insurance Fund which will be a centralised funding pool which would be responsible for purchasing healthcare services on behalf of all South Africans. The NHI fund will purchase healthcare services; in a similar manner to the purchasing role of medical aids.
However, there are a few key differences from the way medical scheme currently operate – medical aids limit patient benefits in each area of care such as GP visits, medicines, optometry etc. while the NHI will not have such limits provided you access care at the right level. For example, you cannot go directly to a specialist without a referral by a GP.
Secondly, medical aids currently impose co-payments for services which will not be the case when NHI is implemented. The current system, where you are told that your medical aid does not pay the full amount for the cost of consultation, will not occur under NHI.
Thirdly, the NHI fund will cover all healthcare services from preventative care, primary care, emergency care, hospital and tertiary level care, as well as palliative care, unlike the current medical scheme structure where mainly hospital level care and limited primary care is covered.