NHI – the jour­ney be­gins

The Star Early Edition - - NEWS - DR AARON MOT­SOALEDI

THERE is a global move­ment to­wards univer­sal health cov­er­age to en­sure that peo­ple get the health care they need re­gard­less of abil­ity to pay. Through the pur­suit of univer­sal health cov­er­age, poverty should not mean poor health and ill health should not lead to poverty.

June 29 marked an im­por­tant/his­toric day in the lives of South Africans with re­spect to their health. The White Pa­per on Na­tional Health In­sur­ance was re­leased as of­fi­cial gov­ern­ment pol­icy.

There have been many ques­tions and con­cerns raised about the ac­tual prob­lem we are try­ing to solve. This is sim­ple.

The cur­rent health sys­tem is frag­mented and this has cre­ated sig­nif­i­cant in­equities. This is fur­ther com­pounded by com­pli­cated fund­ing flows in the public and pri­vate sec­tors. These in­equities are de­fined by where peo­ple live (ge­og­ra­phy), their so­cio-eco­nomic sta­tus in­clud­ing in­come lev­els, and whether ser­vices are ob­tained in the public or pri­vate sec­tors. The re­sult of these in­equities is that large sec­tions of the pop­u­la­tion are not able to ac­cess qual­ity health care ser­vices when they need it.

The gazetting of the White Pa­per is a clear demon­stra­tion that our gov­ern­ment is com­mit­ted to pro­vide all peo­ple with ac­cess to a com­mon set of comprehensive health ser­vices of suf­fi­cient qual­ity, while also en­sur­ing that the use of these ser­vices does not ex­pose South Africans to fi­nan­cial hard­ship due to ill-health.

A key el­e­ment of fi­nanc­ing for UHC is that the health costs for the poor and vul­ner­a­ble are shared by the whole of so­ci­ety, which im­plies that the health care fi­nanc­ing sys­tem should spread the fi­nan­cial risks of ill­ness across the en­tire pop­u­la­tion. This can only be achieved by col­lect­ing large pools of pre­paid funds that peo­ple can draw on to cover their health care costs in times of need, re­gard­less of their eco­nomic sit­u­a­tion.

The gov­ern­ment has cho­sen to achieve this goal through a na­tional health in­sur­ance sys­tem. This uses public and pri­vate-sec­tor providers to de­liver per­sonal health care ser­vices, with pay­ment from a gov­ern­ment-run in­sur­ance pro­gramme (the NHI Fund) that ev­ery cit­i­zen pays into.

Un­der NHI, there is no fi­nan­cial mo­tive to deny treat­ment and the Fund will be a non-profit en­tity. In­ter­na­tional ex­pe­ri­ence shows that univer­sal in­sur­ance pro­grammes are able to pro­vide health ser­vices more cost ef­fec­tively be­cause of economies of scale.

The gov­ern­ment, through the NHI Fund, will act as an agent for the peo­ple in pur­chas­ing health care ser­vices. In this way, the Fund as a sin­gle pur­chaser will have con­sid­er­able mar­ket power to ne­go­ti­ate lower prices for ser­vices as well as com­modi­ties – as al­ready il­lus­trated by the De­part­ment of Health’s abil­ity to pur­chase a range of medicines at sig­nif­i­cantly lower costs, even when bench­marked against in­ter­na­tional prices.

What does this mean for the peo­ple of South Africa? You as a pa­tient never get a bill from a health care provider. The Fund de­ter­mines the ser­vice to be pro­vided, the rates of re­im­burse­ment as well as the mode of pay­ment. The claims are re­viewed, as­sessed and paid in line with the pre­scrip­tions of the Fund through a de­cen­tralised sys­tem.

It is im­por­tant to state that NHI does not work on a bud­get al­lo­ca­tion sys­tem. Health care providers, be they hos­pi­tals, clin­ics or in­di­vid­u­als or groups of health care pro­fes­sion­als, are re­im­bursed directly for ser­vices that they ren­der.

With the re­lease of the White Pa­per, we be­gin the tran­si­tion into the NHI. The White Pa­per recog­nises that achiev­ing full im­ple­men­ta­tion of NHI is a jour­ney. This means that the NHI will not be im­ple­mented overnight but over time.

In re­leas­ing the White Pa­per, we an­nounced the es­tab­lish­ment of tran­si­tional struc­tures to im­ple­ment NHI in a phased man­ner over the next eight years. The im­ple­men­ta­tion struc­tures are linked to four pil­lars – fi­nanc­ing, ser­vice pro­vi­sion, gov­er­nance and reg­u­la­tions.

Each pil­lar has ac­tiv­i­ties linked to trans­for­ma­tion of the public and pri­vate sec­tors.

With re­spect to fi­nanc­ing ar­range­ments, in the public sec­tor, the fol­low­ing are key im­me­di­ate ac­tiv­i­ties – re­struc­tur­ing of eq­ui­table share; case-mix based bud­gets for hos­pi­tals; es­tab­lish­ing clinic bud­gets; and in­tro­duc­ing cap­i­ta­tion-based con­tract­ing.

In the pri­vate sec­tor key im­me­di­ate ac­tiv­i­ties are: price reg­u­la­tion for all ser­vices in­cluded in the NHI comprehensive ben­e­fit frame­work; re­moval of dif­fer­en­tial pric­ing of ser­vices based on di­ag­no­sis; the re­moval of co-pay­ments; and bal­anced billing.

With re­spect to pro­vi­sion in the public sec­tor, en­sur­ing that vul­ner­a­ble sec­tors of our pop­u­la­tion have im­proved ac­cess is crit­i­cal. In this re­spect, the fol­low­ing are pri­ori­tised: school health ser­vices; ma­ter­nal and women’s health ser­vices; men­tal health ser­vices; ser­vices for the el­derly; dis­abil­ity and re­ha­bil­i­ta­tion ser­vices; ex­pan­sion of ser­vice ben­e­fits to other groups over time; the strengthening of public health care ser­vices through NHI “ready” and ac­cred­ited clin­ics.

In the pri­vate sec­tor the fol­low­ing are key im­me­di­ate ac­tiv­i­ties: in­tro­duc­tion of a ser­vice ben­e­fits frame­work; re­duce the num­ber of op­tions avail­able in each med­i­cal scheme; re­form of pre­scribed min­i­mum ben­e­fits and align­ment to NHI ser­vice ben­e­fits, in­clud­ing com­mon pro­to­cols/ care path­ways.

Strengthening gov­er­nance in the public sec­tor will in­volve es­tab­lish­ing cen­tral hos­pi­tals as semi-au­ton­o­mous struc­tures, strengthening hos­pi­tal gov­er­nance and del­e­ga­tions and strengthening dis­trict gov­er­nance and del­e­ga­tions.

Strengthening gov­er­nance in the pri­vate sec­tor will in­volve strengthening of gov­er­nance in med­i­cal schemes, the re­la­tion­ship be­tween in­ter­me­di­aries and re­struc­tur­ing of the re­serves and sol­vency of med­i­cal schemes.

Reg­u­la­tory is­sues in the public sec­tor, in­clude leg­is­la­tion to cre­ate the NHI Fund, through the in­tro­duc­tion of an NHI Bill and leg­isla­tive amend­ments re­lated to, in­ter alia, the Na­tional Health Act and the Health Pro­fes­sions Act.

Reg­u­la­tory is­sues in the pri­vate sec­tor, in­clude the Med­i­cal Schemes Act and reg­u­la­tions re­form.

Consolidation within the med­i­cal schemes en­vi­ron­ment will in­clude the consolidation of gov­ern­ment em­ploy­ees’ med­i­cal schemes and other state med­i­cal schemes into a sin­gle scheme, re­duc­ing the num­ber of med­i­cal schemes, re­duc­ing the num­ber of op­tions in med­i­cal schemes and li­cens­ing of health es­tab­lish­ments.

Dur­ing July 2017, we will con­vene stake­holder con­sul­ta­tions on the im­ple­men­ta­tion process.

The White Pa­per process demon­strated that there is wide­spread agree­ment amongst stake­hold­ers that the global call for univer­sal health cov­er­age must be heeded by South Africa. We may not al­ways agree on the de­tail but the need for equity in ac­cess to ser­vices based on need is not con­tested. Now is the time to work on the de­tailed im­ple­men­ta­tion plans that will pro­vide all South Africans with the best qual­ity of health care that we can af­ford as a coun­try. The De­part­ment of Health is com­mit­ted to this task and to en­sur­ing that all stake­hold­ers are able to play their role in re­al­is­ing this vi­sion.

SA joins a global move­ment to­ward univer­sal health cov­er­age, re­gard­less of the in­di­vid­ual’s cir­cum­stances

CLINIC SCENE: All de­serve equal ac­cess to health care ser­vices, re­gard­less of lo­ca­tion and fi­nan­cial cir­cum­stance.

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