PRESENTATION ON NATIONAL
HEALTH INSURANCE POLICY FOR
THE PORTFOLIO COMMITTEE OF
HEALTH
Click to edit Master subtitle style
National Department of Health
23 August 2011
8/19/11
OUTLINE
•
•
Introduction
Problem Statement: Key Health Sector
Challenges
•
Public Sector
•
Private Sector
•
Principles of NHI
•
Objectives
8/19/11
INTRODUCTION...../1
•
•
•
Introduction of an innovative system of
healthcare financing
Far reaching consequences on the health of
South Africans
Ensures that everyone has access to health
services that are:
•
appropriate
•
efficient
8/19/11
INTRODUCTION......./2
•
•
Improve service provision
Promote equity and efficiency to ensure all
South Africans have access to affordable,
quality healthcare services regardless of their
socio-economic status
8/19/11
INTRODUCTION......./3
•
•
SA health system inequitable.............with the
privileged few having disproportionate access
to health services
Recognition that this system is neither rational
nor fair
Current system of healthcare financing is two-
•
8/19/11
INTRODUCTION......./4
•
Private Sector:
•
•
•
covers 16.2% of the population
relatively large proportion of funding allocated
through medical schemes, various hospital care
plans and out of pocket payments
provides cover to private patients who have
purchased a benefit option with a scheme of their
choice or as a result of their employment
conditions
8/19/11
INTRODUCTION......./5
•
Public Sector:
•
Covers 84% of the population
•
funded through the fiscus
•
Poor management systems and oversight esp hospitals
•
•
under-resourced relative to size of population that it
serves and the burden of disease
less human resources than the private sector – longer
waiting times and lower clinical consultation time –
increased risk of error
8/19/11
INTRODUCTION......../6
•
To successfully implement a healthcare
financing mechanism that covers the whole
population such as NHI, four key interventions
need to happen simultaneously:
•
•
a complete transformation of healthcare service
provision and delivery;
the total overhaul of the entire healthcare system
the radical change of administration and
management
8/19/11
•
PROBLEM STATEMENT
•
The 2008 World Health Report of the WHO
details three trends that undermine the
improvement of health outcomes globally,
namely:
•
•
Hospital centrism, which has a strong curative focus
Fragmentation in approach which may be related to
programmes or service delivery
Uncontrolled commercialism which undermines
principles of health as a public good
8/19/11
•
KEY CHALLENGES IN THE HEALTH SYSTEM
•
Quadruple Burden of Disease
•
Quality of Healthcare
•
Distribution of Financial and Human Resource
•
High Costs of Health Care
•
Out-of-pocket payments and co-payments
8/19/11
QUALITY IN PUBLIC HEALTH
FACILITIES
•
Cleanliness
•
Safety and security of staff and patients
•
Long waiting times
•
Staff attitudes
•
Infection control
Drug stock-outs
•
8/19/11
EXORBITANT COSTS OF HEALTH CARE IN
SOUTH AFRICA (PUBLIC AND PRIVATE)
•
•
Cost of Private Health Care out of control at
the expense of members of medical schemes
Cost of Public Health Care escalating at the
expense of the fiscus
8/19/11
1212
WHAT DRIVES THE COSTS IN THE
PUBLIC SECTOR?
5 Major identifiable areas:
1.
Compensation of employees
2.
Pharmaceuticals
3.
Laboratory Services
4.
Blood and Blood products
5.
Health Technology / Equipment
8/19/11
1313
Trends in Total Benefits Paid, 1997 - 2005
8/19/11
Source:
Council for Medical Schemes
… THE COST DRIVERS ARE
HOSPITALS AND SPECIALISTS…
8/19/11
AFFORDABILITY OF MEDICAL
SCHEME CONTRIBUTION
•
•
A number of medical schemes have collapsed,
been placed under curatorship or merged
Schemes have reduced from over 180 in the
year 2001 to about 102 in 2009
To sustain their financial viability, schemes
tend to increase premiums at rates higher
8/19/11
•
THE EVOLUTION OF HEALTH CARE FINANCING
IN SOUTH AFRICA
•
•
•
•
•
•
Commission on Old Age Pension and National Insurance
(1928)
Committee of Enquiry into National Health Insurance
(1935)
National Health Service Commission (1942 – 1944)
Health Care Finance Committee (1994)
Committee of Inquiry on National Health Insurance
(1995)
The Social Health Insurance Working Group (1997)
•
Committee
8/19/11
of Inquiry into a Comprehensive Social
PRINCIPLES OF THE NHI
•
•
•
•
•
•
•
•
The Right to Access Health
Social Solidarity
Equity
Effectiveness
Appropriateness
Effectiveness
Efficiency
Affordability
8/19/11
1818
OBJECTIVES OF NHI
•
•
To provide improved access to quality health
services for all South Africans irrespective of
whether they are employed or not
To pool risks and funds so that equity and social
solidarity will be achieved through the creation of
a single fund
8/19/11
SOCIOECONOMIC BENEFITS
•
•
•
Increased output as a healthy person works more
effectively and efficiently and devotes more time to
productive activities (i.e. fewer days off, longer work life
span);
Broader knowledge base in the economy as the gains to
education increase as life expectancy increases;
Increased “work life” and savings as a result of increased
life expectancy may result in earning and saving more for
retirement;
8/19/11
2020
CONSIDERATIONS FOR ACHIEVING UNIVERSAL
COVERAGE-DIMENSIONS
Source: WHO (World Health Report: 2010)
8/19/11
2121
POPULATION COVERAGE
•
•
All South Africans and legal permanent
residents will be covered
Short-term residents, foreign students and
tourists required to obtain compulsory travel
insurance
•
produce evidence of this upon entry into South
8/19/11
HEALTH SYSTEM REENGINEERING
Primary health care services shall be delivered according
to the following three streams:
•
•
District-based clinical specialist support teams supporting
delivery of priority health care programmes at a district
School-based Primary Health Care services
8/19/11
•
Municipal Ward-based
2323
Primary Health Care Agents
DISTRICT CLINICAL SPECIALIST SUPPORT
TEAMS
•
To address high levels of maternal
and child mortality and to improve
health outcomes
The teams will based in districts and
include:
8/19/11
•
SCHOOL HEALTH SERVICES
•
•
Delivered by a team that is headed by a
professional nurse
Services will include health promotion,
prevention and curative health services that
address the health needs of school-going
children, including those children who have
missed the opportunity to access services such as
child immunization services during their pre8/19/11
MUNICIPAL WARD-BASED
PRIMARY HEALTH CARE AGENTS
•
•
•
A team of PHC agents will be deployed in
every municipal ward
At least 10 people will be deployed per ward.
Each team will be headed by a health
professional depending on availability
Each member of the team will be allocated a
certain number of families
8/19/11
•
MUNICIPAL WARD-BASED
PRIMARY HEALTH CARE AGENTS
•
The teams will collectively facilitate
community involvement and participation in:
•
•
Identifying health problems and behaviours that
place individuals at risk of disease or injury
Vulnerable individuals and groups
Implementing appropriate interventions from the
service package to address the behaviours or
8/19/11health problems
•
HEALTHCARE BENEFITS
•
Primary health care services:
•
prevention,
•
promotion,
•
curative,
•
•
community outreach and community-based
services as well as school-based services
Inpatient and outpatient hospital care
(including specialist and rehabilitation
8/19/11
services)
HOSPITALS BENEFITS
•
As part of the overhaul of the health system and
improvement of its management, hospitals in South
Africa will be re-designated as follows:
•
District hospital
•
Regional hospital
•
Tertiary hospital
•
Central hospital
8/19/11
•
Specialized hospital
ACCREDITATION OF PROVIDERS
•
•
Draft Bill on Office of Health Standards Compliance
(OHSC) will soon be tabled in Parliament
An independent OHSC to be established with 3 units:
•
Inspection
•
Ombudsperson,
•
Certification of health facilities
8/19/11
PAYMENT OF PROVIDERS
•
•
At PHC Level: Risk-adjusted per capita
payments for accredited and contracted
public and private providers
At Hospital level: Global Fee with a move
to Case-based payment mechanisms as
an alternative to fee-for-service with a
strong focus on cost containment
8/19/11
UNIT OF CONTRACTING
•
District Health Authority will be given the
responsibility of contracting with the NHI
•
supported by the NHI Fund’s sub-national offices
to manage the various contracts with accredited
providers
monitor the performance of contracted providers
8/19/11within a district
•
PRINCIPAL FUNDING MECHANISMS
•
Combination of sources:
fiscus
•
•
•
employers
•
individuals
Revenue base to be as broad as possible:
•
to achieve the lowest contribution rates
8/19/11
•
generate sufficient funds to supplement the
Role of Co-payments
•
Co-payments will be levied under
the following circumstances:
•
•
Services rendered not in accordance with NHI
treatment protocols and guidelines
Health care benefits not covered under the NHI
benefit package (e.g. originator drugs or expensive
spectacle frames)
Non-adherence to the appropriately defined referral
8/19/11
system
•
INDICATIVE COSTS OF NHI
Year
Non-AIDS
services
AIDS
services
Other
services
Direct
NHI
Costs
Total
Costs
Modelled
2012
57
17
42
8
124
2015
74
26
46
9
156
2020
112
37
52
13
214
2025
149
45
54
7
255
8/19/11
3535
THE ROLE OF MEDICAL SCHEMES
•
Medical Schemes will continue to exist side by
side NHI
•
May also provide top up cover
•
No one will be allowed to opt-out of NHI
8/19/11
PILOTING OF NHI IN 2012
•
•
•
•
The first steps towards implementation of
National Health Insurance in 2012 will be
through piloting.
10 districts will be selected for piloting.
NDOH conducting audits of all healthcare
facilities
Criteria of choosing these 10 districts will be
based on the results of the audits as well as the
8/19/11
demographic profiles and key health indicators
PREPARING FOR NHI
•
CEO Assessments
•
Designation of Hospitals
•
Revenue retention
•
PHC Re-engineering
•
District Health Profiles
•
Health Facility Audits
Provincial Quality Plans
•8/19/11
3838
PREPARING FOR NHI
•
•
•
Regulations to be drafted to define levels of
hospitals and the appropriate skills
requirements to manage hospitals / public
health facilities
Ministerial Task Team to advise on District
Specialist Teams led by Chair of Confidential
Inquiries into maternal, neonatal and under 5
deaths
Audit of Community Health Workers has been
8/19/11
3939
PREPARING FOR NHI
Job Description -Population Focused
Specialists (All levels and all facilities in
catchment area)
•
•
•
Quality of health care for mothers, newborns
and children
Equitable access
Coordinate, monitor, supervise and support
MNCH services
8/19/11
4040
PREPARING FOR NHI
•
In 2010 there were 150,509
registered health professionals in
South Africa.
From 1996 – 2008 there was a
stagnation in growth of health
professionals and a decline in key
categories such as specialist and
8/19/11
4141
specialist nurses.
•
PREPARING FOR NHI
•
•
Filling currently listed public sector
vacancies would cost billions.
Staffing requirements should be based on
service plans informed by norms and
needs.
It is evident that South Africa has a nurse
based health care system with 80% of
health
professionals
comprising
nurses.
8/19/11
4242
•
PREPARING FOR NHI
•
•
•
Education output of most professions
has been stagnant for the past fifteen
years.
Faculty output of MBChB graduates is
not a full capacity for all faculties, and
varies in quality for all professions.
Budget cuts in the 1990s led to a
8/19/11
4343
Data Mapping for District Health
Profiles
•
•
Data has been collected to develop profiles of
health districts, for selection and prioritization
for piloting
Following dimension have been applied:
•
Demographic
•
Socio-economic
•
Epidemiology/ Health Status
Service
delivery
8/19/11
•
4444
4 Groups of indicators used

District management functionality self
assessment. 5 Sections:
1.
Service delivery platform
2.
District management team
3.
Other management functions



1.
2.
8/19/11
Financial management
Governance and community participation
Health information
Staffing
District office infrastructure
4545
4 Groups of indicators used

10 Socio-economic indicators
Deprivation Index District Health
Barometer (DHB) 2007
2. Population with private medical
insurance rate (Household
Survey 2007)
3. Unemployment rate
1.
8/19/11
4646
4 Groups of indicators used

10 Health Outcome (MDG proxy) indicators
1.
2.
3.
4.
5.
6.
7.
8.
9.
8/19/11
HIV prevalence (Antenatal survey 2009)
TB cure rate 2008 (ETR.Net)
Weighing rate 2010 (DHIS)
Diarrhoea incidence 2010 (DHIS)
Severe malnutrition 2010 (DHIS)
Pneumonia incidence 2010 (DHIS)
Measles 1st dose coverage 2010 (DHIS)
Antenatal coverage 2010 (DHIS)
Delivery in facility 2010 (DHIS)
4747
4 Groups of indicators used

6 Service delivery indicators
1.
Cost per PDE district hospitals 2008/09 (DHB)
2.
PHC expenditure per capita 2008/09 (DHB)
3.
PHC (non-hospital expenditure) per patient visit
2008/09 (DHB)
4.
PHC utilisation 2010/11 (DHIS)
5.
PHC utilisation under 5 years 2010/11 (DHIS)
6.
PHC supervision 2010/11 (DHIS)
8/19/11
4848
PREPARING FOR NHI
Methodology (first 3 groups)
•
•
District and provincial profiles have been
developed
Districts were ranked from best to worst
performing for the 26 selected indicators and
a score from 1-52 given where 1 is best
performing district and 52 the worst.
Where districts have the same value the same
8/19/11
score was given resulting in the last4949
value is
•
PREPARING FOR NHI
8/19/11
5050
Total scores and ranking across all districts socio-economic indicators
Best
8/19/11
Worst
5151
Total score and ranking health service and utilisation indicators
8/19/11
5252
PREPARING FOR NHI
•
•
Audit Scope
HST led consortium appointed to audit all
public health facilities;
•
Infrastructure
•
Equipment
•
HR
•
Finance management
• Services
8/19/11
provided
PUBLIC HEALTH FACILITIES
Province
PHC
District
Hospital
Regional
Hospital
Specialised
Hospital
Tertiary
Hospital
Central
Hospital
Total
EC
808
45
2
18
6
1
880
FS
280
25
5
4
1
1
316
GP
421
10
12
6
0
4
453
KZN
591
37
12
18
2
2
662
LP
463
31
5
3
2
0
504
MP
305
23
3
5
2
0
338
NC
212
18
2
3
0
0
235
NW
363
18
4
2
0
0
387
WC
282
34
5
11
1
2
435
TOTAL
8/19/11 3825
241
50
70
14
10
4210
PROGRESS
Province
Provincial Total
Completed
Completed
Estimate
June 2011
July 2011
Completion date
EC
880
78
140
May 2012
FS
316
42
109
Feb 2012
GP
453
26
94
Feb 2012
KZN
662
59
135
April 2012
LP
504
6
64
March 2012
MP
38
18
73
Feb 2012
NC
235
120
161
Sept 2011
NW
387
28
93
March 2012
WC
435
0
7
April 2012
TOTAL
4210
337
876
9%
21%
TOTAL %
8/19/11
ESTIMATED COMPLETION RATE – 2011/12
MONTH
NUMBER
%
August
1378
33%
September
1794
43%
October
2175
52%
November
2556
61%
December
2927
70%
January
3318
79%
February
3698
88%
March
3962
94%
April
4136
98%
May
4210
100%
8/19/11
PILOTING OF NHI
•
Additional districts will be determined on an
annual basis for inclusion in the roll out.
Aspects for inclusion:
•
Re-engineered PHC streams
•
Basic infrastructure
•
Compliance with standards
• Functionality
8/19/11
of districts and facilities including
THE FIRST 5 YEARS OF NHI
•
•
NHI will be phased-in over a period of 15 years
Will include piloting and strengthening the health
system in the following areas:
•
Management of health facilities and health districts
•
Quality improvement
•
Infrastructure development
8/19/11•
Medical devices including equipment
Thank You
8/19/11
5959
59