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NHI Bill - What will work, what needs to change
THE NATiONAl HEAlTH iNSurANCE Bill
What will work, what needs to change
SelAelO MAMeTJA MBBCh, MMED Public Health (FCPHM(SA), Chief Research Officer, GEMS
Various arguments have been made pro- and anti-NHI as a financing mechanism for the country. Among many arguments is that South Africa already has existing Universal Health Coverage (UHC) through the tax-financed public sector- and medical scheme-funded private sector. Despite what many may define as UHC, both medical scheme beneficiaries and patients accessing state healthcare find that on the ground, both systems leave them vulnerable to lack of access (especially in resource-constrained public sector facilities), exorbitant premiums and out-of-pocket expenditures. The inequitable distribution of healthcare resources (e.g. hospitals, human resources) further exacerbates geographical and income disparities. The introduction of NHI to advance equitable access to healthcare for all South Africans is both a moral imperative and a tool to advance our constitutional right to quality healthcare irrespective of our socio-economic means. Pooling of financing mechanisms and having a mandatory prepaid NHI will provide South Africans with equal opportunity to participate meaningfully in their healthcare financing, irrespective of their socioeconomic means. The bill also outlines mechanisms to improve efficiencies, such as using general practitioners (GPs) as gatekeepers, referral pathways and formularies. A Government Employees Medical Scheme (GEMS) study has shown that this mechanism can improve efficiency and reduce costs by 16-20%. Section 27 of the South African Constitution guarantees everyone the right to healthcare and places upon the state a duty to take reasonable measures within its available resources to achieve the progressive realisation of this right. Therefore implementation of National Health Insurance (NHI) using various legislative frameworks is pro-South African Constitution. The purpose of this article is to highlight what will work.
NHI as a means to achieve equity is in line with international debates and policies. In countries where NHI exists, debates have shifted to reducing gaps in healthcare and ensuring equality. Among many determinants of health in South Africa, healthcare financing remains a key determinant of inequity. Equality has been on the South African agenda since 1994.
RISK-POOlIng
Risk-pooling is perhaps one of the things that can easily be achieved once the bill is approved. In creating a unitary fund, it is important to consider the uniqueness of South Africa. As part of health policy to expand access to healthcare, the state gazetted the Medical Schemes Act that allowed the existence of a high number of medical schemes.
The introduction of demarcation regulations under Section 70(2b) of the Short-term Insurance Act means that demarcation products continue to create fragmented risk pools. While the Medical Schemes Act is not proequity it did create some entitlements in the form of prescribed minimum benefits (PMBs). When consolidating medical schemes and other sources of financing, it is therefore imperative to ensure that no South African is left worse off than they were before, as FOOD FOR THOuGHT
Inclusion of a basic benefit package will create some form of assurance as well as a mechanism for accountability.
A clinically sensitive and independent mechanism needs to be introduced as part of the governance structure within NHI.
The bill must introduce a definition of quality healthcare and the requirements for the independent assessment thereof.
the state is required by the Constitution to be progressive and not regressive in the realisations of healthcare.
ACCOuntABIlItY
The inclusion in the NHI legislation of something similar to the PMBs in the form of a basic benefit package will create some form of assurance as well as a mechanism for accountability. Such a basic benefits package needs to be both pragmatic and practical, and the public sector has introduced a similar mechanism in the form of the Essential Medicine List. The WHO recommends the commitment to a basic benefits package and refers to this as essential healthcare.
As a single purchaser, the government may lack the capacity to effectively negotiate fair prices. The private sector can collude and push prices up, or the government can negotiate poor quality at low prices. In the South African health market, a monopsonous purchaser will further entrench the imperfect and ineffective conditions, drive out small players and stifle productivity.
dECEntRAlISAtIOn And gOVERnAnCE
South Africa has been considering the delivery of healthcare at district level. Although this has been advancing slowly, it is not clear how a single purchaser is going to advance decentralised healthcare. Furthermore, the governance structure gives the Minister all the powers. The NHI Bill tries to advance the contracting units for primary healthcare as devolved structures. However, their decision-making powers are not well defined.
The United Kingdom National Health Service has made a remarkable journey in the evolution of healthcare and balancing of powers. In 2012 it devolved to Primary Care Trust (PCT). By 2015, as part of the government's stated desire to create a clinically driven commissioning system that was more sensitive to the needs of patients, clinical commissioning groups led by GPs were established.
It is therefore imperative that South Africa similarly ensure that the single purchaser's desire for low prices does not compromise the population’s
Selaelo Mametja, Chief Research Officer, GEMS
healthcare needs and that we remain patient-centric.
A clinically sensitive and independent mechanism needs to be introduced as part of the governance structure within NHI. The NHI Bill refers to a Benefits Advisory Committee, which will also be appointed by the Minister and thus have no independence at all. In addition, it is necessary to have an independent body (i.e. independent of the fund and Minister of Health) to assess the quality of healthcare provided.
Accreditation of health facilities is a prerequisite, but it only addresses one of the three pillars of quality of healthcare: the structure, but not the processes and outcomes. Since quality and equity are the inseparable twins of healthcare, it is necessary that the bill introduce a definition of quality healthcare and the requirements for the independent assessment thereof.
fIghtIng fRAud And CORRuPtIOn
A big uncertainty is whether the NHI fund can effectively pool resources and distribute them efficiently and equitably in the face of three big threats: fraud, corruption and the existing massive inequalities in social determinants of health.
According to Transparency International, South Africa ranked number 66/180 in terms of corruption; 65% of people thought that corruption increased between 2019 and 2020, and 18% of people have paid a bribe to a public sector official. Despite these statistics, COVID-19 has revealed that a lot of corruption took place. Like equity, corruption and fraud need to be recognised as key determinants of health and require the necessary redress.
A robust and effective legal system is both a deterrent and tool to prosecute corruption. It is therefore important that the NHI Bill seeks to prevent corruption by ensuring that no individual has absolute power and by establishing a corruption-proof governance structure. The current governance structure has been criticised for giving the Minister of Health excessive powers and weaknesses in accountability. It is imperative to address the social determinants of health by ensuring that all policies address unemployment. This will be critical to the success of NHI.
In closing, South Africa needs to provide universal coverage through an equitable financing mechanism, and the NHI Bill provides for such a structure. However, the implementation needs to be pragmatic and barriers to equitable and quality healthcare, such as fraud, waste, abuse and corruption, must be addressed.
