NATIONAL HEALTH INSURANCE Navigating a route up the NHI mountain

Navigating a route up the NHI mountain

Universal healthcare in South Africa is a natural extension of incremental legislation aimed at meeting the government’s constitutional obligation to create equitable access to healthcare for all – currently available at nowhere near the scale required.

Intense debate roils around the government’s healthcare track record, high medical inflation, profit-oriented private medical aids and private sector over-servicing. Whether South Africa can afford an estimated R500 billion, phasedin National Health Insurance, NHI, in the current parlous economy – recently degraded by institutional corruption and Covid-19, is also hotly contested. As with all redistributive moves, those who stand to lose the most complain the loudest, whether they be healthcare businesses or higher-income taxpayers.

Many problems in the South African healthcare system can be traced back to the apartheid era (1948-1993) when the healthcare system was highly fragmented, discriminating between four different racial groups (black, mixed race, Indian and white). To worsen the situation, the apartheid government developed 10 Bantustans (the so-called ethnic homelands) into which Africans were unwillingly segregated, each with their own departments of health.

It’s been 27 years since the first democratic elections allowed racial and geographical integration to begin addressing gaping inequities in resource distribution and delivery. The NHI is an attempt to comprehensively deal with this legacy, making it a steep mountain to climb – and the air seems to have got thinner half-way up.

Most rational protagonists agree that it’s a moral imperative to create equal healthcare in a country with the world’s worst Gini co-efficient and such severe structural imbalances. Where it gets really interesting is in the ‘yes, but how?”

Government’s answer The government’s answer is a health financing system designed to pool funds and actively purchase services more cost-effectively to provide universal access to quality health services for all South Africans based on their health needs – irrespective of their socio-economic status. All NHI services will be provided free at point of care. At present the money South Africa uses to buy healthcare sits in several different pockets or “pools” – across dozens of individual medical schemes – and in the public purse. When money is split like this over many, smaller pools – which in the case of medical schemes are accessible only to a privileged few – it limits any

one pool’s ability to enable crosssubsidisation based on income or risk. Put another way, with so many different pots of money the country is unable to effectively use funds from the rich to help cover the poor, or payment from more healthy people to offset costs incurred by those who are sicker. A single pool obviously provides massive bargaining power when it comes to buying medicines and equipment in bulk.

The NHI will be financed through mandatory pre-payment. No taxpayer will be able to opt out of an incomerelated hike, though they may choose not to use NHI healthcare services and stick with their medical aid – which will eventually be legally constrained to provide only NHI-complementary services. This is another big debate, with many in the private sector arguing that there are simply not enough resources to go around, and contending that the NHI will lead to worse, not better overall healthcare delivery. Medical aids have added their voices to the protest choir saying the envisaged NHI is unaffordable, not to mention limiting an individual’s right to purchase additional healthcare (the latter, an argument the Constitution seems to rebut). The State merely shrugs and says sorry, all healthcare providers and facilities, public and private, will be paid from an NHI pool, based on proper accreditation, services delivered – and the quality of healthcare outcomes. Like it or not, the NHI is intended to be up and running by 2026.

The public healthcare system as it currently stands serves 80% of the population and South Africa spends 9% of GDP on healthcare, or US$499.2 per capita, a relatively high figure globally – yet one that hardly matches healthcare outcomes. Of the 9% of GDP, approximately 42% is government expenditure.

South Africa currently lies 48th among 93 countries in the 2021 World Healthcare Index, (Taiwan and South Korea numbers One and Two, and Bangladesh and Venezuela 92nd and 93rd.)

According to World Health Organization, (WHO), 2019 statistics, South Africans have a 26% probability of dying from cardiovascular disease, cancer, diabetes or chronic respiratory disease between ages 30 and 70. That’s just the non-communicable diseases. The others making up our quadruple burden are communicable diseases (e.g HIV/TB), maternal and child mortality, and injury and trauma. More than 28% of adults are obese – the highest rate among sub-Saharan African countries.

Human resource inequities An estimated 79% of doctors work in the private sector with an overall

The public healthcare system as it currently stands serves 80% of the population and South Africa spends 9% of GDP on healthcare, or US$499.2 per capita, a relatively high figure globally – yet one that hardly matches healthcare outcomes. Of the 9% of GDP, approximately 42% is government expenditure.

doctor to population ratio of just under one to 1 000, well below the world average. Professional nurses in both sectors have the highest share of 50- to 65-year-olds at 40%, posing a risk to the implementation of NHI, which relies heavily on nursing staff as part of the primary healthcare re-engineering.

The process of policy development began in 2012 and included piloting of health system strengthening initiatives. Activities in the initial phase were funded through a combination of sources which included National Health Conditional Grant and the Health Infrastructure Grants. Workstreams were established to further refine the policy and incorporate public input

as well as make recommendations for phased NHI implementation. The NHI pilot phase threw up useful lessons in the implementation of integrated school health services, maternal and child health initiatives, district clinical specialist teams and primary health care outreach teams. These were integrated into the 2nd phase scale up which began in 2017 and continues to 2022 – also focusing on amendments to NHI-related legislation.

Included in this phase is the establishment of institutions that will be the foundation for a fully functional NHI Fund. The current phase will also entail purchasing of personal healthcare services prioritising vulnerable groups such as children, women, people with disabilities, the elderly orphans, adolescents and underserviced rural populations. Health systems strengthening initiatives will run concurrently as the primary healthcare backbone of the NHI is strengthened. Health facilities that are compliant with the certification requirement of the Office for Healthcare Standards Compliance and meet set criteria will be accredited by the NHI Fund as part of strategic purchasing. The Fund will contract directly with accredited public hospitals (including regional, tertiary, central and specialised hospitals). In the latter phases of implementation, the NHI will also contract with certified and accredited private providers at higher levels of care, based on need.

Overseeing all this is the pragmatic Dr Nicholas Crisp, a veteran public healthcare specialist whose experience has taken him into every nook and cranny in the system.

Corruption – SA now ‘alert’ Asked about setting up a R500 billion NHI fund in the aftermath of State Capture and the mismanagement and corruption at most State-Owned Enterprises, Crisp replies confidently; “now is the best time to do it.”

He explains that civil society has been rendered ‘super-observant’ and strongly believes they’ll never allow grand theft again. This, combined with state-of-theart IT systems in the NHI, will enable unprecedented fraud-proofing. He scotches any narrative depicting the private sector as angels, pointing to multiple adverse findings of the Health Market Inquiry, HMI, and talking of ‘massive, institutionalised organised fraud,” which the HMI diplomatically labelled as ‘supplyinduced demand,’ (aka over-servicing).

In a November 2020 webinar, hosted by the SA Academy of Family Physicians, Dr Crisp paints a picture of how the new system will work for healthcare providers.

“There’s no reason to change individual private practices, group practices, managed care or NGO outfits. The NHI will pay everyone via a Contracting Unit for Primary Health (adapted from the Thai model), known as CUPs – using risk-adjusted capitation,” he explains. These ‘CUPs’ will contract primary healthcare services embracing prevention, promotion, curative, rehabilitative ambulatory, home based and community care. Each health district-based CUP will have its own catchment area and population and will have to fulfil certain criteria. Patients will register with a health facility in a CUP catchment and access services within that area. The entire population will be registered using a unique identifier linked to the Department of Home Affairs’ identification system. The registration information will be from cradle to grave, encrypted and be used to access services at different levels of the health system. Also in November 2020, Health Minister, Dr Zweli Mkhize reported to parliament that a total of 3,059, (of 4 200), public healthcare facilities had implemented the Health Patient Registration System (HPRS) and that registered NHI beneficiaries had reached a total of 45,286,288. (The estimated population of South Africa in 2021 is

60,041,994, a 1.24% increase from 2020).

“Digital first” approach Dr Mkhize said that the HPRS would act as the ‘backbone of an electronic health patient record’.

Ironically, South Africa’s current pre-eminent healthcare challenge – Covid-19 – has boosted efficient healthcare referral pathways and brought digital devices that support this (like the Vula cellphone app) and those addressing other dire needs, to the fore, smoothing the path for the NHI. Multiple papers on human resources for healthcare have stressed that without a “digital first’ and agile, innovative task-shifting approach, the current medical campus’s and nursing colleges will never be able to produce enough healthcare professionals to keep up with population growth – or lower the dismal healthcare worker to patient ratio.

Covid-19 has concentrated the minds of the country’s top healthcare strategists around planning, supply chain management and the efficient use of resources, proving that a crisis can provide huge opportunity besides, and perhaps because of, the danger it poses. The coronavirus battleground has prompted unheard-of teamwork between NGOs, overseas agencies, the public and private healthcare sector, laboratories, epidemiologists, health economists, researchers and clinicians, even outstripping the chronic HIV/ Aids pandemic at it’s peak, though that left stakeholders more robust than before, gaining South Africa as many bouquets as the corruption and dysfunctional management have since earned brickbats. According to Paul Cox, Managing Director at the Essential Group of Companies, South Africa has been forced to make a digital shift in the wake of the pandemic.

“Traditional paper records could potentially transmit the virus among healthcare workers. In turn, this led to the adoption of new technologies which have made data collection and analysis far easier and faster,” he says.

Cox believes that data extracted could potentially transform healthcare and deliver better outcomes for patients. “When health practitioners have access to a patient’s complete health data, they can offer more efficient, more personalised care. Additionally, health data used in scientific research could potentially accelerate the development of new medical products and treatments for those who need them.” Also, with the increased uptake in personal health monitoring apps and devices, “patients have greater insight into their own health and are able to make lifestyle changes accordingly, which can further augment their care outcomes and positively impact their quality of life.”

The MD says better health data will speed up diagnoses, prevent disease by identifying transmission pathways, and increase the effectiveness, quality and safety of treatments. “Moreover, it could

patients have greater insight into their own health and are able to make lifestyle changes accordingly, which can further augment their care outcomes and positively impact their quality of life.”

enable better coordination of care amongst health providers to ensure that a patient’s health conditions are managed appropriately.”

He adds that advantages for the NHI include the ability to design better care pathways, insights for strategic planning, and consequently using healthcare resources more efficiently.

Crisp low down continues. Dr Crisp told NHI-curious clinicians that in rural areas where staff were only available at hospitals, the accredited health providers would have to associate with the District Hospital to constitute a CUP.

“The amount of money available for patients you look after will be decided by the number of people living in your particular area – and obviously multidisciplinary practices that cover the specific disease profile in that area will prove the most viable,” he said. He said the outcomes-based capitation model would be risk adjusted (higher payment if a practice was seen to be referring less stroke or diabetes patients to hospitals or wwas treating more women of childbearing age.)

“If you’re contributing to the primary healthcare system working, then you should be rewarded for that with an outcomes-based adjustment,” he explained, adding that the entire remuneration system remained a work-in-progress, though the

If you’re contributing to the primary healthcare system working, then you should be rewarded for that with an outcomesbased adjustment.”

broad principles were set. The risk adjustment capitation model would thus encourage gatekeepers like GP’s or multi-disciplinary practices to tailor their services to the specific healthcare needs of the community.

“If you can show that your outcomes are good, for example on diabetes or kids that are hard of hearing in your community, you’ll get more money. That’s a far cry from just spending money on curative care – preventative care is fundamental to your outcomes,” he stressed.

He said the quicker the fund paid providers (probably weekly), the less chance there’d be for corruption, and stressed that a stack of unwieldy legislation blocking better healthcare delivery would be scrapped as soon as possible.

The air might be thin, but the peak of the NHI mountain is finally visible.