5. NHI and the four UHC alternatives

In the earlier report 7, the four scenarios that were presented (Status Quo Gold Standard, NHI Rejigged, Power to the People, and Reorienting Towards Value) allowed the reader to reimagine UHC implementation in South Africa. We conducted a comprehensive literature review before the report and also used interviews and documentation to differentiate the scenarios.

Each scenario has the five policy objectives embedded into its core, and therefore represent a reimagining of the ‘how’ for NHI (see Table 6). The scenarios may help the South African government and various UHC stakeholders to continue furthering the important UHC agenda, without risking the public purse or service continuity.

Table 6: Alternative UHC scenarios explored in this document

Model NHI costing estimate: upper threshold (in R billion) NHI costing estimate: lower threshold (in R billion) Implications for total health expenditure

Status Quo Gold Standard

• Better service delivery through improvements in quality of care and system hardware.

NHI Rejigged • Better regulation of private sector that will bring down high costs. • Improved quality of care in the public sector.

Power to the People

• User given a choice of insurer by allowing for multiple purchasers, but with a centralised risk equalisation fund to ensure equity across funds. • This should ensure administration of funds is more responsive to client needs (smaller bureaucracies). • More competition between insurers to encourage better administration of funds. • Government is able to hold insurer to account because they are not solely reliant on them. • Equity across the system as a whole. • Governance strengthened through bottom-up accountability. • Sustainability driven through strategic purchasing and competition between purchasers. • Competing insurers incentivised to drive efficiency. • Quality driven through greater participation.

• Better data quality and transparency to facilitate evidence for decision-making.

• Earlier development of basic benefit package. • Development of transitional central risk equalisation fund across sectors to lay foundation for NHI

Fund. • Equity within the public sector, but not between sectors. • Improved public sector governance. • Sustainability of the public sector strengthened, but costs likely to continue to spiral in the private sector. • Public sector efficiency improved through data and decision-making. • Minimum quality standard is raised.

• Equity within each sector, and then improved equity between sectors. • Improved governance in both sectors. • Improved sustainability in both sectors. • Efficiency gains as a result of shifts in incentives in the private sector. • Minimum quality standard is raised as equity improves.

Reorienting Towards Value

• Better quality of care. • More affordable care.

care. • Improved equity between sectors. • Better data quality to compare and measure providers. • Equity achieved over time through alignment across sectors. • Governance strengthened through bottom-up accountability. • Sustainability achieved through orientation towards value. • Efficiency driven through bottom-up reorganisation of service delivery. • Quality becomes key focus of this approach.