An independent assessment of the National Health Insurance‘s 10 pilot projects nationwide gave them a cautious “mixed success” verdict on the basis that none was an outright failure, writes MedicalBrief. Factors that to “a great degree hindered” success included inadequate planning, lack of resources — especially of staff — inconsistent communication, and a lack of co-ordination.
Responding to the report, Health Minister Zweli Mkhize said the successful implementation of the National Health Insurance (NHI) will rely on unified collaborations and effective political will. Business Tech reports the minister was speaking at the release of the Public Health Strengthening (Genesis) Report on the NHI. This comes a day after the release of the Presidential Health Compact signed by the president.
The evaluation report was the collaborative effort of a consortium led by Genesis Analytics (Genesis), with support from PriceWaterhouseCoopers Advisory (PwC), the Centre for Health Policy (CHP) at the University of Witwatersrand and Insight Actuaries and Consultants (Insight) at 10 pilot projects across the country.
Mkhize said it was important to note that universal health coverage was largely supported by society. “There are those who are concerned because of the impact it has on the way they are running their businesses. That’s not a big issue because we are (building) a system that will make everybody adjust,” he said.
Across the world, Mkhize said, the success of any system begins with political will. “Without it, it doesn’t happen. For any of these things to happen, the system will need champions. Staff must be championed by people who know where we are going and what we need to do.”
Collaboration is another critical element in the implementation of the system, the report quotes Mkhize as saying. “Working together to achieve better results creates a sense of a unified vision. It’s not only collaboration between government and outsiders, but also collaboration within government. Departments have to work together. Even in the Health Department, sections have to work together.
The report says evaluating of phase 1 of the implementation, the report in its findings and discussion notes that overall, the implementation of the pilot intervention had mixed success across the pilot districts.
“None of the interventions can be considered ‘failures’, as all were implemented at scale. However, as with the implementation of any programme, there are important lessons to be learned, which can strengthen these programmes in the future,” notes the report.
Where successful, the panel identified a few common factors. Among these are strong political will, adequate human and financial resources for implementation, good coordination and communication, and good monitoring systems put in place at the time of implementation.
The factors that to a great degree hindered success included inadequate planning, lack of resources, inconsistent communication, a lack of coordination where necessary and insufficient mechanisms to monitor progress to ensure course correction.
Business Day reports that the detailed 200-page document on the 11 pilot projects makes for depressing reading. The report reveals that children identified as needing health care didn’t get it, there were incomplete infrastructure projects, and computers were sent to clinics without access to the internet.
Business Day notes that due to problems with data quality, it cannot be concluded that the NHI pilot projects, which cost more than R4bn over five years, improved each district’s overall health.
Head of Genesis Analytics Saul Johnson said: “It was difficult for the evaluation team to assess the overall impact of the interventions in the pilot districts.” Things that prevented conclusions included “a lack of control group due to the interventions being implemented in both pilot districts and non-pilot districts, and a lack of baseline measures”.
Johnson added that data sets used by Statistics SA often changed each year, making it difficult to measure accurately whether NHI pilots led to an overall improvement in health
According to the report, Johnson said the evaluators found NHI needed a clear vision. “Does everyone know what the vision is and where we are going in our health system?” He said health workers surveyed also called for consequences for poor performance. Health workers in the pilot districts told the evaluators: “We don’t need more training. People have been over-trained. If people aren’t delivering there, there needs to be accountability.”
MedicalBrief extracts from the Final NHI Evaluation report Executive Summary:
South Africa faces numerous challenges in delivering high quality health services to the majority of its population. The majority of the population in South Africa cannot afford private healthcare and must access public healthcare in a congested and understaffed public sector, contributing to slower, less responsive services. The South African Government, through the NDoH, is committed to moving the country towards the goal of Universal Health Coverage (UHC), which is being pursued in South Africa through implementation of National Health Insurance (NHI), as articulated in the Draft NHI Bill.
The NHI is being implemented by the National Department of Health (NDoH) through a gradual process, over three phases. These three phases are each implemented over a period of five years each. Phase 1 commenced in 2012 and was completed in 2017. The 10 NHI Pilot districts were made up of one district in every province, except KwaZulu-Natal (KZN), which had two districts. Subsequently, KZN included a third district which was solely funded through provincial funding. The NHI pilot districts were intended to become sites for innovation and testing throughout the implementation of NHI phase 1. The pilot districts were as follows: OR Tambo (Eastern Cape), Thabo Mofutsanyana (Free State), Tshwane (Gauteng), UMgungundlovu and uMzinyathi (KZN), Vhembe (Limpopo), Gert Sibande (Mpumalanga), Pixley ka Seme (Northern Cape), Dr Kenneth Kaunda (North West), Eden (Western Cape). Amajuba district was the additional district included by KZN.
Overall, the implementation of the pilot interventions had mixed success across the pilot districts. Where successful, we identified a few common factors: strong political will, adequate human and financial resources for implementation, good coordination and communication, and good monitoring systems put in place at the time of implementation. However, the interventions also faced a number of challenges, and, to varying degrees, these factors hindered their success: inadequate planning, lack of resources, inconsistent communication, a lack of coordination where necessary and insufficient mechanisms to monitor progress to ensure course correction.
Assessment of Ward Based Primary Healthcare Outreach Teams (WBPHCOTS), which were responsible for the provision of promotive and preventative health care to households;
Successes: There was a total of 3,323 WBPHCOTs providing basic health services to children and adults at the end of 2017/18. These teams were able to successfully fulfil their mandate to provide outreach health services within the community. WBPHCOTs did not only complete community visits but they were also able to report on the ill health or wellbeing of the individuals at the households visited.
Challenges: Teams often lacked the envisioned team composition, with many teams lacking outreach team leaders. Data collection was insufficient to adequately monitor the effectiveness of the referral systems and follow up processes. At times there were insufficient funds for transport and equipment; this impacted the team’s ability to successfully undertake their work.
Assessment of The Integrated School Health Programme (ISHP), which aimed to provide a range of health promotion and preventative services to school going children at their place of learning;
Successes: A total of 4 339 875 learners had been screened through ISHP since 2012, of these 504 803 were identified to have various health barriers and referred for treatment. This intervention is particularly successful in its ability to demonstrate good inter- departmental collaboration between the NDoH and Department of Basic Education (DBE).
Challenges: There is a lack of data to support the effectiveness of the referrals and a lack of feedback mechanisms between school teams and facilities. The lack of sufficient equipment, such as measurement scales and transport to travel to schools, often impacted its success.
There was a lack of prioritisation and targeting of learners within this intervention was evident during NHI phase 1 implementation.
Assessment of General Practitioner (GP) contracting, which aimed to increase the number of GPs at primary healthcare (PHC) facilities to improve the quality and acceptability of care;
Successes: A total of 330 GPs had been contracted by end of 2017/2018 and where contracting general practitioners (GPs) was implemented successfully, it is evident that the access to doctors improved at facilities. Patient perception was that the quality of care improved at facilities due to the presence of GPs.
Challenges: Inadequate monitoring of these GPs caused some challenges during implementation. Unforeseen contractual challenges during the implementation of this intervention, resulted in GPs having substantially higher expense claims than expected.
Assessment of Ideal Clinic Realisation and Maintenance Model (ICRM), which aimed to increase quality of services through the establishment of minimum standards;
Successes: A total of 3,434 facilities had been assessed and of these 1507 had attained ideal clinic status at end of 2017/2018. ICRM is seen to have improved the ability of facilities to procure much needed equipment. Where ICRM was believed to have been implemented as planned, there was a perceived improvement in quality of care by both facility managers and patients. ICRM limited flexibility and the ability for managers to adapt it to the local context and to the needs of the facilities at the time.
Challenges: The changing manual and frequent change of standards which made it difficult for managers to keep up and resulted in frustration among them. ICRM limited flexibility and the ability for managers to adapt it to the local context and to the needs of the facilities at the time.
Assessment of District Clinical Specialist Teams (DCST) responsible for supporting clinical governance, undertaking clinical work and undertaking research and training;
Successes: At the end of March 2017, 45 of 52 districts in nine provinces had functional DCSTs with at
least three members per team. The DCSTs, where available, were able to
provide specialist oversight within the districts. The introduction of these teams was perceived by some stakeholders to have promoted clinical governance within the districts.
Challenges: The team composition, which often lacked critical specialists, limited their ability to provide the envisioned training and support structures. The lack of gynaecologist and paediatricians meant that DCSTs were not able to adequately improve child andmaternal health as envisioned. Not all specialist are necessarily good mentors and may be unable to provide adequate support. The DCST model is a costly model and stretches the limited specialist resources in the public sector.
Assessment of Centralised Chronic Medicine Dispensing and Distribution (CCMDD), which aimed to improve distribution of medicines to patients through the provision of chronic medication at designated pick up points closer to the communities;
Successes: A total of 2 182 422 patients enrolled on the CCMDD, collecting medicines in over 855 PUPs at the end of 2017/2018. The strong political leadership and will behind CCMDD contributed towards its successful implementation. CCMDD was scaled up beyond target and the consistent monitoring of the programme contributed to the availability of reliable data to support continued implementation
Challenges: The change of service provides threatened the intervention’s continuity. The lack of sufficient integration between CCMDD pick up points and facilities resulted in inadequate tracking of patients between the two systems.
Assessment of the Health Patient Registration System (HPRS), which has the ultimate goal of a fully electronic patient record keeping system, but has started with data capturing of patients and generation of electronic files;
Successes: At the end of 2017/2018, 2968 PHC facilities were using HPRS and there were over 20 million (20 700 149) people registered on the system. Good communication and feedback loops are seen to have facilitated implementation success.
Challenges: The poor connectivity at some facilities and challenges with hardware have contributed to the challenges experienced during NHI phase 1 implementation. The lack of human resources and lack of capacity to implement affected the success of HPRS
Assessment of the Stock Visibility System (SVS) aimed to improve oversight of stock through an electronic stock monitoring system, and thereby reduce stockouts by allowing for appropriate and timely ordering;
Successes: At the end of 2017/2018, SVS was being implemented in 3167 clinics and community health centres (92% coverage). The successful training of available staff, which led to an in-depth understanding of the system at facility level. The introduction of SVS led to reduced stock outs and improved efficiency at facilities
Challenges: The lack of reliable internet connectivity and hardware, impacted its success. The minimal number of available pharmacists and pharmacy assistants limited facilities ability to ensure the smooth running of the system. The sustainability of this intervention poses a challenge as implementation during NHI phase1 relied heavily on the support from external funders.
Assessment of Infrastructure projects implemented to improve health infrastructure to ensure increased access and quality of care;
Successes: Since 2013/2014, work in 139 of 140 identified CHCs and clinics has been completed through the NHI rehabilitation projects. In 2017/2018 alone, 107 facilities were maintained, repaired and/or refurbished in NHI districts. Where completed, patients perceived an improvement in the quality of care as a result. Small infrastructure changes had a positive impact on the overall environment at facilities.
Challenges: Projects were rarely implemented or completed due to the lack of planning capacity to release the assigned funds. Funds which were released were used mainly for new infrastructure projects and insufficient attention was paid to the maintenance of facilities, which is critical to both access and the provision of quality services and preventing unnecessary new-build costs due to deterioration because of a lack of basic maintenance.
Assessment of Workload Indicator for Staffing Needs (WISN), which is a WHO planning tool conducted to help facility managers make more efficient staffing decisions.
Successes: The introduction of WISN provided a standardised, evidence-based staffing needs assessment at facility level. These assessments were implemented widely across the pilot districts
Challenges: The resource constrained environment meant that hiring of staff had been frozen and as a result the WISN findings were not always implementable and caused further frustration among facility managers who had done the assessment.
The evaluation findings highlighted the importance of strong leadership and good governance in order to drive a successful and effective health system. There are four main components of governance which are critical for the successful implementation of NHI: clarity of vision, setting appropriate priorities, performance management and accountability.
In many interventions, the presence of strong champions who held the vision of NHI, and of that specific programme, ensured that there was robust implementation. However, this was not evident in some the interventions. In many cases managers implemented the interventions in silos, and seemed to lose the overall objective of the NHI process, which was to improve access to and the quality of services at facilities. In these cases, there was lack of regular communication at different departmental levels about progress toward meeting the objectives of NHI phase 1. In addition, while interventions were often well designed to meet objectives, the allocated budgets did not always follow priorities and at times led to the interventions going underfunded. The rationalisation of budget allocations and intentions was not always well-understood or aligned to the contextual needs at a provincial and district level. Some performance management structures were put into place during implementation but there was not always an adequate amount of upward feedback. Overall there was insufficient monitoring, and course correction was insufficient in some interventions.
Finally, the organisational culture within some parts of the department is perceived by staff to be overly bureaucratic. The culture is often not supportive of problem solving and leaves little room for creativity or innovation. There is also little recourse for consequences of poor performance, a lack of accountability and insufficient use of data to monitor progress. Likewise, there is little incentive for high performance and to encourage staff to produce high quality data.
There is a need to strengthen health system governance during NHI phase 2, otherwise there is the potential for new interventions to continue to have varied implementation success across the country.
It was difficult for the evaluation team to assess the overall impact of the implementation of the health systems strengthening interventions in the pilot districts on the access to and quality of services, because of various important factors. These include: a lack of control group due to the interventions being implemented in both pilot districts and non-pilot districts; a lack of baseline measures, and the variation of performance indicators which made it difficult to identify clear trends in performance over time.
However, almost all of the interventions were appropriately designed to either improve access to services, or improve quality. Most were implemented at scale, and in many cases, there were qualitative findings of significant improvement in the delivery of PHC across the pilot districts where the interventions were successfully implemented. However, it must be noted that public health services face well documented systemic challenges, included planning and budgeting weaknesses, a lack of qualified staff at all levels, and weak governance systems. These hindered the implementation of NHI Phase 1 interventions.
Mkhize said that certain aspects of the assessments were not meant to be read as “a fail or a pass, but for us to strengthen what we can do”. City Press reports that Johnson, a member of the evaluation team, agreed, saying: “Overall, the implementation of the pilot interventions had mixed successes across the pilot districts. None of the interventions can be considered failures in and of themselves, as all were implemented at scale and reached lots of people. However, there were important lessons to be learnt.”
The Public Health Strengthening Report assessed phase 1 of the project, which ended in 2017. The report, finalised at the end of last year, looked at nine parameters of interventions under the NHI. These included assessing the municipal ward-based primary healthcare outreach teams, who were responsible for providing and promoting healthcare to households; the integrated school health programme; the contracting of general practitioners (GPs); and the ideal clinic realisation and maintenance model.
Regarding ward-based healthcare, the report states: “Teams often lacked the envisioned composition, with many of them lacking outreach team leaders. Data collection was insufficient to adequately monitor the effectiveness of the referral systems and follow-up processes.”
Regarding the school health programme, the report found that 4.3m pupils have been screened through the programme since 2012, and that 504 803 of them were found to have various health problems and were referred for treatment.
However, City Press says the report also states: “There is a lack of data to support the effectiveness of the referrals and a lack of feedback mechanisms between school teams and facilities. A lack of sufficient equipment, such as measurement scales and transport to travel to schools, often impacted on its success.”
The report also found that 330 GPs were contracted by the end of 2017/2018. Where this had been done successfully, it was clear that there was improved access to doctors at facilities – and patients reported that the quality of care had improved at facilities because of their presence.
But, states the report: “Inadequate monitoring of these GPs caused some challenges during implementation. Unforeseen contractual challenges … resulted in GPs having substantially higher expense claims than expected.”
With regard to the ideal clinic model, 3 434 clinics were assessed. Of these, 1 507 attained ideal clinic status at the end of 2017/2018.
But the changing manual and frequent change of standards made it difficult for managers to keep up, the report found.
City Press quotes Health director-general Precious Matsoso as saying that the department had followed up with some of the clinics which had dropped in status to see where they needed help, in accordance with the report’s recommendations.
Johnson said the determining factors in those clinics that recorded successes were strong political will, sufficient staff, good coordination and communication, and good monitoring systems. But these factors were absent in the projects that had performed poorly. He also attributed their poor performance to a lack of resources and insufficient mechanisms to monitor progress.
Answering questions at the event, Mkhize said medical aid schemes will be allowed to exist when NHI is rolled out, after employers or employees have paid their premiums for the fund. The Times reports he also said that the private medical industry was lobbying against NHI but he would not allow them to derail it.
He said first and foremost the NHI single fund would buy services for the whole country. The medical aids could step in. “Are we banning medical aids? No. That role is going to keep changing as NHI opens up right now. We are engaging with medical aids. We will change the way medical aids work.”
“Let’s try and separate the issue of medical aid … we are not going to be bogged down on one issue … by medical aids. Their roles will be evolving.”
“The issue of pretending that is everything in private care and medical aids are rosy is not correct.”
According to the report, the minister added: “Some people say NHI is unaffordable. What is unaffordable is the rising cost of (private) care.” He also said there was a lot of lobbing by medical aids who wanted to block the progress of NHI.
The report says he admitted, however, that the public sector was characterised by “corruption” and “mismanagement” and poor quality and he repeatedly said it needed to be fixed.
Meanwhile, President Cyril Ramaphosa called the signing of the Presidential Health Compact a turning point for the healthcare sector, reports Health-e News. “We are closer to the fundamental transformation of our healthcare system. Through our actions, we are bringing our collective energies to bear to be of service to our people,” he said at the ceremony at the George Mukhari Hospital in Tshwane.
Ramaphosa said the signing of the Health Compact was the conclusion of a long journey that began at last year’s Presidential Health Summit. Key stakeholders were brought together at the 2018 summit to design a roadmap for South Africa’s path to universal healthcare with the NHI as the entry point.
The report quotes Ramaphosa as saying that the compact’s goal was “one country, one health system”. “This means quality of care must be the same regardless of whether you have money or not, and regardless of where you live,” he said.
Many South Africans have raised serious concerns about their healthcare experiences, such as staff shortages, long queues, poor infrastructure, corruption and stock-outs of medicine.
Ramaphosa said the government was aware of these issues, “[but] by working in a collaborative way, we will be able to reach our goals faster and implement them efficiently and with the best use of resources”. He is quoted in the report as saying that the government was mindful of the legacy of decades of skewed resource allocation and under-funding of facilities, especially primary healthcare, and added that 25 years into democracy there had been strides in broadening access to healthcare, in reducing the burden of disease and in raising life expectancy.
The Health Compact is expected to contribute to the improvement of the public healthcare system so that many more South Africans can access quality care – and lead healthy and productive lives.
There would be an active partnership between the Presidency and government departments to ensure accountability and stakeholders are expected to report annually to the president on the progress made in improving the health system.
“We are working together towards the achievement of redress,” said Ramaphosa. “We are working together for the public good, for social cohesion, for economic progress and, as Madiba said, for peace.”
The report says according to the Minister of Health, frozen posts would be unfrozen and critical posts would be filled. “We need to precipitate the expansion of nursing colleges and train more nurses to be deployed into communities as well as strengthen the contingency of community-based doctors,” he said.
According to the report, Mkhize also said the Health Compact would assist in the implementation of critical tasks, such as providing the financing model for the NHI as well as infrastructure upgrading for health facilities to enable the rollout of the NHI in the next phase of implementation.
“The biggest contribution the private sector can make to ensuring better healthcare for all South Africans, is to build sustainable business models within the communities they set out to help”. A Weekend Argus report says this is according to Paul Miller, CEO of Cipla Medpro, speaking at the Cipla Leadership Forum, hosted at the site of two newly launched Cipla Foundation initiatives in Klipheuwel
The report quotes Health MEC Dr Nomafrench Mbombo as saying said: “No-one can deny that issues of equity in access to health services must be addressed: the gap between the haves and have nots, the relationship between public and private. No-one can say we can’t address that.”
Miller said: “Lack of access to healthcare is one significant problem, but there is also a lack of education, as well as a lack of job opportunities. The biggest contribution that private sector companies can make is to partner with the organisations working to solve these problems, and present them with self-sustaining solutions.”
He said turning social responsibility initiatives into workable business models would help to create job opportunities within communities.
Mbombo pointed out that the solutions provided by Cipla Foundation in the form of its Ajuga and Sha’ Left initiatives have shown great promise. “One thing that we at the Health Department understand all too well, is that availability is not the same as accessibility. We can build major hospitals and other facilities, but if community members have to travel far distances and wait in long queues without the guarantee that they will be assisted that day, it does not help.”
An explanatory summary of the NHI Bill was gazetted on Friday of last week in anticipation of its being tabled in Parliament, which is in recess until 20 August. Since new Bills tend not to be made available before being formally introduced in the National Assembly, there is no telling when this important piece of legislation will be released, notes Pam Saxby for Legalbrief Policy Watch.
However, Saxby says, according to the summary, once in force it will establish a national health insurance fund; prescribe its powers, functions and governance structures; provide “a framework for the strategic purchasing of health care services by the fund on behalf of users”; and “create mechanisms” for the “equitable, effective and efficient” utilisation of the fund’s resources. The Bill also seeks to ‘preclude or limit undesirable, unethical and unlawful practices in relation to the fund and its users’. These objectives are underpinned by government’s commitment to facilitating ‘universal access to quality health care services’, in line with section 27 of the Constitution.
Saxby writes that a media statement on the Cabinet meeting at which the Bill was approved for tabling in Parliament promised that it will be subjected to a “rigorous parliamentary process”. This will give NHI critics the opportunity to express their concerns – among other things about government’s capacity to manage an NHI system and fund given the numerous “challenges” associated with financial resources management across the public sector.
Saxby says Deputy President David Mabuza alluded to these in his address to delegates at the Presidential Health Summit last October, when government and its social partners agreed to develop the Health Compact.
Business Tech report
Public Health Strengthening Report on the NHI
Business Day report
City Press report
The Times report
Health-e News report
Weekend Argus report
Legalbrief Policy Watch report
Cabinet meeting statement