Uncertainty about how and when the National Health Insurance will be implemented has stalled reform efforts in the healthcare sector, but it is critical to start addressing the challenges in the sector now, a group of experts say.
Writing in the SA Medical Journal, G C Solanki, T Wilkinson, N G Myburgh, J E Cornell, and V Brijlal, say it is critical that the process of strengthening the health system to advance universal healthcare (UHC) begins now, and several viable initiatives can be implemented immediately.
Assuming the Bill is approved by the NCOP and enacted, it will face three hurdles, the first being legal challenges from various stakeholders, including political parties, the private sector, civil society organisations and potentially one or more of the provinces, regarding legal loopholes relating to constitutional infringements.
The second is simply the inability to fund such a massive social and structural transformation in a weak and stagnant economy.
The third stems from the structural challenges of implementing NHI in an environment of endemic corruption, including in the health sector, lack of trust in government, a highly divided and unequal society, and a health system in which the building blocks required for successful implementation are severely compromised.
The Health Department says the laws currently being processed are intended to lay the groundwork for NHI – which will be rolled out in phases, starting in 2026 and only expected to be fully realised in 15-30 years.
Given the challenges, uncertainties and long timelines, it is very difficult to predict what will be implemented and when.
Against this background, what are the options, in the interim, for making progress toward the ultimate goal of UHC?
The options are to wait – or do something now.
The first option is to continue with the status quo until the NHI is finally approved and implementation begins.
The underlying rationale for this approach is that (i) NHI will be approved and any potential legal challenges to the Bill will be dismissed, and (ii) NHI will provide the ‘silver bullet’ for resolving all health and health systems, on the presumption that the lack of NHI system design and regulations is the root cause of all the existing challenges in our health system.
This is largely the approach adopted since NHI came to dominate the reform agenda 10 years ago.
It has, arguably, stalled efforts to carry out the other reforms required to build and strengthen the health system, and contributed to the neglect and deterioration of both public and private health systems.
The second option is to embark immediately on a plan of action to build and strengthen other key building blocks of the system (regardless of the outcome of the NHI process).
The underlying rationale of this approach is that it would assist in (i) making advances towards UHC in the short-to-medium term and (ii) put in place the other building blocks necessary for successful implementation of NHI once legal challenges are settled.
The second should be the preferred option, representing a more pragmatic, lower risk, more achievable, incremental change. Importantly, an immediate plan of action would not preclude NHI but rather create the conditions for a more achievable transition to an NHI-type funding arrangement.
It would move away from the sterile and non-constructive ‘for v against NHI’ discourse to one that focuses on what can be done now to strengthen health system capacity to achieve UHC, from financing reforms to strategies known to be capable of health system improvement.
Examples of possible reforms in five areas that could assist in advancing towards UHC:
• Progress on urgently needed legislative reform: the Health Professions Act needs to be reformed to allow for implementation of alternative reimbursement models, group practices etc. The National Health Act No 61 of 2003[12] must be reviewed to address issues including control of central hospitals. The regulations related to the Office of Health Standards Compliance (OHSC) must be reviewed, to allow the OHSC to play a foundational role in ensuring health facilities provide – and keep providing – safe and quality care.
The Medical Schemes Act No 131 of 1998 must be reviewed to address the extensive recommendations of the Health Market Inquiry (HMI), which have had limited implementation. The HMI provided detailed recommendations of steps that could improve the performance, efficiency and sustainability of the private voluntary health insurance market and private healthcare providers. Central to these recommendations was a supply side regulator. The immediate establishment of this regulator would generate sector improvements and would also align with NHI aims: the effectiveness and efficiency of the private sector is important, given the integral role of private sector providers in the implementation of NHI.
• Reforms to processes for improving sound and competent management, administrative and clinical oversight and governance: changes take a long time to effect, and we need to start by tackling the lack of separation between the political and operational spheres. While policy determination is inevitably a political process, technical competence should be the over-riding concern in the operational sphere, including for all appointments. Much can be learned from the Western Cape Department of Health, which has managed to balance political and operational imperatives better than most of the other provinces and has performed better on key indicators as a result.
• Establishing a national health information system: the National Digital Health Strategy, needs to be fast-tracked, including implementation of a common health patient registration system and health patient registration number for all residents (both public and private sector users). Only through this can we start capturing the data necessary to plan for the health and healthcare needs of the country. The Covid period generated several innovative information agreements and dashboards that brought public and private sector data together, making information both transparent and useful. Other IT systems (like the Hospital Emergency Centre Triage and Information System (HECTIS) in the Western Cape, used to triage and track patient flow through services) are already available to roll out to other areas.
• Steps to improve prioritisation and use of evidence and analysis to inform decision-making across private and public sectors: health technology assessment and evidence-informed design of benefits packages would both contribute to progress towards UHC and generate immediate efficiency, quality and equity improvements. A key driver of sustainability and public trust in NHI will be the technical and procedural competence to define what health technologies and interventions the NHI will offer and for whom. International experience indicates such systems take years to develop. A functioning system of prioritisation is critical, and existing work can be accelerated regardless of NHI reform progress. In previous work, it became clear that the public sector largely operates according to defined clinical protocols, whereas private sector practices showed much more variation, with influences on practice from professional organisations, clinical networks and international practice. Adopting a set of agreed common protocols and clinical guidelines based on SA-specific evidence of efficacy and cost-effectiveness would go some way to standardising quality of care as well as providing a common and recognised medico-legal baseline for clinical practice.
• Learning from health system reform experience within SA and in other countries, particularly low- and middle-income countries: we have an existing health system in which some elements and innovations work very well, and lessons from this success could be applied to other focus areas for improvement or rolled out across more parts of the country. A call to identify such programmes is sure to elicit a long list of examples. More than 70 countries have attempted health reforms in the past decade. While SA has experienced difficulties in rolling out NHI policy, other countries like Ghana have made significant progress in implementing their reforms and advancing towards UHC. We need to learn from these experiences in shaping our reform process.
It is critical that the process of strengthening the health system to advance UHC begins now, rather than waiting for NHI to solve all problems. Viable initiatives exist and can be implemented without delay. The adage that UHC is a “journey not a destination” has never been more relevant, as South Africa resumes this journey
Dr GC Solanki – SA Medical Research Council/Health Economics Unit, University of Cape Town/ NMG Consultants; T Wilkinson – Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town; NH Myburgh – Faculty of Dentistry and WHO Collaborating Centre for Oral Health, University of the Western Cape; JE Cornell – Nelson Mandela School of Public Governance, University of Cape Town; V Brijlal, Clinton Health Access Initiative, Pretoria.
See more from MedicalBrief archives:
NHI now closer to becoming law after passing NCOP hurdle
Other options than NHI for quality UHC
SA Health Review: HR weaknesses threaten NHI
Fix current system before NHI implementation
Current version of NHI Bill risks continuation of status quo