The official passing of the NHI Act, which has stirred enormous debate, has the potential to be the most transformative health policy since our democracy – if implemented ethically, with the right priorities and the requisite organisational and health system capability, argues a group of experts.
Fewer than 16% the population has private medical insurance and yet 50% of the country’s entire health spend serves this tiny margin of private sector users.
Despite this, write Tracey Naledi, Krish Vallabhjee, Atiya Mosam and Mark Heywood in Daily Maverick, the public health sector, with the other 50% of health expenditure has still been able to ensure that 70% of the population has access to Universal Health Care (UHC) services.
Has this care been as quick and as excellent as we’d all like? No. But neither has care in the private sector.
They write:
The 2019 report of Health Market Inquiry shows that South Africa’s private healthcare over-services its clients, offers variable patient experiences, and varying quality of care. This inquiry calls for regulatory reforms to enhance efficiency, competitiveness, affordability and service quality.
It is with this context in mind that the government passed the National Health Insurance (NHI) Act, which has, judging by the media, caused fear and outrage in sections of the population.
Yet for the authors of this article, as public health practitioners and social justice activists, we recognised the opportunity the NHI poses to be the most transformative health policy since our democracy – if implemented ethically, with the right priorities and the requisite organisational and health system capability.
The ongoing debate around the NHI in this period has facilitated public discussion about its financing, governance, administration and resourcing.
These debates should be considered alongside the evidence shown by the WHO’s data that increased healthcare investments promote social protection, cohesion and economic growth; offering 9:1 returns; and increasing per capita GDP by 4% for every extra year of added life expectancy.
Limited lens
The focus on the NHI debates are too often made through a limited lens on the impact of hospitals and private care in particular. It often neglects an understanding of providing and adequately funding the essential components of primary healthcare, like preventive, promotive, rehabilitative, and palliative care; advancing agency, economic development and democracy.
Even though the NHI has its foundation in primary healthcare, the reality is that investments in the health system are largely hospicentric and focus on curative care.
The government spends less than a third of its total health budget on limited primary healthcare; seven times less than its hospital expenditure. And there is no real impetus for change. Private sector health users fund their primary healthcare out of pocket or through limited health insurance benefits, or through the public service.
The WHO defines universal health coverage as “when all people have access to the full range of quality health services they need, when and where they need them, without financial hardship”.
If our goal is UHC, which many who denounce the NHI still insist they support, then the focus needs to shift to ensuring that health system reforms prioritise primary healthcare that is proven to deliver universal health coverage cost effectively.
According to the WHO, primary healthcare means it is: available to people closest to their communities embedded in a strengthened health system; empowerment of people and communities; and multisectoral action to address social determinants of health.
To advance UHC, the NHI could implement five key elements:
• Prioritise neglected, under-served areas.
• Orient the system towards primary healthcare.
• Explore a blended funding model.
• Implement the Contracting Units of Primary Care system within a District Health Services model.
• Strengthen social accountability and community involvement to improve governance and oversight.
Prioritise neglected and under-served areas
Addressing health inequities means allocating resources based on greatest need and where we can have the biggest impact on population outcomes: i.e, primary healthcare and rural health. About 80%-90% of patient contacts happen in primary healthcare services; and a large footprint of primary healthcare facilities and community-based services reach into households, schools and other sites.
However, in the early stages of implementation, the NHI is unlikely to reach significantly into rural and underserved areas, because funding is dependent on compliance with a set of standards within the current infrastructure. Due to historically better funding, secondary and tertiary hospitals are more likely to meet these standards than district hospitals, primary healthcare facilities and rural facilities.
Until more targeted interventions are initiated to support primary healthcare facilities to comply with necessary standards, the NHI will merely entrench existing inequalities that marginalise rural and chronically poor communities, and continue to slant delivery towards hospicentric and urban healthcare.
Orient the system towards primary healthcare
A recent article in The Lancet shows the benefits of orienting health towards primary healthcare systems. Focusing on disease prevention, early detection and treatment, treatment adherence support, rehabilitation and appropriate palliation, improves access to quality services, reduces the use of specialists and hospital services, and improves population health. Both user satisfaction and self-reported health improved. Primary healthcare-based systems are better prepared for, and more resilient in, emergencies like pandemics.
The Lancet further asserts that the long-term benefits of reorienting health towards primary healthcare outweigh the costs. However, specialised hospitals are important to ensure a balanced health system for more complex health conditions. But with a strong primary healthcare system they can be more cost effective and efficient.
Commentators in the NHI debate focus on whether the economy can “afford” and sustain the NHI.
We believe a focus on primary healthcare offers the most important starting place. Innovation and technology provide opportunities to develop newer service delivery models. Paradoxically, greater expenditure on private healthcare is a cost containment and cost-saving strategy.
Explore blended funding model for primary healthcare
Within the NHI framework, medical practitioners at private healthcare level will be paid a fixed amount per patient for a specified period, regardless of how often the patient visits them, or for what service (this is known as capitation). It aims to incentivise providers to offer cost-effective care by rewarding them for maintaining their patients’ health, rather than the volume of services rendered. This will only work if healthcare providers reorient their services to collaboratively work within a cost efficient and effective team-based approach.
On the other hand, inefficient service delivery models could result in providers under-servicing or “cherry-picking” healthier patients with less costly care.
And for service providers in rural and peri-urban areas this model poses more flaws. Fewer medical practitioners in underserved populations mean the fixed-fee arrangement might not cover the overheads and investment needed to register with and operate within the NHI.
A blended financing model may be the most feasible – a mix of capitation, some subsidisation for overheads or infrastructure or human resources as well as performance-based payments. The financing model can be adjusted as the system evolves.
We don’t pretend blended funding for the strategic purchasing mechanism necessary to allocate resources – without corruption and in a way that maximises health outcomes, efficiency and equity – will be easy. Nor that ensuring providers are well versed in these mechanisms will be straightforward either. But both are imperative.
Implement the Contracting Units of Primary Healthcare system
The Contracting Units of Primary Care system represents a real opportunity to develop a multi-stakeholder and community based approach to primary healthcare. This would be a system network comprising a district hospital, clinics or community health centres, and ward-based outreach teams including private providers like local private GPs and pharmacies in horizontal organised networks within a specified sub-district.
It is at this level that service delivery and population based interventions can best respond to local needs. We need ward-based outreach teams with well trained and fairly compensated community health workers and other mid-level workers supported by district clinical specialist teams including family physicians: to be effective these teams must be strengthened and supported by efficient referral mechanisms to specialised care and outreach. Done properly, support by these specialised services to the
Contracting Units of Primary Care system network could be a gamechanger in healthcare access, equity and quality.
There could be stronger focus on prevention, promotion, early disease detection and adherence to medicines, rehabilitation and palliation, closest to people’s homes.
Currently, how the Act addresses the organisation of the Contracting Units of Primary Care system is opaque.
Some issues needing clarification are the primary healthcare benefit package, mechanisms to distribute patients between private and public sector, the relationship with the District Health Management Office, systems for governance and inter-sectoral action needed to address social determinants of health. All provinces have been asked to identify learning sites for these networks and with publication of regulations, greater conceptual clarity will emerge.
Apart from training in hospitals, Contracting Units of Primary Care systems allow inter-professional education of health workers to provide a collaborative package of preventive, promotive, curative, rehabilitative and palliative services. Health sciences students could be “learning while serving and serving while learning” while improving access to healthcare.
Strengthen social accountability and community involvement to improve governance and oversight
Implementing NHI requires ongoing strengthening of the system as a whole. Critical to this are ethical and values-based leadership/management, stronger governance, better operational processes, and more flexible, adaptable implementation mechanisms based on emerging evidence and learnings.
We can hypothesise for a long time, but there is no better teacher than real life experience in a complex adaptive system. South Africa has some of the best health academics in Africa and globally, and we need to harness their expertise to support the creation of learnings and knowledge for a successful NHI.
Our public health physicians, data scientists, health economists, and health system researchers, partnering with health system practitioners, offer strong knowledge generation muscle to try out models of implementation, and to adapt and pivot if required; keeping clear the goal of transforming the system towards equitable access to cost effective, quality healthcare.
South Africans demand accountability in all spheres of public life including in healthcare. It is essential to properly resource and strengthen the authority of community governance structures envisaged by the National Health Act. This includes getting District Health Councils, hospital boards and clinic committees to listen to their communities and ensure accountability to those they serve.
The consultative process for drawing up annual district health plans, for example, needs the same recognition and support as that given to Integrated Development Plans in local government – but with learnings from the Integrated Development Plans experience and without the corruption.
Strengthening trust, social accountability and community involvement is an important dimension to deepening democracy.
In the interests of health, stop bickering, start doing
It is well recognised that the implementation of the NHI will take many years. This is not unique to South Africa; experiences worldwide have shown that these kinds of health reforms take time to fully implement. In that time, we must continue public dialogue, improve governance mechanisms to prevent corruption and over-centralisation of power and resources, provide regulatory details of how the NHI Act will be implemented, and explain some of the opaque issues to give citizens comfort and trust in the process.
Health is a cornerstone of societal well-being, particularly in a most unequal country like South Africa. Improved quality of life can break the cycle of poverty and empower citizens to contribute meaningfully to society. If we take this constructive approach, the NHI is a vital opportunity for transforming health outcomes.
The road ahead will probably be convoluted given the nature of complex adaptive systems, but we believe South Africans have the determination to embark on this journey.
Naledi is a Public Health Medicine Specialist, an Associate Professor of Public Health Medicine and Deputy Dean: Social Accountability and Health Systems, Faculty of Health Sciences, UCT. Vallabhjee is a Public Health Medicine Specialist, an Adjunct Associate Professor at the Health Systems and Policy Division, School of Public Health, University of the Cape Town and Technical advisor to Clinton Health Access Initiative ( CHAI). Mosam is a Public Health Medicine Specialist and an independent consultant and founder of Mayibuye Health. Heywood is an adjunct professor at the Nelson Mandela School of Public Governance at UCT and an independent health and human rights activist.
Daily Maverick article – What would it take to turn NHI into universal healthcare? (Open access)
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Eight steps to get SA’s health sector right
Health funders flag poverty, quality of care, in NHI challenges
Let’s be pragmatic to make NHI work for us