The current approach to a contentious draft provision in the National Health Insurance (NHI) has the potential to undermine the implementation of the scheme and delay urgent reform to the health system.
The crux of the major disagreement is around Section 33 of the NHI Bill, which states that medical schemes may only provide cover that "constitutes complementary or top up cover and that does not overlap with the personal health care service benefits purchased by the National Health Insurance Fund on behalf of users".
Fin24 reports that the issue was a key concern raised in research and interviews conducted by Section 27 and consultancy Concentric Alliance with numerous stakeholders on how to work together to fix the "fatal" stagnation in the healthcare sector. A report on the findings highlighted that people were interviewed from the national and provincial Departments of Health, health regulators, medical schemes, public and private health care workers, trade unions and private hospital groups, among others.
Their report found that the role of the private sector is one of the most contentious aspects of health reform in South Africa, particularly around medical schemes.
"The private health sector contributes significantly to the South African economy, is a large employer and many respondents in both the public and the private sector believe could be an important role player in health reform, having significant excess capacity and resources available," the report found.
The report said ultimately "private medical schemes that are not gap cover, will cease to operate, with members covered by those schemes being required to use the NHI." This was the cause of "significant disagreement" between the private sector and the national department of health.
"Unsurprisingly, all respondents from the private sector have argued that even in countries with the most developed and extensive public health services there still exist private healthcare funders," the report said.
"Additionally, an academic argued that it would better to incentivise people into abandoning private funders by establishing a reliable and well-functioning public funder, rather than threatening to remove a functioning service."
One private sector participant said the NHI said Section 33 would constrain competition and limit the efficiency of the NHI.
Submissions on the Bill raised concerns about the transition to NHI and how "without careful forethought this section will result in many additional users moving into an already overburdened public sector, without the necessary strengthening of the public sector".
It said that for some stakeholders Section 22 has become "something of a hill to die on."
The report found that the current approach to this draft provision has the potential to undermine the implementation of the NHI and delay urgent reform to the health system.
However, a Business Day report says the report found that government does not need to wait for NHI to take steps to improve healthcare, such as those recommended by the Health Market Inquiry.
“We have had real stagnation of health reform efforts while waiting for the NHI Bill. (But) there are things we can do now,” said Section 27 head of health Sasha Stevenson.
The report drew on interviews with participants from national and provincial government departments, private hospitals, the pharmaceutical industry, medical schemes, trade unions, healthcare workers, academia and the media.
“Everyone agreed on the urgent need for health reform,” said Stevenson. “They also agreed there’s a need for, and possibility of, collaboration.”
Recommended measures to improve healthcare in parallel to the government’s work on NHI include adopting some of the HMI recommendations: reforming procurement systems, establishing projects to measure health outcomes in the public and private sector, and devising pilot projects to experiment with different ways of procuring and financing health services for NHI.
The HMI was established by the Competition Commission in 2014 to investigate the dynamics in the private healthcare market and whether there were barriers to competition hindering patients’ access to care. None of the recommendations from its final report, published in 2019, has been implemented.
These included establishing a “supply-side health regulator” to oversee private sector pricing, the quality of services, and licensing of private healthcare facilities.
Nearly all participants indicated a willingness to attempt dialogue, suggesting scope for building consensus in areas of disagreement such as the role of medical schemes, said Stevenson. One of the most contentious aspects of the NHI Bill is its proposal to reduce the role of medical schemes to providing only “complementary cover”, limited to benefits not provided under NHI.
Discovery group executive director Ayanda Ntsaluba said various parallel processes could be undertaken as NHI was developed, like strengthening the public sector, implementing public-private partnerships, and implementing the HMI’s recommendations. “Many people really want to make sure our country works,” he said.
Health department’s deputy director-general for NHI Nicholas Crisp said officials had decided which aspects of the HMI report to implement before the coronavirus pandemic in early 2020, but their work was delayed by the crisis. “We lost two whole years of things we wanted to do,” he said.
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