The Department of Health has stated that “The National Health Insurance (NHI) is a health financing system that is designed to pool funds to provide access to quality affordable personal health services for all South Africans based on their health needs, irrespective of their socio-economic status”. It is essentially a funding and contracting mechanism to facilitate the achievement in South Africa of equitable access to quality health services translating into Universal Health Care (UHC).
THE OBJECTIVES OF NHI
To achieve universal access to quality health care services in accordance with Section 27 of the Constitution
To establish an NHI Fund and to set out its powers, functions, governance structures
To provide a framework for the strategic purchasing of health care services by the Fund on behalf of users
To create mechanisms for the equitable, effective and efficient utilisation of the resources of the Fund to meet the health needs of the population
To preclude or limit undesirable, unethical and unlawful practices in relation to the Fund and its users
WHAT IS A REFERRAL PATHWAY?
A patient referral pathway is the process by which a patient is referred from one doctor to another
As outlined in the NHI Bill, you will be referred to Specialists or hospitals with a referral from a primary health care service provider.
WHAT IS A FORMULARY?
A formulary is a list of medicines that is approved for use in the health care system by authorised prescribers and dispensers.
HOW WILL IT WORK?
The NHI appointed Benefits Advisory Committee will determine the health services to be covered by the NHI Fund. Health care services must be accessed first through a primary health care service provider, by following and adhering to the prescribed referral pathways.
Treatment will not be provided if:
- No medical necessity exists for the health care service in question
- No cost-effective intervention exists for the services as determined by a health technology assessment
- The health care product or treatment is not included in the formulary.
Users who are dissatisfied with the reasons for a declined decision, where the Fund will not pay for the health care service, may lodge an appeal against the Fund as covered in Section 43 of the NHI Bill.
THE NATIONAL HEALTH INSURANCE BILL – UPDATE
The new National Health Insurance (NHI) Bill was released on Thursday, 8 August 2019. The NHI Bill elaborates on its aim to provide “free” access to quality health care and health services, at both private and public health, through a package of comprehensive health services.
The NHI Bill will now need to go through the normal parliamentary process, including a public participation phase, before it is put before the National Assembly and the National Council of Provinces. The next steps: