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:

WHO WILL BE COVERED?

The NHI Fund will purchase health care services on behalf of the following population groups:

  • All South African Citizens
  • Permanent residents
  • Refugees
  • Inmates and
  • Certain categories of foreigners.

Asylum seekers and illegal foreigners will only be entitled to emergency medical services and services for notifiable conditions of public health concern.  All children, including those children of asylum seekers or illegal migrants are entitled to basic health care services as provided for in Section 28(1)(c) of the Constitution.

Those who are eligible to receive the services must register as a user with the Fund. This can be done through an accredited health care service provider or health establishment.  In order to register, the user must provide his or her biometrics and other information, for example proof of residence, fingerprints, photographs, an identity card and an original birth certificate.

HOW MUCH WILL IT COST?

There have been several figures released since 2011 including that of R256 billion.  However, during the launch of the NHI Bill on the 8th of August 2019, the Minister of Health indicated that the estimated cost is currently being determined through an actuarial costing model commissioned by the National Treasury.  The Memorandum to the NHI Bill outlines figures that will be needed to get the Fund up and running, and to support a quality of care improvement programme required to accelerate quality initiatives.  Further audits will be conducted by the Office of Health Standards and Compliance (OHSC) to support progressive accreditation of facilities for the Fund.

WHERE WILL THE MONEY COME FROM?

The main revenue sources for the NHI Fund will consist of money through the fiscus which will be appropriated annually by Parliament.  This includes money collected from general tax revenue and the reallocation of funding for medical scheme tax credits paid to various medical schemes.  The general tax revenue will consist of existing funds which are currently provided to the Provincial Departments of Health through the equitable share and through conditional grants.

New funds will be raised through a payroll tax (employer and employee) and a possible surcharge on personal income tax.

RIGHTS OF USERS

Amongst other rights, the user will be entitled to the following within the State’s available and appropriated resources:

  • To receive the necessary health care services free at the point of care from an accredited health care provider or health establishment upon proof of registration with the fund (membership)
  • To access any information or records relating to his or her health kept by the Fund
  • To access health care services within a reasonable time period
  • To purchase health care services that are not covered by the Fund through a complementary cover, which is voluntary medical insurance scheme registered in terms of the Medical Schemes Act or any other private health insurance scheme or face out of pocket payments.

There is no detail given on the extent or prescribed benefits of the “complementary or top up cover” that medical schemes/insurers may cover.  Chapter 11, “Miscellaneous”, does, however, include detail on the drafting of the regulations to the proposed Act. Sub-sections relevant to private medical cover include:

(m) the relationship between public and private health establishments, and the optional contracting in of private health care service providers

(n) the relationship between the Fund and medical schemes registered in terms of the Medical Schemes Act and other private health insurance schemes

(x) the scope and nature of prescribed health care services and programmes and the manner in, and extent to which, they must be funded.

No other details are available regarding the benefit set or timing of their release to the public.

One of the more contentious aspects of the NHI Bill is its treatment of the current funding structures in the private sector (notably medical schemes and health insurers).  Media coverage since the release of the NHI Bill has been around how the NHI Bill effectively “does away” with the traditional forms of private health and that you will no longer be able to use the services of a medical scheme or private health insurer to access health services in private setting.

A full review of the NHI Bill reveals these reports are partly true where it is the NHI Bill’s intent to be the primary purchaser of health services in South Africa.  However, it makes a very specific allowance for the continued existence of such mechanisms, with the schemes and insurers only covering those items which are deemed to be “complementary” to those paid for under NHI.

Further to Rights of users, section 33 under Chapter 8 – General Provisions Applicable to Operation of Fund – states:

“Once National Health Insurance has been fully implemented as determined by the Minister through regulations in the Gazette, medical schemes may only offer complementary cover to services not reimbursable by the fund.”

HOW WILL THE MONEY FLOW?

ACCESS TO CARE – PRIMARY HEALTH CARE ORGANISATIONS
The NHI Bill provides tor the establishment of different organisations at a District and Sub-District level, who will be responsible for the coordination and management of the provision of primary health care services in compliance with national policy guidelines and relevant law. These are the:

  • District health Management Offices (DHMO’s)
  • Contracting Units for Primary Health Care (CUP’s)

DISTRICT HEALTH MANAGEMENT OFFICES
The DHMO’s will be established as a national government component and their responsibilities will be to manage, facilitate, support and coordinate the provision of primary health care services for personal health care services and non-personal health services at a District Level.
The NHI Bill is not clear who these offices will report to, although as national components, it means that they will report directly into the Minister of Health.  There are 52 Districts in South Africa and therefore there will need to be 52 offices established.  Their role in relation to the CUPs is also unclear now.

CONTRACTING UNITS FOR PRIMARY HEALTH CARE (CUP’s)
The CUP’s will be established at a sub-district level and their role will be to manage the provision of primary health care services, such as prevention, promotion, curative, rehabilitative ambulatory, home-based care and community care. This organisational unit will contract for the provision of health care services within a specified geographical sub-district level.
Each CUP will be comprised of a district hospital, clinics or community health care centers and ward-based outreach teams as well as private service providers.

THE IMPORTANCE OF PRIMARY HEALTH CARE IN NHI

Primary health care (PHC) has been a focus in every NHI engagement. It is the view of the Department of Health that for health service delivery to be sustainable, access to care must be rationalised and delivered in the most appropriate setting. Tertiary facilities are currently over-burdened with patients seeking basic services such as the collection of medication, nurse and doctor consultations, basic diagnostics and simple procedures.

The provision of these PHC services within a hospital setting not only clogs up the tertiary system unnecessarily, it adds a layer of cost that are inherent in hospital-based care that doesn’t exist in a stand-alone PHC setting.

Having PHC providers act as “gatekeepers” is key to ensuring that care is provided at the appropriate level, costs are rationalised and higher care is accessed via a referral process to avoid unnecessary higher-level care “walk-ins”.  The NHI Bill makes provision for the contracting of private PHC providers to increase service delivery capacity, particularly in rural and under-served areas.  The contracting of these providers will be integrated into the PHC service delivery platform and will be coordinated through the CUP’s.

HOW WILL THE FUND BE STRUCTURED?

THE ROLE OF THE MINISTER
The Minister is responsible for the governance and stewardship of the national health system and governance and stewardship of the Fund. The Minister will establish three advisory committees:

  • Benefits Advisory Committee – must determine and review the health care service benefits and types of series to be funded at each level of the health system, as well as provide detailed and cost-effective treatment guidelines
  • Health Care Benefits Pricing Committee – must recommend the prices of the health care benefits to the Fund
  • Stakeholder Advisory Committee – comprised of representatives from the statutory profession’s councils, health public entities, organized labour, civil society organisations, associations of health professionals and providers as well as patient advocacy groups.

THE ROLE OF THE BOARD
The Board is accountable to the Minister of Health and will consist of no more than 11 persons appointed by the Minister of Health who are nominated through a public nomination process. The Board’s main role is to advise the Minister of Health on the management administration of the Fund, including operational, financial and administrative policies and practice.

THE ROLE OF THE CEO BOARD
The CEO will be appointed based on his or her experience and technical competence, he or she will be interviewed by the Board and appointed by the Minister of Health. The CEO is directly accountable to the Board and responsible for the functions specifically designated by the Board, The CEO must establish the units outlined in the diagram above. The CEO may appoint ad hoc Technical Advisory Committees as may be necessary to achieve the purpose of the NHI Bill.