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NHI: Moving forward in interests of all South Africans

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File picture: African News Agency (ANA) -The passing of the Bill paves the way for the government to create the mechanism for the NHI fund, its corporate governance structures, single-payer single fund, strategic purchasing by the fund, accreditation of service providers, and establishment of the contracting unit for primary healthcare.

By Prof. Saloshni Naidoo and Prof. Ozayr Haroon Mahomed

On June 13, South Africa’s Parliament passed the National Health Insurance (NHI) Bill, leading to mixed reactions in the country. The Minister of Health hailed it as the “most revolutionary piece of legislation passed since 1994”, while others call it a national catastrophe.

There is no arguing our tremendous inequity in health is palpable. A staggering statistic that remains central to all arguments on the NHI is that health expenditure is approximately 8.5% of our GDP, but 50% of this spending covers only 16% of the population, who are located in the private sector. Embracing a system that ensures universal health coverage, where all South Africans, irrespective of socio-economic status, get quality and appropriate healthcare will ensure a healthier nation.

The passing of the Bill paves the way for the government to create the mechanism for the NHI fund, its corporate governance structures, single-payer single fund, strategic purchasing by the fund, accreditation of service providers, and establishment of the contracting unit for primary healthcare.

While the financial mechanisms are core to an efficiently functioning NHI, the fundamental pillars of an effective health system are necessary to ensure equitable universal health coverage. These include quality service delivery, appropriately trained health professionals in adequate numbers, a functioning health information system that includes the health profiles of all individuals in the country that access health services, appropriate financing, and leadership. However, to achieve this the government will need to collaborate with role players beyond the public sector because the current public health system is ineffective.

NHI will need an efficient health information management system to track patients for care management, contracting, billing, and payment of service providers and service planning and delivery. Currently, the Health Patient Repository System in the public health sector attempts to create a unique patient identifier, but its implementation faces numerous challenges. The health records systems within and between provinces are fragmented, with each province pursuing different paths. As a result, systems within provinces cannot provide continuous patient records and information for management purposes. Although the Department of Health will claim the existence of the Uniform Patient Fee Schedule, a lack of a scientific coding system for patient billing and policy impediments hinder fee collection.

Private medical aids and hospitals can provide the expertise and know-how on several aspects required to implement an efficient health information system.

Adequate human resources at all levels are required to ensure an efficient NHI implementation. This means training more doctors, nurses, allied health staff, and individuals to handle the administrative and technical aspects of the system than we currently do. Most training institutions are stretched to capacity with resource challenges and limited training sites for students.

Increasing medical and nursing student numbers will prove challenging, especially when most training sites are in the overburdened public sector. Visionary thinking and planning between health, higher education, and training institutions are needed. Alongside training, the issue of absorption and retention must be addressed. Graduates cannot assume they will be employed, as we have seen. Despite the obvious need, trained staff are not absorbed into the health sector due to the limited number of funded posts.

Then there are the infrastructure challenges of public health facilities that need attention.

NHI cannot be seen as the public sector shifting its patient load onto the private sector. This would be simplistic thinking. A radical overhaul of public sector facilities is required to ensure these hospitals and clinics function efficiently and deliver services to people. The delivery of services to rural areas is of particular concern, where even the private sector has a limited presence. The government must draw on the financial and management expertise beyond the public sector and not leave this to current public health sector managers.

Health services at the primary care level, including preventive services such as family planning, immunisation, antenatal care, screening for health problems, nutrition and development, and school health programmes, should be delivered as public health goods through NHI. Multi-disciplinary primary care practices, including general practitioners, dentists, and allied health professionals, should be contracted to provide acute curative primary care services. Management and contracting of hospital services should include public and private hospitals and be based on a clearly defined referral pathway with appropriate gatekeeping rules by the fund. Medical schemes should be allowed to provide additional cover for hospital services that function externally to the NHI.

The NHI’s objectives are noble and may result in positive health outcomes if implemented correctly. The lack of clarity and expeditiously approved bill raises many constitutional concerns creating an environment of animosity rather than unity of purpose. A partnership approach using skills and expertise from the public, private sectors, academia, non-governmental organisations, and other relevant role-players without political allegiance and expediency will create the impetus for making a difference in the lives of all South Africans.

*Professor Saloshni Naidoo is Head of Public Health Medicine, School of Nursing and Public Health at the University of KwaZulu-Natal and Professor Ozayr Haroon Mahomed is Honorary Professor in Public Health Medicine, School of Nursing and Public Health at UKZN.