From: <b class="gmail_sendername">Global Health Check</b> <span dir="ltr"><<a href="mailto:oxfamblogs@gmail.com">oxfamblogs@gmail.com</a>></span><br><div class="gmail_quote"><br><br>Global Health Check has posted a new item, 'Will South Africa finally make<br>
progress towards a universal health system?'<br>
<br>
South Africa has long faced considerable health system equity challenges. In<br>
particular, 43% of total health care expenditure is attributable to private<br>
health insurance schemes, which only cover 16% of the population. General tax<br>
funding allocated to the health sector also accounts for about 43% of<br>
expenditure, and is used to provide services for most of the rest of the<br>
population. Out-of-pocket payments account for the remainder of expenditure,<br>
most of which relates to co-payments by private insurance scheme members but<br>
also includes direct payments to private primary care providers by some of those<br>
not covered by private insurance. <br>
<br>
The Minister of Health recently released a Green Paper on introducing a National<br>
Health Insurance (NHI). It indicates that the NHI will be guided by the<br>
principles of the right to health service access, social solidarity, equity,<br>
affordability and the provision of appropriate and effective health services. <br>
It also states that the objective is to achieve universal coverage, where<br>
everyone has financial protection from the potentially impoverishing costs of<br>
health care and access to needed health care. Core elements of the proposed<br>
NHI include:<br>
<br>
Substantially increasing the pool of public funds (previous statements indicate<br>
that this will take the form of tax funding including: increased allocations to<br>
the health sector from general tax revenue; a surcharge on personal income; a<br>
payroll tax on employers; and/or increased VAT);<br>
The creation of an independent public entity to pool these public funds and use<br>
them “to purchase health services on behalf of the entire population from<br>
contracted public and private health care providers” on a single payer basis;<br>
All South Africans, legal permanent residents and registered refugees and<br>
asylum seekers will be entitled to benefit from these services;<br>
A relatively comprehensive package of out- and in-patient services will be<br>
funded; and<br>
There would be no fees charged at the point of service.<br>
<br>
The Green Paper recommends that the NHI be phased in over a period of about 15<br>
years, divided into three five-year phases. The first phase will be devoted to<br>
rebuilding the public health system. The capacity and quality of public health<br>
services declined dramatically during the late 1990s and early 2000s, when a<br>
neo-liberal fiscal policy restricted government spending at precisely the time<br>
that the HIV epidemic was exploding, increasing the burden on public sector<br>
services. Specific interventions planned are: ‘re-engineering’ primary<br>
care services, including the deployment of teams of community health workers in<br>
every ward; an audit of all public sector facilities and improvements in<br>
physical infrastructure and ensuring all facilities have a full complement of<br>
functioning equipment; increased training of the full range of health care<br>
workers; service quality improvement measures; and measures to improve<br>
management in hospitals and health districts. Other preparatory activities<br>
such as establishing the NHI fund/independent public purchasing entity will also<br>
occur during this phase.<br>
<br>
The second phase will focus on changing the way of paying health care<br>
providers. It is proposed that primary care services will be paid for on a<br>
capitation basis while diagnosis-related groups (DRGs) will be used to pay<br>
hospital services. Strategic purchasing of services from both public and<br>
private health sectors will also be initiated during this phase. The final<br>
phase will be devoted to further expanding health service capacity to achieve<br>
universal access.<br>
<br>
While there has been a relatively muted response to the release of the Green<br>
Paper, with many stakeholders adopting a ‘wait-and-see’ approach, there has<br>
been sufficient public commentary to identify key areas of support and<br>
concern. The proposals have been praised for:<br>
<br>
Being based on universal coverage principles;<br>
Adopting a carefully phased approach;<br>
Focussing firmly on addressing the problems in the public health sector first;<br>
and<br>
Building a strong foundation of improved primary care services.<br>
<br>
The major concerns expressed include:<br>
<br>
Although there appears to be a commitment to a single public pooling and<br>
purchasing entity, the Green Paper makes mention of also considering a<br>
multi-payer option whereby private insurance schemes would act on behalf of the<br>
NHI, raising concerns about high administration costs, limiting income and risk<br>
cross-subsidies and less ability to cost-containment benefits of a<br>
single-purchaser;<br>
Purchasing of services from the private sector may retain a two-tier system as<br>
wealthier groups live closer to private providers than the less well-off and<br>
given the rapid increase in fee levels among private for-profit providers, may<br>
threaten the sustainability of the NHI; and<br>
Although it is proposed that there will be no fees at the point of service, the<br>
Green Paper also mentions having to consider co-payments, which would limit the<br>
financial protection afforded to beneficiaries.<br>
<br>
There are clearly some contradictions within this policy document that need to<br>
be resolved. It is also apparent that key stakeholders will use the period<br>
before the finalisation of the policy to influence the NHI design to best meet<br>
their personal objectives. While the release of the Green Paper is a positive<br>
development in efforts to move towards universal coverage in South Africa,<br>
unwavering commitment to the core principles outlined in this policy document is<br>
required if the final NHI design is to be compatible with achieving these<br>
principles.<br>
<br>
Di McIntyre is the South African Research Chair in ‘Health and Wealth’ and a<br>
Professor in the School of Public Health and Family Medicine at the University<br>
of Cape Town<br>
<br>
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<a href="http://www.globalhealthcheck.org/?p=411" target="_blank">http://www.globalhealthcheck.org/?p=411</a><br>
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Anna Marriott<br>
<a href="mailto:Email%3Aamarriott@oxfam.org.uk">Email:amarriott@oxfam.org.uk</a><br>
Twitter:@anna_marriott<br>
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