SA urged to tackle NHI as one

2017-07-23 06:04
The SA Life Improvement Charitable Trust is a nonprofit organisation that sponsors cataract operations and cornea transplants. Picture: Lisa Hnatowicz

The SA Life Improvement Charitable Trust is a nonprofit organisation that sponsors cataract operations and cornea transplants. Picture: Lisa Hnatowicz

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Countries that have established national healthcare systems have advised government to consider partnering with the private sector to ensure the National Health Insurance (NHI) plan is successful here.

Representatives from these countries say that the only way to silence resistance while ensuring that every citizen has access to quality healthcare is to forge a healthy joint venture with the private sector.

Government is gearing up for the second phase of the NHI’s finance system, which was launched six years ago. This is part of its objective to abolish the country’s two-tier health system by pooling funds to enable it to provide quality healthcare services to all South Africans based on need, and irrespective of income.

Once fully implemented – by 2025, according to the health department – the NHI system should work the same way medical schemes do. Patients will go to accredited doctors and hospitals without paying upfront, and the NHI fund will reimburse doctors and hospitals for the services provided.

Universal healthcare and its implementation were discussed among local and international experts at the Board of Healthcare Funders conference in Cape Town this week.

Dr Clarence Mini, the board’s acting managing director, urged the department of health to consider partnerships with the private health sector as it rolled out the NHI scheme.

Organised under the banner “private sector embracing universal healthcare”, he said the private sector had the resources that the public sector would need to support and help drive the insurance system.

“The journey towards universal healthcare will present new challenges. However, the promise of a partnership, along with political will and good leadership, may make the journey ahead a lot easier than we have all imagined,” Mini said.

International speakers warned that, while the implementation of the NHI scheme sounded easy on paper, it would be a different story in reality.

Lessons from Obamacare

Dr Elizabeth Fowler, vice-president for global health policy at multinational Johnson & Johnson, worked in former US president Barack Obama’s administration on healthcare and economic policy.

She said South Africa could learn a lot from how the US implemented its universal health coverage policy, popularly known as Obamacare.

She said that, while universal health coverage was a journey worth fighting for, it was better to have the support of the private healthcare sector.

She pointed out that it had taken the US a century to implement Obamacare: “We have had about 100 years of trying to achieve universal coverage in the US, beginning in the early 1900s and leading up to 2010, when the Affordable Care Act was passed.

“In 2009, when Obama took on healthcare, we tried to focus on why the previous attempts failed, especially in 1993/94 during former president Bill Clinton’s tenure. We took a few lessons from that.

“Firstly, the debate over healthcare was very long and it lost the political capital.

“Secondly, a task force comprising about 500 people was created to put together a proposal and send it to Congress. That proposal answered too many questions and had too many details. It was a full, written proposal with little room for input.

“Thirdly, it moved people out of existing coverage [about two-thirds of the US population had private medical insurance] and the Clinton proposal proposed moving everybody into the new system. That was threatening to people who had coverage they really liked. So it created a lot of enemies right from the start.

“Fourthly, every stakeholder in the healthcare system – doctors, hospitals, insurance companies and pharmaceutical industries – was opposed to it. It made it difficult to get things done.”

Fast-forward to 2008, when Obama was elected president. The US published a White Paper that laid out a framework for health reform – similar to what South Africa has done.

It was followed by many hearings, legislative processes, debates and final votes, which led to its approval in March 2010, Fowler said.

In terms of the politics, Obama prioritised healthcare reform at a time when the country was going through a recession. This did not sit well with private healthcare stakeholders.

“We did an analysis of each stakeholder in the system to try to work out what they were afraid of, what they wanted and what they would lose,” said Fowler.

“We figured out how much the private sector stood to gain from covering the uninsured. We quantified this and went back to each stakeholder group to ask if they wanted to come to the table and also finance covering the uninsured. They agreed.

“The pharmaceutical industry contributed $80 billion [R1.04 trillion]; the hospital industry, $155 billion. It was important to have everyone at the table.”

Lessons from Ghana

Nathaniel Otoo, Ghana’s former chief executive officer of the National Health Insurance Authority, championed a similar health reform.

He said: “The journey to achieving this goal will be long and bumpy.”

Before launching its National Health Insurance Scheme (NHIS), Ghana’s health system was two-tiered, with a small part of the population (20%) affording private healthcare and the rest relying on the public system.

Ghana launched its NHIS in 2003 in response to the decline in public access to healthcare. Because of its 1980s full user-fee payment system called Cash and Carry, a minimum percentage of operating costs had been recovered. Otoo said the aim was to increase financial access to healthcare, especially for the poor and vulnerable.

However, running the NHIS has been a daunting task that has taught the country a few lessons.

Problems in Ghana have included citizens’ poor geographical access to quality healthcare services, ensuring the financial sustainability of the NHIS, poor regulation in the health sector, inequitable distribution of services and poor quality of services.

“With more than 4 000 health facilities accredited by the NHIS to provide services, and about 11 million members, moral hazards and maladministration in the distribution of funds for the purposes of expanding and sustaining the NHIS posed a major challenge,” said Otoo.

Despite these battles, Ghana’s NHIS has made significant progress towards providing financial risk protection to its population. The public’s health-seeking behaviour has also improved.

Otoo urged South Africa to form and strengthen partnerships with the private healthcare sector as it phased in the NHI.

“I believe the private sector could be a good partner for regulation, governance, health service provision, improvements on quality, information system support, the commodity supply chain, financial intelligence – by way of providing systems to get more funds to improve healthcare delivery – as well as customer care.”

Fowler and Otoo agreed that South Africa was “doing the right thing” by forging ahead with universal coverage despite resistance and criticism.

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