This is health insurance related things. Every person who are living in the society must be known about their health policies. Health is the key factor of life that's why everyone must be care about their health. It's very necessary to know the status of the life . Health policy is made up for society which is included in social medicine subject . It's also known as PSM. Social medicine means to know the health and disease in a community or social life. Epidemiology is the one of topic in the PSM . it means that study of diseases.

1. PRESENTATION ON NATIONAL
HEALTH INSURANCE POLICY
FOR
THE PORTFOLIO COMMITTEE
OF
HEALTH
Click to edit Master subtitle style

2. OUTLINE
• Introduction
• Problem Statement: Key Health Sector
Challenges
– Public Sector
– Private Sector
• Principles of NHI

3. • Objectives
8/19/11
• WHO Recommendations on Universal
INTRODUCTION...../1
• Introduction of an innovative system of
healthcare financing
• Far reaching consequences on the health of
South Africans

4. • Ensures that everyone has access to health
services that are:
– appropriate –
efficient
8/19/11

5. INTRODUCTION......./2
• Improve service provision
• Promote equity and efficiency to ensure all
South Africans have access to affordable,
quality healthcare services regardless of their
socio-economic status

6. 8/19/11
INTRODUCTION......./3
• SA health system inequitable.............with the
privileged few having disproportionate access
to health services
• Recognition that this system is neither
rational nor fair

7. 8•
/19/Current system of healthcare financing is
11 two-
INTRODUCTION......./4
• Private Sector:
– covers 16.2% of the population
– relatively large proportion of funding allocated
through medical schemes, various hospital care
plans and out of pocket payments

8. 8/19/11
– provides cover to private patients who have
purchased a benefit option with a scheme of
their choice or as a result of their employment
conditions
benefits employed subsidised by their employers

9. 8/19/11
INTRODUCTION......./5
• Public Sector:
– Covers 84% of the population
– funded through the fiscus
– Poor management systems and oversight esp
hospitals
– under-resourced relative to size of population that
itserves and the burden of disease

10. 8/19/11
– less human resources than the private sector – longer
waiting times and lower clinical consultation time –
increased risk of error
INTRODUCTION......../6
• To successfully implement a healthcare financing
mechanism that covers the whole population
such as NHI, four key interventions need to
happen simultaneously:
– a complete transformation of healthcare service
provision and delivery;

11. 8/19/11
– the total overhaul of the entire healthcare system
– the radical change of administration and
management
PROBLEM STATEMENT
• The 2008 World Health Report of the WHO details
three trends that undermine the improvement of
health outcomes globally, namely:
– Hospital centrism, which has a strong curative focus
– Fragmentation in approach which may be related to
programmes or service delivery

12. 8/19/11
– Uncontrolled commercialism which undermines
principles of health as a public good
KEY CHALLENGES IN THE HEALTH
SYSTEM
• Quadruple Burden of Disease
• Quality of Healthcare
• Distribution of Financial and Human Resource

13. 8/19/11
• High Costs of Health Care
– Out-of-pocket payments and co-payments

14. 8/19/11
QUALITY IN PUBLIC HEALTH
FACILITIES
• Cleanliness
• Safety and security of staff and patients
• Long waiting times
• Staff attitudes
• Infection control

15. 8•/19/Drug stock-outs11
EXORBITANT COSTS OF HEALTH CARE IN
SOUTH AFRICA (PUBLIC AND PRIVATE)
• Cost of Private Health Care out of control at
the expense of members of medical
schemes

16. 8/19/11
• Cost of Public Health Care escalating at the
expense of the fiscus
1212
WHAT DRIVES THE COSTS IN THE
PUBLIC SECTOR?
5 Major identifiable areas:
1. Compensation of employees

17. 2. Pharmaceuticals
3. Laboratory Services
4. Blood and Blood products
58/19/. Health Technology / Equipment11 1313

18. 8/19/11
Trends in Total Benefits Paid, 1997 - 2005
Source: Council for Medical Schemes

19. … THE COST DRIVERS ARE

20. 8/19/11
HOSPITALS AND SPECIALISTS…

21. 8/19/11
AFFORDABILITY OF MEDICAL
SCHEME CONTRIBUTION
• A number of medical schemes have
collapsed, been placed under curatorship or
merged
• Schemes have reduced from over 180 in the
year 2001 to about 102 in 2009

22. 8/19/11
• To sustain their financial viability, schemes
tend to increase premiums at rates higher
THE EVOLUTION OF HEALTH CARE
FINANCING
IN SOUTH AFRICA
• Commission on Old Age Pension and National
Insurance (1928)
• Committee of Enquiry into National Health Insurance
(1935)
• National Health Service Commission (1942 – 1944)
• Health Care Finance Committee (1994)

23. • Committee of Inquiry on National Health Insurance
(1995)
• The Social Health Insurance Working Group (1997)
8•
/19/Committee of Inquiry into a Comprehensive Social11
Security for South Africa (2002)
PRINCIPLES OF THE NHI
• The Right to Access Health
• Social Solidarity
• Equity
• Effectiveness

24. 8/19/11
• Appropriateness
• Effectiveness
• Efficiency
• Affordability
1818
OBJECTIVES OF NHI
• To provide improved access to quality health
services for all South Africans irrespective of
whether they are employed or not

25. • To pool risks and funds so that equity and social
solidarity will be achieved through the creation
of a single fund
8/19/11
SOCIOECONOMIC BENEFITS
• Increased output as a healthy person works more
effectively and efficiently and devotes more time to
productive activities (i.e. fewer days off, longer work life
span);

26. 8/19/11
• Broader knowledge base in the economy as the gains to
education increase as life expectancy increases;
• Increased “work life” and savings as a result of increased
life expectancy may result in earning and saving more for
retirement;
2020

27. 8/19/11
CONSIDERATIONS FOR ACHIEVING UNIVERSAL
COVERAGE-DIMENSIONS
Source: WHO (World Health Report: 2010)

28. 8/19/11
2121

29. POPULATION COVERAGE
• All South Africans and legal permanent
residents will be covered
• Short-term residents, foreign students and
tourists required to obtain compulsory travel
insurance
– produce evidence of this upon entry into South
Africa

30. 8/19/11
HEALTH SYSTEM
REENGINEERING
Primary health care services shall be delivered
according to the following three streams:
– District-based clinical specialist support teams supporting
delivery of priority health care programmes at a district
– School-based Primary Health Care services

31. 8/19/
– Municipal Ward-based Primary Health Care Agents11 2323

32. DISTRICT CLINICAL SPECIALIST SUPPORT
TEAMS
• To address high levels of maternal
and child mortality and to improve
health outcomes

33. • The teams will based in districts and
8/19/include:11
SCHOOL HEALTH SERVICES
• Delivered by a team that is headed by a
professional nurse
• Services will include health promotion,
prevention and curative health services that

34. address the health needs of school-going
children, including those children who have
missed the opportunity to access services such
8as child immunization services during their pre-
/19/11
MUNICIPAL WARD-BASED
PRIMARY HEALTH CARE AGENTS
• A team of PHC agents will be deployed in
every municipal ward

35. • At least 10 people will be deployed per ward.
• Each team will be headed by a health
professional depending on availability
• Each member of the team will be allocated a
8/19/certain number of families11
MUNICIPAL WARD-BASED
PRIMARY HEALTH CARE AGENTS

36. • The teams will collectively facilitate community
involvement and participation in:
– Identifying health problems and behaviours that
place individuals at risk of disease or injury
– Vulnerable individuals and groups
– Implementing appropriate interventions from the
service package to address the behaviours or
8/19/11health problems
HEALTHCARE BENEFITS

37. • Primary health care services:
– prevention,
– promotion,
– curative,
– community outreach and community-based
services as well as school-based services
• Inpatient and outpatient hospital care
(including specialist and rehabilitation
8/19/services)11

38. HOSPITALS BENEFITS
• As part of the overhaul of the health system
and improvement of its management,
hospitals in South Africa will be re-designated
as follows:
• District hospital
• Regional hospital
• Tertiary hospital

39. • Central hospital
8/19/11
• Specialized hospital
ACCREDITATION OF PROVIDERS
• Draft Bill on Office of Health Standards
Compliance
(OHSC) will soon be tabled in Parliament
• An independent OHSC to be established with 3
units:

40. – Inspection
– Ombudsperson,
– Certification of health facilities
8/19/11

41. 8/19/11
PAYMENT OF PROVIDERS
• At PHC Level: Risk-adjusted per capita
payments for accredited and contracted
public and private providers
• At Hospital level: Global Fee with a
move to Case-based payment
mechanisms as an alternative to fee-

42. 8/19/11
forservice with a strong focus on cost
containment
UNIT OF CONTRACTING
• District Health Authority will be given the
responsibility of contracting with the NHI
– supported by the NHI Fund’s sub-national offices
to manage the various contracts with accredited
providers

43. 8/19/11
– monitor the performance of contracted
providers within a district
PRINCIPAL FUNDING
MECHANISMS
• Combination of sources:
– fiscus
– employers
– individuals

44. 8/19/11
• Revenue base to be as broad as possible:
– to achieve the lowest contribution rates
– generate sufficient funds to supplement the

45. Role of Co-payments
• Co-payments will be levied under
the following circumstances:
– Services rendered not in accordance with NHI
treatment protocols and guidelines
– Health care benefits not covered under the NHI
benefit package (e.g. originator drugs or expensive
spectacle frames)

46. – Non-adherence to the appropriately defined
referral
8
/19/
system11
INDICATIVE COSTS OF NHI
Year Non-AIDS
services
AIDS
services
Other
services
Direct
NHI
Costs
Total
Costs
Modelled
2012 57 17 42 8 124
2015 74 26 46 9 156

47. 2020 112 37 52 13 214
2025 149 45 54 7 255
8/19/11 * 3535
THE ROLE OF MEDICAL SCHEMES
• Medical Schemes will continue to exist side by
side NHI
• May also provide top up cover

48. • No one will be allowed to opt-out of NHI
8/19/11
PILOTING OF NHI IN 2012
• The first steps towards implementation of
National Health Insurance in 2012 will be
through piloting.
• 10 districts will be selected for piloting.

49. • NDOH conducting audits of all healthcare
facilities
• Criteria of choosing these 10 districts will be
based on the results of the audits as well as the
8
demographic profiles and key health
indicators/19/11
PREPARING FOR NHI
• CEO Assessments

50. • Designation of Hospitals
• Revenue retention
• PHC Re-engineering
• District Health Profiles
• Health Facility Audits
8•/19/Provincial Quality Plans11 3838

51. 8/19/11
PREPARING FOR NHI
• Regulations to be drafted to define levels of
hospitals and the appropriate skills
requirements to manage hospitals / public
health facilities
• Ministerial Task Team to advise on District
Specialist Teams led by Chair of Confidential
Inquiries into maternal, neonatal and under
5 deaths

52. 8/19/11
• Audit of Community Health Workers has been
3939
completed and retraining and re-skilling to be
PREPARING FOR NHI
Job Description -Population Focused
Specialists (All levels and all facilities in
catchment area)
• Quality of health care for mothers, newborns
and children

53. 8/19/11
• Equitable access
• Coordinate, monitor, supervise and support
MNCH services
4040
PREPARING FOR NHI
• In 2010 there were 150,509
registered health professionals in
South Africa.

54. 8/19/11
• From 1996 – 2008 there was a
stagnation in growth of health
professionals and a decline in key
categories such as specialist and
specialist nurses. 4141
PREPARING FOR NHI
• Filling currently listed public sector
vacancies would cost billions.

55. 8/19/11
• Staffing requirements should be based
on service plans informed by norms and
needs.
• It is evident that South Africa has a nurse
based health care system with 80% of
health professionals comprising nurses.
4242

56. PREPARING FOR NHI
• Education output of most
professions has been stagnant for
the past fifteen years.
• Faculty output of MBChB graduates
is not a full capacity for all faculties,

57. 8/19/11
and varies in quality for all
professions.
8
•
/19/
Budget11
cuts in the 1990s led43
to43
a
Data Mapping for District Health
Profiles
• Data has been collected to develop profiles of
health districts, for selection and prioritization
for piloting

58. • Following dimension have been applied:
– Demographic
– Socio-economic
– Epidemiology/ Health Status
– Service delivery
8/19/11 4444
4 Groups of indicators used
❑District management functionality self assessment.
5 Sections:

59. 8/19/11
1. Service delivery platform
2. District management team
3. Other management functions
▪ Financial management
▪ Governance and community participation
▪ Health information
1. Staffing
2. District office infrastructure
4545

60. 4 Groups of indicators used
❑10 Socio-economic indicators
1. Deprivation Index District
Health Barometer (DHB) 2007

61. 8/19/11
2. Population with private medical
insurance rate (Household
Survey 2007)
3.8/19/Unemployment rate11 4646
4 Groups of indicators used
❑10 Health Outcome (MDG proxy) indicators
1. HIV prevalence (Antenatal survey 2009)
2. TB cure rate 2008 (ETR.Net)

62. 3. Weighing rate 2010 (DHIS)
4. Diarrhoea incidence 2010 (DHIS)
5. Severe malnutrition 2010 (DHIS)
6. Pneumonia incidence 2010 (DHIS)
7. Measles 1st dose coverage 2010 (DHIS)
8. Antenatal coverage 2010 (DHIS)
9. Delivery in facility 2010 (DHIS)
10. Couple year protection rate 2010 (DHIS)4747

63. 8/19/11
4 Groups of indicators used
❑ 6 Service delivery indicators
1. Cost per PDE district hospitals 2008/09 (DHB)
2. PHC expenditure per capita 2008/09 (DHB)
3. PHC (non-hospital expenditure) per patient visit
2008/09 (DHB)
4. PHC utilisation 2010/11 (DHIS)
5. PHC utilisation under 5 years 2010/11 (DHIS) 6. PHC
supervision 2010/11 (DHIS)

64. 8/19/11
4848
PREPARING FOR NHI
Methodology (first 3 groups)
• District and provincial profiles have been
developed
• Districts were ranked from best to worst
performing for the 26 selected indicators and a
score from 1-52 given where 1 is best
performing district and 52 the worst.

65. 8/19/11
• Where districts have the same value the same
score was given resulting in the last value
is4949
PREPARING FOR NHI

66. 8/19/11
5050

67. 8/19/11
Total scores and ranking across all districts socio-economic
indicators
Best Worst
5151

68. 8/19/11
Total score and ranking health service and utilisation indicators
5252

69. PREPARING FOR NHI
• Audit Scope
• HST led consortium appointed to audit all
public health facilities;
– Infrastructure
– Equipment
– HR
– Finance management

70. 8/19/11
8/19/–
11Services provided
Province PHC District
Hospital
Regional
Hospital
Specialised
Hospital
Tertiary
Hospital
Central
Hospital
Total
EC 808 45 2 18 6 1 880
FS 280 25 5 4 1 1 316
GP 421 10 12 6 0 4 453
KZN 591 37 12 18 2 2 662
LP 463 31 5 3 2 0 504
MP 305 23 3 5 2 0 338
NC 212 18 2 3 0 0 235
NW 363 18 4 2 0 0 387

71. PUBLIC HEALTH FACILITIES
WC 282 34 5 11 1 2 435
TOTAL 3825 241 50 70 14 10 4210

72. 8/19/11
Province
EC
FS
GP
KZN
LP
MP
NC
NW
WC
TOTAL
Provincial
Total
880
316
453
662
504
38
235
387
435
4210
Completed
June 2011
78
42
26
59
6
18
120
28
0
337
Completed
July 2011
140
109
94
135
64
73
161
93
7
876
Estimate
Completion
date
May 2012
Feb 2012
Feb 2012
April 2012
March 2012
Feb 2012
Sept 2011
March 2012
April 2012

73. TOTAL
%8/19/11
9% 21%

74. 8/19/11
PROGRESS

75. ESTIMATED COMPLETION RATE – 2011/12
MONTH NUMBER %
August 1378 33%
September 1794 43%
October 2175 52%
November 2556 61%
December 2927 70%
January 3318 79%
February 3698 88%
March 3962 94%
April 4136 98%
May 4210 100%

76. 8/19/11
PILOTING OF NHI
• Additional districts will be determined on an
annual basis for inclusion in the roll out.
Aspects for inclusion:
– Re-engineered PHC streams
– Basic infrastructure
– Compliance with standards

77. 8/19/–
11Functionality of districts and facilities including
appropriate management
THE FIRST 5 YEARS OF NHI
• NHI will be phased-in over a period of 15
years
• Will include piloting and strengthening the
health system in the following areas:
• Management of health facilities and health districts

78. 8/19/11
• Quality improvement
• Infrastructure development
• Medical devices including equipment
Thank You

79. 8/19/11 5959 59