A world class National Health Insurance for SA

Humphrey Zokufa (Supplied)

Humphrey Zokufa (Supplied)

With the much anticipated White Paper due soon, it is apt now that all South Africans understand as much as possible about this new system. When one considers that almost every developed nation in the world has a National Health Insurance (NHI) programme in some shape or form, the South African model is long overdue and if managed correctly could vastly improve our health outcomes, which at present are a blot on our copybook.

In 2001 the World Health Organisation rated South Africa 175 out of 191 countries surveyed for expenditure versus outcomes, and although there have been some improvements, we still lag far behind our counterparts such as Brazil, Chile and Mexico when it comes to life expectancy, infant and maternal mortality, among others. South Africa’s quadruple burden of disease is quite unique as it spans the spectrum from those diseases related to poverty and malnutrition to lifestyle diseases associated with the affluent.

It includes HIV, Aids and TB; maternal, infant and child mortality; non-communicable diseases (diabetes, high blood pressure and others); and injuries and trauma. The spread of human resources within the sector also hampers efficiencies. For example, there is approximately one pharmacist for every 1 000 beneficiaries in the private sector, and approximately 13 000 beneficiaries to one pharmacist in the public sector.

This pattern is similar for most other healthcare provider disciplines. It is anticipated that the NHI will provide a more equitable and socially efficient distribution of health resources within the health sector.

Objectives

Although details pertaining to the overhaul of the system are still to be published, the Green Paper states the NHI objectives as follows:

• To provide improved access to quality health services for all South Africans.

• To pool risks and funds so that equity and social solidarity will be achieved through the creation of a single fund.

• To procure services on behalf of the entire population.

• To strengthen the under-resourced and strained public sector.

The various constituencies within the private healthcare sector have thus been able to put their minds to the roles they could play in support of this new system. “In our submission to the NHI Green Paper, the Board of Healthcare Funders (BHF) emphasises that the private funding sector is a national asset, rich in expertise and experience in governing and administering healthcare financing systems,” said Dr Humphrey Zokufa, managing director of BHF.

“This sector could be made available to government as it implements NHI.”

The BHF believes that the South African NHI model could be similar to the Gautrain model, where the private sector was contracted by the government to fulfil the function of building the entire rail system and managing it through the establishment of the Gautrain Management Agency, under the provincial government.

This model creates flexibility and establishes an appropriate platform to attract, retain, contract and remunerate the required skills and expertise adequately. A well functioning NHI system may well require such a model. “After all,” says Zokufa, “medical schemes, which have been around in South Africa since 1889 are, in essence, ‘mini-NHIs’. The social soli­darity principles on which medical schemes operate are the same as those proposed for the NHI.”

These principles include risk cross-subsidisation, community rating and a not-for-profit environment, to name but a few. Therefore, the business model and expertise that exists in the private healthcare funding environment should be harnessed and utilised both in the implementation of NHI and the administration of the system.

Effective systems

But the expertise that could be tapped into does not end there.Medical scheme administrator ­companies, healthcare actuaries, managed care organisations and health economists have all developed complex and sophisticated ­sys­tems to respond to the needs of the 8.5-million medical scheme members.

These systems could well be extended to manage the health needs of the 50-million-plus beneficiaries of the South African NHI. The Green Paper specifies a ­single-purchasing system where the NHI Agency will procure healthcare services on behalf of the entire ­population, thereby utilising the economies of scale.

Complementary to this principle, the BHF proposes that medical schemes play an integral part in such a system. The BHF has presented an offering of support to government in a number of areas necessary for the successful development and implementation of a NHI.

These include:

• Designing and costing of the NHI package of benefits.

• Development of coding structures for reimbursing healthcare providers.

• Development of healthcare tariffs, payment and provider reimbursement models.

• Measurement of healthcare quality and other outcomes.

• Forensic management inter­- ventions.

• Accreditation of providers/facilities and provider contracting.

• Communication and awareness relating to NHI — to the general population and providers of service.

• Provider network management.

• Peer review and profiling .

• Administration, claims and information systems and managed care services.

• Call centre support services.

The implementation along the lines suggested by the BHF will ensure a seamless health financing experience for members of medical schemes and a smooth transition for the entire population.

Global Healthcare Fraud Prevention Summit

The BHF is delighted to announce that the Global Healthcare Fraud Prevention Summit 2014 will, for the first time, be hosted in South Africa on Sunday August 24 at the ICC in Durban. This annual international event is a joint venture between five partner organisations dedicated to addressing fraud, waste and abuse globally within the healthcare arena.

The Global Summit will provide a platform for delegates to network and gain insight from various industry leaders and experts in addressing and mitigating fraud in healthcare. The experts are being drawn from medical schemes, healthcare insurers, law enforcement and other professional organisations across South Africa, SADC, Canada, US, UK, Europe, Australia and the Middle East.

For more information on this event, please contact Lynette Swanepoel on [email protected]

BHF conference to bring new solutions

The days of business as usual within the private healthcare ­sector are over. The 15th Annual BHF Southern African Conference, to be held at the Durban ICC will focus on the tools required to achieve an efficiency-based, patient-centred private health system.

Maximising value will be at the core of the conference programme and will offer workable solutions to areas of complexity, such as:

• Stemming the tide of escalating utilisation

• Doing nothing now. Projections for the future 

• Using managed care in the transformation to a value agenda

• Collective coding

• Measuring, managing and ­mitigating the double dip

• The how, who and what of ­mandatory cover

• “The strategy that will fix healthcare”

• Co-operative funding of orphan diseases

• Why do schemes fail? An ­exploration into corporate governance.

The largest event of its kind in Southern Africa, the BHF ­conference attracts up to 1 000 delegates from the healthcare industry, including local, regional and international healthcare ­executives, healthcare professionals, policy makers and regulators.

Carefully selected presenters, all experts within their fields, will ensure that delegates derive ­tangible value from this event. For more information or to ­register, please visit www.bhfglobal.com

This article has been made possible the Mail & Guardian's advertisers. Content has been signed off by the Board of Healthcare Funders.