What the NHI Bill actually says and how it will affect access to health care services
Business Day: 15 NOVEMBER 2019 – SASHA STEVENSON
National Health Insurance (NHI) can be divisive, not just because of what it proposes to do but because of how it is often sold as an all-or-nothing issue – either you buy into NHI completely, or you want things to stay essentially the same.
There are few people in SA who would argue that any of our health systems are functioning as they should. The public sector is underfunded, overstretched and the site of gruesome daily news reports and personal experiences.
Similarly, everyone who uses the private sector has a story of bad treatment, poor quality or overcharging. The evidence for the failures in each system come from daily anecdotes from both health care providers and users, the Competition Commission’s health market inquiry, and the health journalists who continue to uncover and reveal the truth.
The NHI has been presented as the solution to most, if not all, our health-system problems. The principles behind NHI – equity, financial protection from the costs of health care, efficient use of resources and quality assurance – are laudable. But even while many of the details of the bill, and whether an insurance model can achieve these ideals, remain in question.
There seems to be significant political pressure to push through the NHI Bill and it appears unlikely that the bill will be entirely thrown out, despite ongoing criticism and concern. In the light of these political realities, we must consider what the NHI Bill actually says and how it will practically affect access to health care services for all.
Participatory democracy requires that we do not merely vote and then step back, but that we participate in lawmaking. Real participation, however, requires a deeper understanding than most people have of how the NHI Bill will affect the health system as a whole. This is a situation not helped by the public participation process now led by the parliamentary portfolio committee, which has been criticised as a process designed to elicit only messages of support.
While we agree with the principles underlying NHI, below we lay out three key components of the NHI Bill that we think need to change to make for a better, more equitable, less expensive, higher-quality health system that realises the rights of everyone to access to health-are services.
The minister of health appoints the NHI Fund board members (after appointing the ad hoc panel that interviews and recommends them), the board chairperson, and the CEO of the NHI Fund. He appoints the members of the Benefits Advisory Committee and Health Care Benefits Pricing Committee (the main decision-making committees of the NHI Fund) and there is a representative of the minister on each of them.
The minister even appoints members of the Stakeholder Advisory Committee. In simple terms, decision-making is far too concentrated. In our view, it is not necessary, given the legal structure of the NHI Fund, for so much power to rest with the minister. It does not make him more accountable. It makes all health funding and decisions subject to the control of one person.
Some of the problems at the National Student Financial Aid Scheme (NSFAS) have been attributed to similar governance weaknesses. Appointment power under NHI must be decentralised.
Do you agree that NHI governance should be decentralised? Or should the minister, as the politician with ultimate responsibility for the provision of health care services, retain the power to make all the appointments?Section 27
To increase public trust in the NHI and to reduce the risk of corruption under NHI, it is imperative that all NHI-related processes and decisions are as transparent as possible. In our view, this requires specific provisions in the law to guarantee such transparency.
The NHI Act should unambiguously state that certain types of information should be made available to the public as a matter of routine. This includes details of all transactions of the NHI Fund, details of decisions relating to the benefit package under NHI, details of decisions about what to procure and from whom, and details of decisions to contract certain facilities.
Everyone should be able to access their own health information without having to make application through the Promotion of Access to Information Act (which is often used by state and private bodies to frustrate access to information rather than promote it).
Do you agree that we should have insight into decisions and contracts? Or, should we let the NHI Fund make its decisions in a closed boardroom, largely out of the public eye?
The NHI Bill introduces a range of new structures and administrations. District health management offices will be established at district level to co-ordinate health services (now the role of the provinces). Contracting units for primary care will be established at subdistrict level to enter into contracts with all of the health facilities in an area and manage those contracts.
The Office of Health Products Procurement will negotiate on behalf of all health facilities to get the best price for medicines and medical devices. These new structures may work, or they might not. The NHI pilot process (which we are now told was not actually an NHI pilot process) mostly unsuccessfully introduced health-system strengthening initiatives without consideration of alternative interventions or how to measure success.
We haven’t tried clustering or large-scale contracting of health facilities before. We have disempowered officials at district level for decades in favour of a provincially run system. But as the bill now stands, we are bringing the establishment of these new structures into law, with no way to turn back if they fail, and without any transition provisions that could stagger implementation and allow for learning.
We are not giving ourselves the space to see what works and to learn from what does not – the basis for reasoned health-system change. We are not testing what level of administration is needed before introducing further layers, at great cost. Health-system change is not easy but there is no need to make it more complicated and risky by building in centralisation, opacity and layers of expensive administration without testing them out first.
Do you agree that we should build in processes and principles for testing new structures before signing them into law? Or, should we put all our weight behind the structures outlined in the bill?
There are many ways to bring about fundamental health-system changes. Given that government is clearly committed to introducing NHI in some form, we need to focus public participation on what is needed to ensure that the move towards NHI will assist in improving access to quality health care services for all, rather than creating new obstacles to access.
There are three major aspects of the NHI Bill that we think need to change. Let us know what you think and we will incorporate your views into our submission on NHI.
This article was paid for by Section 27 and appeared in Business Day
Mark Banfield is an independent health Technology consultant providing Quality and Regulatory advisory, business development and market research services in South Africa.