Transcript NATIONAL HEALTH INSURANCE

NATIONAL HEALTH INSURANCE
AND THE WORKPLACE
25th Annual Labour Law Conference
Sandton
Johannesburg
Outline
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Baseline: Health System Challenges
Green Paper on National Health Insurance
Piloting NHI
Possible implications for the workplace
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KEY CHALLENGES IN THE HEALTH SYSTEM
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Quadruple Burden of Disease
Quality of Healthcare
Distribution of Financial and Human Resource
High Costs of Health Care
– Out-of-pocket payments and co-payments
Baseline
• Poor health outcomes and poor overall performance
– IMR, MMR, Life Expectancy, worsening BOD (Quadruple)
• Fragmented funding pools
– Rich, healthier = funded separately
– Poor, more susceptible to illness = reliant on State
• Huge exposure to health-related catastrophic
expenditures
• Hospicentrism and growing commercialism
• Inequitable access to key health resources
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OVERALL, SOUTH AFRICA GETTING POOR PERFORMANCE RELATIVE TO COST
Countries sitting above the trend line are producing relatively better performance for the cost per capita inputs that
they are investing
Performance vs. Cost Comparison, 2008
Bahrain
High
UK
UAE
Kuwait
New Zealand
Czech Republic
Singapore
Spain
South Korea
Oman
Saudi Arabia
Poland
Slovakia
Performance
Low
India
Germany
Netherlands
US
Qatar
Hungary
Hong Kong
Italy
Israel
Argentina
R2=0.5367
Venezuela
Morocco
Peru
Namibia
Low
Middle East
Africa
Europe
Asia Pacific
Latin America
US & Canada
Switzerland
Canada
Uruguay
Brazil
Philippines
Malaysia
Russia
Taiwan
Algeria
Chile
China
México
Turkey
Colombia
South Africa
Kenya
Sweden
Australia
Belgium
Ireland
France
Cost (Spend per capita /Int.$)
Note: Trend line is a polynomial
Source: Discovery Health Pool Stream Database, Monitor Analysis
High
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Selected Health Statistics, BRICS Countries
Indicator
Brazil
Russian
Federation
India
China
South Africa
Total population (millions)
193.7
140.8
1198 0
1353 3
50.1
Total expenditure per
capita (PPP int $)
943
1,038
132
309
862
Total expenditure on as %
of GDP
General government
expenditure on health as
% of total government
expenditure
Life expectancy at Birth
Males
Females
Both
9.0
5.4
4.2
4.6
8.5
6.1
8.5
4.1
10.3
9.3
70
77
73
62
74
68
63
66
65
72
76
74
54
55
54
Indicator
Brazil
India
China
South Africa
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Russian
Federation
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Infant mortality rate (per 1,000
live births)
Under 5 mortality
Adult mortality rates, 15-59
years (per 1,00 population)
Male
Female
Both
Maternal Mortality Ration (per
100,00 live births)
Distribution of years of life lost
by causes (%)
Communicable
Non Communicable
Injuries
Prevalence of HIV among adults
aged 15-49 (%)
Prevalence of TB (per 100,000
population)
Tobacco smoking 15+ (%)
Males
Females
50
17
43
21
12
66
19
62
205
102
154
58
391
144
269
39
250
169
212
230
142
87
116
38
521
479
496
410
20
56
24
0.6
11
64
25
1.0
52
35
13
0.3
15
65
19
0.1
79
15
6
17.8
50
132
249
138
808
19.4
12.0
70.1
27.7
33.2
3.8
59.5
3.7
29.5
9.4
LIST OF GINI-COEFFIECIENTS FOR DIFFERENCT COUNTRIES, LATEST WORLD BANK DATABASE
2000 to 2009
South Africa
South Africa (2006)
67
2006
Seychelles
Seychelles (2007)
66
2007
Comoros Islands
Comoros (2004)
64
2004
Micronesia, Fed. Sts.
Micronesia, Fed. Sts. (2000)
61
2000
Haiti
Haiti (2001)
60
2001
Angola
Angola (2000)
59
2000
Honduras
Honduras (2007)
58
2007
Colombia
Colombia (2006)
58
2006
Bolivia
Bolivia (2007)
57
2007
Central African Republic
Central African Republic (2008)
56
2008
Guatemala
Guatemala (2006)
54
2006
Brazil
Brazil (2009)
54
2009
Rwanda
Rwanda (2005)
53
2005
Lesotho
Lesotho (2003)
53
2003
Nicaragua
Nicaragua (2005)
52
2005
Mexico
Mexico (2008)
52
2008
Chile
Chile (2009)
52
2009
Panama
Panama (2009)
52
2009
QUALITY IN PUBLIC HEALTH FACILITIES
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Cleanliness
Safety and security of staff and patients
Long waiting times
Staff attitudes
Infection control
Drug stock-outs
Trends in Total Benefits Paid, 1997 - 2005
Rands
Billions
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13
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11
10
9
8
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3
2
1
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
General Practitioners
Dentists
Provincial Hospitals
Medicines
Ex-Gratia Payments
Capitated Primary Care
Source: Council for Medical Schemes
Medical Specialists
Dental Specialists
Private Hospitals
Supplementary and Allied Health Professionals
Other Benefits
Sustainability of Medical Scheme Industry
• A number of medical schemes have collapsed,
been placed under curatorship or merged
• Registered schemes have reduced from over 140
in the year 2001 to under 100 in 2010
• To sustain their financial viability, schemes tend
to increase premiums at rates higher than CPIX
– Declining depth & breadth of benefits
• Industry has registered deficits two years
consecutively
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There are no simple solutions to the
systemic challenges...
1. Sit back, relax and watch as system
and outcomes worsen 
OR
2. Recognise that we cannot wish our
problems away so we must get up, rollup our sleeves and take action now 
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CONSTITUTIONAL OBLIGATION:
THE BILL OF RIGHTS
Section 27. Health care, food, water and social security
1. Everyone has the right to have access to
a. health care services, including reproductive health care;
b. sufficient food and water; and
c. social security, including, if they are unable to support
themselves and their dependants, appropriate social
assistance.
2. The State must take reasonable legislative and other
measures, within its available resources, to achieve the
progressive realisation of each of these rights.
3. No one may be refused emergency medical treatment.
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Principles
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The Right to Access Health
Social Solidarity
Equity
Effectiveness
Efficiency
Appropriateness
Affordability
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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)
• Committee of Inquiry on National Health Insurance (1995)
• The Social Health Insurance Working Group (1997)
• Committee of Inquiry into a Comprehensive Social Security
for South Africa (2002)
• Ministerial Task Team on Social Health Insurance (2002)
• Advisory Committee on National Health Insurance (2009)
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
• Legally required to produce evidence of this upon entry into
South Africa
– Refugees and asylum seekers will be covered in line
with provisions of the Refugees Act, 1998 and
International Human Rights Instruments ratified by
the State
• NB: DHA amending this so may be reviewed further
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Healthcare Benefits under NHI (Illustrative)
• Primary health care services:
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Prevention,
Promotion,
Curative,
Community outreach and community-based services as well as
school-based services
• Inpatient and outpatient hospital care (including specialist and
rehabilitation services)
• Prescription drugs
• Emergency care
• Mental health services
• Oral health services
• Basic vision care and vision correction
• Appropriate technologies for diagnosis and treatment including
assistive devices
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Health System Re-engineering
• Shift emphasis from high cost, curative service
delivery/provision to health promotion and prevention
(incl. community outreach)
• Primary health care services shall be delivered
according to the following three streams:
1. District-based clinical specialist support teams supporting
delivery of priority health care programmes at the district
level
2. School-based Primary Health Care services
3. Municipal Ward-based Primary Health Care Agents
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Accreditation of Providers
• All facilities/establishments to be accredited according to the
same set of standards and norms
• Draft Bill on Office of Health Standards Compliance (OHSC)
tabled in Parliament
• An independent OHSC to be established with 3 main units:
– Inspection
– Ombudsperson,
– Certification of health facilities
• Developmental and multidisciplinary approach using evidencebased principles for standard development to evaluate
compliance and to monitor progress
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Principal Funding Mechanisms
• Combination of sources:
– General tax allocations
– Employers
– Individuals
• Revenue base to be as broad as possible:
– To achieve the lowest contribution rates
– Generate sufficient funds to supplement the
general tax allocation to NHI
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The Role of Medical Schemes
• Medical Schemes will continue to exist within
the NHI environment
• May provide top-up cover
• No one will be allowed to opt-out of NHI
– Mandatory contributions >>> payroll- or income
linked
• Technical capacity exists within the sector to
help with roll-out
– What, how and when....
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The Ten Point Plan
1.
Provision of strategic leadership and creation of a social compact for
better health outcomes
2. Implementation of a National Health Insurance Plan
3. Improving Quality of Services
4. Overhauling the health care system and improve its management
5. Improving Human Resources Management
6. Revitalization of physical infrastructure
7. Accelerated implementation of HIV and AIDS Plan and reduction of
mortality due to TB and other communicable diseases
8. Mass mobilization for better health for the population
9. Review of the Drug Policy
10. Strengthening Research and Development
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Health System Performance
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Piloting of NHI Started in 2012 April
• Policy position: Phased-in over a period of 14 years
• First steps towards implementation through
piloting
• 10 health districts selected for piloting
• Selection of the 10 districts based on the following
factors:
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Health profiles, demographics
Health delivery performance
Management of health institutions
Income levels and social determinants of health
Compliance with quality standards
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Selected Pilot Districts and Respective Population Numbers
Province
District
Total Population based on STATSA
2010 Population Estimates
Eastern Cape
OR Tambo
1,353,349
Mpumalanga
Gert Sibande
944,694
Limpopo
Vhembe
1,302,107
Northern Cape
Pixley ka Seme
192,157
uMzinyathi
514,840
Kwa-Zulu Natal
Kwa-Zulu Natal
uMgungundlovu
1,066,150
Western Cape
Eden
558,946
Dr K Kaunda
807,752
Thabo Mofutsanyane
832,172
North West
Free State
Gauteng
Tshwane
2,697,423
TOTAL POPULATION
10,269,590
Notes: *KZN will pilot two (2) districts due to high population numbers and high disease burden
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The First 5 Years
• Focus on strengthening the health system in the
following areas:
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Management of health facilities and health districts
Quality improvement
PHC re-engineering incl. roll-out of PHC streams
Infrastructure development
Medical devices including equipment
Human Resources planning, development and
management
• Information management and systems support
• Establishment of the National Health Insurance Fund
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IMPACT OF NHI ON THE
WORKPLACE
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Background
• The 2006 LIMS study attempted to gain insights into health in
the workplace:
– 40 companies surveyed, 8 have all employees covered and
the rest have variable cover.
– 90% of companies offer medical schemes subsidy between
50%-66%, dependents included max 4.
– Employees should pay 10-15% of salary as premium with
max of R200/month/employee
• Strong support for low income members to have cover given
the benefits: better employee health, leading to increased
productivity, reduced absenteeism and reduced requests for
loans.
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Bargaining Council Schemes
• Established under the Labour Relations Act
(Act 66 of 1995)
• 27 Bargaining Councils
• 800,000 employees and about 50,000
employers
• Approach is PHC based with panel doctors
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Occupational Health Facilities
• extensive legislation governing occupational health
issues in the workplace
• staff-based model or directly-contracted model
• Contracted providers usually employed on a parttime consultancy
• Workplace-based occupational health services may
be engaged in the promotion and maintenance of
employee health, maintenance of workforce
efficiency, fulfilment of legal compliance with
regulations.
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Mine Health and Safety Act
• Mine - hospital or clinics and nurses, doctors and
other health professionals are employed by mine
• In 1997 there were 66 mine hospitals with a total of
6,088 beds - more economical than contracting or
insurance
• Significant decline in the number of hospitals over
the next 10 years - decline in the gold price,
development of more efficient mining techniques,
and the fact that many gold reserves are becoming
depleted has led to drastic reductions in employed
miners.
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Provision of HIV/AIDS Treatment
• The mines have lead the widespread provision of
testing and treatment for HIV/AIDS, other have since
followed
• South African Business Coalition on HIV & AIDS
• The mining, metals processing, agribusiness and
transport sectors are most affected by the pandemic,
with more than 23% of employees infected with
HIV/AIDS and with prevalence rates two to three
times higher among skilled and unskilled workers
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than among supervisors and managers.
Possible implications under NHI
• Benefits that were available through
bargaining councils will be replaced by the
universal healthcare package. Tax based
financing as opposed to current out of pocket
payments on a voluntary basis.
• Financing of workplace programmes from the
fund will reduce the burden on companies
since these activities will be eligible for
funding through the NHI. Improved efficiency
through central purchasing and monitoring
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Possible implications under NHI (2)
• Provision of ARVs, monitoring and care of HIV
patients will be funded centrally. Reduced
burden on the employer and greater efficiency
through central purchasing.
• Consolidation of healthcare funding for
workplace injuries such as CCOD. Central fund
that will pay for all healthcare service. Patients
can access care at any NHI provider as
opposed to the current system.
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FAIRNESS
“Fairness, I believe, is at the heart of our ambitions in global health. A quest for greater fairness dominates the
agenda for this forum.
We see this in your concern about vulnerable populations, and about health systems that exclude the poor. We see
this in your support for global health initiatives and funding mechanisms that redistribute some of the world’s
riches towards health needs of the poor.
On the issue of fairness, let me again state the obvious. Our world is dangerously out of balance, also in matters of
health. Differences, within and between countries, in income levels, opportunities and health status are greater
today than at any time in recent history.
Part of the world feasts itself into obesity, while part of the world fasts and starves for want of food. Part of the world
thrives into old age, while part of the world dies young from easily and cheaply preventable causes.
As the historians tell us, such huge extremes of privilege and misery are a precursor for social breakdown.
Is this where the progress of our civilized, advanced, high-tech, sophisticated society has brought us? To the brink of
social breakdown?
Let me make another obvious point. A health system is a social institution. It does not just deliver pills and babies the
way a post office delivers letters. Properly managed and financed, a health system that strives for universal
coverage contributes to social cohesion and stability.
I further believe that a failure to make fairness an explicit objective, in policies, in the systems that govern the way
nations and their populations interact, is one reason why the world is in such a great big mess.”
Dr Margaret Chan;Director-General of the World Health Organization
Address at the United Nations Secretary-General’s Forum on Advancing Global Health in the Face of Crisis, 15 June 2009
Thank You
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