Integration of the public and Integration of the public and private sectors under the NHI private sectors under the NHI

and other researchand other research

Mariné Erasmus21 September 2010

IRF Conference - Sandton

National Health Insurance Authority

Public Healthcare Providers

Private Healthcare Providers

Contributing Individuals

Non-contributing Individuals

Provider Contracting

and Payment

Provider Contracting

and Payment

Contribu-tions

Healthcare Service

Delivery

Healthcare Service

Delivery

Healthcare Service

Delivery

Healthcare Service

Delivery

Key features of the current proposal

Current research

Series of research notes on general health reform� Importance of primary care� Accreditation� Integration of public/private sectors� Human resource requirements� Reimbursement levels and models� Freedom of choice� Earmarked tax for NHI� Other practical issues

Health Minister Motsoaledi’s turnaround strategy: renewed focus on PHC

Evidence of improved affordability & accessibility of public healthcare by poor households since 1994

Quality remains a concern� Waiting times� MDG 4: reduce child mortality� MDG 5: reduce maternal mortality

Assuring quality through accreditation

Role of Primary Healthcare in Health Reform

Percentage of people who experienced the following problems while visiting a public hospital or clinic, GHS 2008

Maternal mortality ratio(maternal deaths per 100,000 live births)

“South Africa is regarded as a superpower in health on the continent. Yet, the irony lies in the fact that most of these countries that turn to South Africa for hi-tech healthcare have low infant and maternal mortality rates.” Minister Motsoaledi

Focus on delivery of PHC will have large impact on poor & vulnerable communities

PHC facilitates less costly and more equitable healthcare But in SA:

� Higher detection rates at PHC level implies greater costs in short to medium term

� Expect cost decreases in long term Implies major changes to current private sector delivery model

PHC in South Africa

Integration of the public and private healthcare sectors

Contracting? Payment mechanisms & levels? Referral system? Choice of provider? Service delivery models?

Current promise:� Universal coverage� Free choice of provider at PHC level (although restricted to

geographical area)� Capitation at PHC level, global budgets for hospitals

Integration of the public and private healthcare sectors (continued)

Private sector: GPs & specialists paid on fee-for-service basis at the moment Not employed by hospitals Large out-of-pocket payments by medical scheme beneficiaries and

non-members Free choice & direct access to specialists in most cases Demand rationed by price

Proposed comprehensive PHC approach: Integrated, holistic & more preventative Outreach beyond hospitals, analysis of upstream factors Focus on family, not just individual Task-shifting (multi-disciplinary practices/ health teams: CHWs,

nurses, doctor)

Integration of the public and private healthcare sectors (continued)

Only limited excess capacity in private sector (±20%) 32% of population already use private out-of-hospital

services(DBSA Roadmap study)

36.7% of population depends on private sector for PHC(McIntyre et. al.)

GPs & specialists (CMSA 2009)

Private GPs: 0.44 per 1,000 population Public GPs: 0.35 per 1,000 population

Private Public

GPs 8,000 (42.1%) 11,000 (57.9%)

Specialists 5,000 (55.6%) 4,000 (44.4%)

Integration of the public and private healthcare sectors (continued)

Private sector players will only contract with NHIA if beneficial to them

Quality differences, implicit rationing Possible perpetuation of current system at higher costs Conversion to higher private sector prices if no differential

payment structures

Patient choice & referral

Rationing choice is inevitable GP gatekeeper model (across the world) South African proposal

� Will restrict choice Current rationing in public sector vs. private sector

� Limited resources vs. to keep system affordable Need clearly defined referral guidelines Geographical inequalities affect choice & referral Information systems Other practical concerns

Provider payment systems

Single-payer system with monopsony powers Different payment options with associated incentives BUT unique SA situation

� Quality differences� Shortage of doctors� HPCSA rules� Private insurers (medical schemes)

Concluding remarks

To deliver on the promise of quality care for all South Africans (under a NHI system), integration between public & private sectors must happen

Many practical concerns, including:� Service delivery model� Referral mechanisms� Contracting & payment� HR requirements� Information systems, etc.

Theoretically, if the hurdles could be overcome, access, affordability, quality & health outcomes (life expectancy, etc.) should improve over the long run

Further research needed

Thank you.