The pathway to NHI - Actuarial Society of South Africa · The pathway to NHI Roseanne Murphy da...

Actuarial Society 2016 Convention 23 – 24 November 2016

The pathway to NHI

Roseanne Murphy da Silva: [email protected]

Sarika Besesar: [email protected]

mailto:[email protected]

mailto:[email protected]


The pathway to NHI

• Universal health coverage

• South African context

• Countries selected

• Key learnings

• Way forward

2


Universal Health Coverage (UHC)

• Non discriminatory health systems

• Accessible to all

• Role of private sector where resources are constrained

• Themes:

• Access to care or insurance

• Coverage

• Identifiable point of entry

• Rights-based approach

• Economic risk protection

3


Health Systems Finance Components

4

Revenue Collection

Pooling Purchasing

Delivery


The South African context

• Medical schemes cover only 16%

• Private primary care purchased OOP (4.8%)

• Inequalities perpetuated

• Pathway to NHI

• Single fund

• Publicly financed

• Comprehensive benefit package

• Free at point of service

• Public and private delivery of care


Countries in the analysis

Brazil

Ghana

Thailand

Chile

Canada

Netherlands

U.K.

France

Low to Middle Income High Income


Health Expenditure vs GDP per Capita

7

$-

$10 000

$20 000

$30 000

$40 000

$50 000

$60 000

$-

$1 000

$2 000

$3 000

$4 000

$5 000

$6 000

$7 000

Brazil Chile Ghana SouthAfrica

Thailand Canada France Netherlands UnitedKingdom

GD

P p

er

ca

pita

He

alth

care

Exp

. p

er

ca

pita

Average Health Care Spend per Capita (2012)

Average Health Care Spend per Capita PPP adj. (2012)

Average GDP per capita (2014)


Health Outcomes (2013)

8

0

10

20

30

40

50

60

70

80

90

0

10

20

30

40

50

60

70

80

90

U5

MR

Life

Exp

ecta

ncy

Life Expectancy U5MR per 1000 live births


Human Healthcare Resources

9

0

10

20

30

40

50

60

70

80

90

100

0

5

10

15

20

25

30

35

Brazil Chile Ghana South Africa Thailand Canada France Netherlands UnitedKingdom

Nu

rse

s

Do

cto

rs

Doctors per 10,000 population (2007-2013) Nurse per 10,000 population (2007-2013)


Low income experience

Brazil Chile Ghana Thailand

Benefit package Implicit Explicit Explicit Explicit

Pooling SUS (Decentralised) AUGE + ISAPRE NHIS (District) Central funds

Purchasing Mixed Mixed Mixed Mainly public

Financing Taxes - 3 levels. Payroll + VAT

Payroll + VAT + Tax

alloc General Tax

VPHI

Duplicative and

Supplementary

Duplicative and

Supplementary

Duplicative and

Supplementary Duplicative

10


OOP & VPHI

11

00%

05%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Brazil Chile Ghana South Africa Thailand Canada France Netherlands UnitedKingdom

OOP as a % of THE (2012) VPHI as % of THE (2012)


Lessons from Higher Income

Countries

Unlimited Wants

Finite Resources

Scarcity

12

The INFINITE DEMAND OF HEALTHCARE RENDERS UHC IMPOSSIBLE


Lessons from lower income

countries

13

Service Coverage

Po

pu

lati

on

C

ove

rage

Service Coverage

Po

pu

lati

on

C

ove

rage

RESEOURCE CONTRAINTS REQUIRE TRADEOFFS IN COVERAGE


Benefit package

• Tradeoff between depth of benefit

package and breath of population

coverage

• Explicit definition of services facilitates

management and empowers patients

• Incremental increases to manage costs

• Community participation for acceptability

An explicit benefit package in SA will limit the NHI’s liability, allow for better cost

containment and empower patients with entitlement to a set of benefits

14


Delivery

• Decentralisation

• Advantages vs Risks

• Quality Assurance

• Quality authority

• Revitalisation of the public

sector

• Private sector contracting

• Competition

Decentralisation is complex but will make the end users closer to NHI structures.

Quality assurance is key. Private sector contracting will enhance competition.

15


Pooling

• Single Funder Inefficiencies –

Ghana, UK and Canada

• Competition does not guarantee

efficiency – Netherlands

• Innovative designs such as France

or Thailand with distinct pools –

inequalities

NHI pooling system should ensure income cross-subsidies.

The system should be responsive to local needs.

16


Financing

• Healthcare reform requires additional

funding

• High reliance on OOPs in low income

countries

• In higher income countries, cost

containment is a challenge

• NHI White paper suggests increasing tax

in South Africa

Mechanisms to raise revenue for the NHI should be progressive with minimal

impact on employment. The impact on OOPs and THE must be considered.

17


Voluntary Private Health Insurance

• Demand for VPHI in lower income

countries is inevitable.

• Private sector should complement

public sector

• An opt out private sector enables

government resources to be focused

on the poor

Private duplicative cover in South Africa is appropriate.

Role of medical schemes must be defined to ensure it is harmonious with the NHI

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The Way Forward

• The pathway as important as the

destination

• Infrastructure and human capital

more important than finance

• Success lies in unlocking current

inefficiencies

• Build on current institutions

• Tackle gross inequalities

19


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Thank You!

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