Outline of the Presentation

1. TOWARDS THE IMPLEMENTATION OF NATIONAL HEALTH INSURANCE, REENGINEERING OF PHC, QUALITY IMPROVEMENT AND HEALTH GOVERNANCE: A CLOSER LOOK

2. Outline of the Presentation • Background- • Renewed interest in PHC, • Crises • Various perspectives • A response-Comprehensive PHC • Lessons from other countries • SA Response, 10 point plan, NSDA • Green paper • Quality, Infrastructure, Pilots

3. Background: Renewed interest on PHC • Thirty four years ago- Alma Ata declaration • Four years ago WHO World Health Report 2008 devoted to PHC, “ Primary Health care, Now More Than Ever” • The Lancet 2008series- “30 years after Alma-Ata: has primary health care worked in countries” • Commission on Social Determinants on Health • The Lancet (Julio Frenk, 2009) “Reinventing Primary Health Care: the need for systems integration” • Subsequent declarations, e.g. RIO Declaration on the Social Determinants of Heath, and RIO 20+ • The South African 10 point plan

4. Crises • The 1970s: Debt crisis, rising unemployment, stagflation, fuel crisis • Since 2007, financial crisis, fuel crisis, food crisis, climate change • Impact in both instances has been negative and decline in public health expenditure and increase in inequities, deterioration in health • Can be minimised, or impact ca be reduced through a comprehensive primary health care

5. Various perspectives • Commission on Macroeconomics and Health (2001 )-health has been considered a central goal of development and an instrument to enhance other welfare outcomes • AmartyaSen (1999) presented a philosophical perspective , that health is an essential element of the human capabilities needed for development • Bloom and Canning (2000), an economic perspective, consider population health as key in contributing towards economic growth at a national level • Liu et al (2003) on poverty , poor health is linked to poverty and household distress

6. Comprehensive primary health care • Elements of a comprehensive approach include equity, high coverage, governance, effective inter-sectoral action, the responsiveness of the non-health sector and community participation • Comprehensive primary health care must be an integration of preventative, promotive, therapeutic and rehabilitative

7. International Experiences Many governments have made attempts to reform health Some have created new insurance schemes, others have changed how primary healthcare is delivered, restructured hospital governance, decentralised service delivery Many of the reforms have yielded mixed results, a combination of successes and failures, improvements in some areas and slow progress in others

8. Success stories • Investments in primary health care: reduction in mortality rates and accelerated action and heightened response towards MDGs • Large scale innovation on PHC implementation • Universal coverage and consistent commitment in achieving equity • Nationally agreed prioritised and phased primary health care, with special attention to district management system

9. Lessons for South Africa Every nation is different and there is no one right answer to reform questions or one standard solution to health problems Countries differ in their level of development, social conditions, value systems, disease profiles, effectiveness of their governance structures and institutions There are best practices to learn from

10. Lessons for South Africa Every country must reform its health system with the involvement and participation of its citizens, mobilisation of its communities, the beneficiaries Common features among countries with experiences in rolling out PHC (Thailand, Rwanda, Brazil) are, an integrated approach in health system development, community participation, use of community health workers, focus on social determinants of health Kaizer Foundation Workshop and visits to the 3 countries and different times Published reports

11. National Health Priorities D A B C D TOP SECRET

12. Pillars Health Financing Health Service Provision Governance and Institutional arrangements Regulatory environment

13. Universal Coverage This principle is based on the understanding that the progressive development of a health system, including its financing mechanisms, should be founded on the principles of access to quality needed health services and protection from financial hardships.

14. Universal Coverage This does not imply that the State must provide everything and anything to the population. Instead, it implies that everyone must be given an equitable and timely opportunity to access needed health services, which must include an appropriate mix of promotion, prevention, curative and rehabilitative care.

15. International Profiles • The Commonwealth Fund • Overviews of healthcare systems of Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, new Zealand, Norway, Sweden, Switzerland and The United States • Focus on health systems, health financing, public private mix, organisation of services, use of health information technology, reforms innovations, access, capacity for quality improvement etc

16. Health Financing • Countries do not finance healthcare through a single mechanism • There are a combination approaches: • Private • Public • Combination of both • Multiple health plans

17. Health Service Provision Predominantly publicly provided services- Scandinavian countries Combination of government care and private health providers (UK) Predominantly private providers (Swiss)

18. Private • Individual private insurance, that may be: • community based health insurance, or • medical savings account, or • private health insurance e.g. medical schemes

19. Public • Payment through taxes or compulsory health insurance: • Social health insurance,(contributions from employer and employee, it is limited to the formal employment sector), • National health insurance, (prepayment scheme that is mandatory and is a compulsory health insurance) • Tax-based finance system (government revenue the main source) (Source: Global Health Watch 3, 2011)

20. Social Health Insurance Limited to the formal employed sector Leaves a significant proportion of the informal employed and self employed sector It has a small pool and hence universal coverage may not be achievable It is socially acceptable to the employed sector May contribute to higher labour costs

21. Tax-based finance system It is a form of prepayment and government is the main source of funding It does not link payment to risk and detaches payment from the experience of ill-health It has better potential in achieving universal coverage and financial protection It may promote social cohesion across different groups

22. Tax-based finance system It requires both fiscal and social contract between the state and society It must be the means by which the state can be made accountable to society The informal sector may be covered but there are challenges with regard to its complexities and heterogenity There must be recognition that informal sector should not necessarily be referred as “poor”

23. Private Health Insurance Self financing scheme for the affluent It is highly selective and universal coverage may not be achievable as it only covers a small proportion of the population Requires robust regulatory systems Countries with predominantly private health insurance schemes are Netherlands, Switzerland and USA In the US, 50 million people are uninsured despite the fact that 2,3 trillion is spent on healthcare ( G. Halvvorson, 2009)

24. Community Based Health Insurance A scheme that is operated by organisations other than government of private for profit sector It may cover part of or all of the healthcare costs It is voluntary and is low cost, with administration managed by the communities themselves It largely provides cover for the socially excluded or populations in the informal sector the schemes have a potential to reduce financial burdens on individuals and reduce out of pocket payments

25. Community Based Health Insurance • Those without income ma not benefit, and thus universal coverage may not be possible without government subsidy • The biggest challenge is long term sustainability • The Chinese and Indian schemes benefit from government subsidy: • Rural Mutual Healthcare (China) • Self Employed Women association (India)

26. What is needed for South Africa? Fair financing means that the risks that each household faces due to the cost of healthcare are distributed not according to the risk of illness (WHO) Will need trade offs if fairness is to be achieved Will need involvement of communities and all stakeholders across all spheres Will need improved governance structures and transparent, responsive and accountability systems across all spheres of government

27. What is needed for South Africa? • A shared value of universal coverage based on principles of • Fairness and without barriers • Social solidarity, promoting unity and ownership • Financial risk protection • What should be the uniting and core elements: • There should be solidarity, the young must subsidise the old, the healthy must subsidise the sick and the rich must subsidise the poor

28. What is needed for South Africa? Shared value of access, availability, acceptability, affordability and quality Access can be therapeutic access, financial access and physical access

29. THE FIRST 5 YEARS OF NHI • NHI will be phased-in over a period of 14 years • Will include piloting and complete overhaul of the health system in the following areas: • Quality improvement • PHC Re-engineering • Management of health facilities and health districts • Infrastructure development • Medical devices including equipment improvements • Human Resources planning, development and management • Improving Access to medicines • Strengthening of information management and systems support • Public sector health finance reform • Establishment of the National Health Insurance Fund in the latter years of the 1st phase

30. PROGRESS ON PHASE 1 DELIVERABLES OF GREEN PAPER ON NHI

31. PROGRESS ON PHASE 1 DELIVERABLES OF GREEN PAPER ON NHI

32. PROGRESS ON PHASE 1 DELIVERABLES OF GREEN PAPER ON NHI

33. Quality Improvement

34. BACKGROUND • Two streams of work on quality: • Regulatory and oversight • Health systems • Regulatory and oversight • Office of Health Standards Compliance (OHSC) • Health systems • The independent Audit of Public Health Facilities commenced May 2011 • Establishment of facility improvement teams

35. QUALITY OF HEALTH CARE - OHSC • OHSC is to be established with at least 3 units: • Inspection • Ombudsperson, • Certification of health facilities • Draft Bill on Office of Health Standards Compliance (OHSC) was tabled in Parliament in December 2011 • Parliamentary hearings currently underway • 20 Inspectors were trained and appointed in December 2011 to inspect and certify facilities • Mock inspections

36. Development and implementation of Facility Improvement Plans • Use the results of the Audit to strengthen and improve health systems performance as well as six priorities of quality • A collaborative, participatory , systems approach that would integrate improvement into routine management practises • Buy in and support from stakeholders is essential for sustainability

37. Facility Improvement Teams • Composition – • Senior Managers from NDoH, PDOH and Districts • Additional Expertise –providers on National data base. • Teams will be district and or facility based • Interventions will be district wide and facility specific depending on the results of the Audit. • Recording of methodology and interventions will assist in the roll-out to other districts

38. PROGRESS FIT • Facility Improvement Teams consisting out of managers from National, Provincial and Districts management were established for 5 Province – (NC, FS, KZN, LP and GP) • The Director General visited Provinces and the National Teams were introduced to Provinces in (NC, FS, KZN and LP ) • Work has started in 4 Districts, namely MangaungZululand; Pixley ka Seme and Vhembe Districts • The high level project plan based on the results of the Audit had been developed for Sedibeng. The work at facility level in Sedibeng district will start in May 2012.

39. Infrustructure

40. Total – RSA High Low Existing Health Estate in SAPublic and Private Health Facilities

41. A Estimated Average Condition of Estate Maintenance Budget Requirement

42. NHI PILOTS

43. 1st PHASE OF NHI PILOTS • The 1st phase occurring in the 1st 5years of rollout includes: • Strengthening of the health system and • Improving the service delivery platform • Policy and Legislative reform

44. NHI PILOTS IN 2012 / 2013 • The first steps towards implementation of National Health Insurance in 2012 will be through piloting • Pilots commenced on the prioritized health districts • 10 (+ 1) districts have been selected for piloting • Pilot district selection has been based on the following criteria: • Demographic profile • Socio-economic profile • Burden of diseases using (MDG Proxy indicators) • Service delivery platform and health system performance • District management capacity to conduct pilots

45. NHI 2012/13 • The NDoH is currently evaluating inputs into the Green Paper on NHI • Green Paper will be converted into draft White Paper • NHI Pilots - undertaken in 10 (+1) Districts in April 2012 with most vulnerable sections of society • Selection criteria are based on demographic and socioeconomic data, service delivery performance and district management capacity • The focus in the 1st 5years is to ensure that South Africans: • Have access to quality health services • Experience reduction in the burden of disease, particularly that borne by women and children • Experience improvements in the overall health system performance • Road shows for stakeholder engagement are being undertaken • Continuous M&E to measure impact on health outcomes and health system performance

46. Governance of the Health System

47. Governance of the Health System • Guided by the National Health Act • National Health Council – Functional • Provincial Health Council – Different levels of functionality • District Health Council – 2010/11 – 32 Functional DHC’s • Hospital Boards - • PHC Facility Committees – 2010/11 – In 43 Districts functional PHC committees were established • Would need amendment of the National Health Act for new governance arrangements-District Health Authorities and relevant governance structures

48. Governance of the Health System • Guided by the National Health Act • Would need amendment of the National Health Act for new governance arrangements-District Health Authorities and relevant governance structures • Implies complete reform of public service and private service • Need to develop a uniform approach for the establishment of governance structures at Provincial, District and Facility Level • Governance Structures to provide more direct oversight aligned to the overhaul of the Health Care System and the Policy implementation of NHI institutional arrangement.

49. THANK YOU FOR YOUR ATTENTION