benefit design: nhi and pmb · 2020. 2. 28. · pmb approach •service benefits...
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Benefit design: NHI and PMB
Strategy officeEvelyn Thsehla
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Contents
• Background
• NHI service design approach
• NHI framework
• PMB framework
• PMB service design approach
• Way forward and resource needs
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Background
• Medical schemes will provide supplementary cover in the implementation phase
– Same services offered under NHI
• Medical schemes will provide complementary cover once NHI fully implemented
– Services not covered by NHI
• Introduction of single service benefits (April 2018)
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Approach
• Health service benefits will be provided and described in terms of the types of services and level of care
• NHI benefits Advisory Committee will develop the comprehensive package.
• Priority setting and HTA will be used to inform decision making
• Service benefits will not be based on a negative or positive list nor PMBs
• Priority setting will be through an explicit guarantees– Number of issues or health conditions considered a priority
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NHI benefits framework
• Primary health care
• Hospital based services
• EMS and patient transport
• Other services
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NHI service benefits
• PHC service benefits– Prevention, promotion, education, PHC outreach homecare
– Maternal, women, child health, reproductive services
– HIV and tuberculosis
– Chronic non-communicable diseases
– Violence and injuries
• EMS– Basic, intermediate, advanced life support
– Medical rescue, initial assessment, stabilisation, management, resuscitation
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NHI service benefits
• Hospital services– Emergency medicine– Internal medicine– Nephrology– Oncology– Psychiatry– Obstetrics and gynaecology– Paediatrics and neonatology– Surgery– Orthopaedics– Organ transplant
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NHI service benefits
• Other services– Nutrition
– Mental Health
– Oral health rehabilitation
– Optometry
– Basic curative
– Environmental
– Clinical support
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Phase I implementation
• Maternal services– Antenatal benefits
• Women– Contraceptives, cervical and breast cancer treatment
• School children– Eye, ear and oral health– Childhood cancers
• Elderly– Cataract, knee replacement
• Mentally ill– Screening, treatment and care
• Disabled– Treatment and rehabilitation
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Implementation structure
Head of NHI
Benefits
Phasing of benefits
Priority programmes
Benefits HTA
Pricing reimbursement
Private sector reform
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Review Goals
• Reduce burden of disease– Prioritise communicable diseases( HIV, TB), non-communicable
diseases, violence and injury
• Improve equity– Children, women, elderly, disabled, mentally ill
• Control moral hazard and cost escalation– PHC gatekeeping, payment mechanism
• Improve allocative efficiency– PHC gatekeeping
• Facilitate transparency in accessing healthcare– Educate population covered about entitlements
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PMB approach
• Service benefits
• Multidisciplinary committees approach
• Priority setting using burden of diseases, cost effectiveness, affordability
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PMB framework
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Way Forward
• Publish a circular to invite stakeholders to consultative meeting. – The aim of the consultative meetings is to engage key stakeholders in
discussions to finalise the structures and processes that will be used to drive the PMB Review (X).
• Appoint members to the different committees (July)– >60 CVs received
• Multi-stakeholder workshop (Aug)
• Invite stakeholders to make submission on the different service benefits (Aug)
• Schedule meetings to discuss submissions of the different service benefits (Aug)
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Review committees
Joint Steering Committee (CMS, NDoH, other regulators
Clinical Advisory Committee on Services Package
Service Package Sub-Committee
e.g. Emergency Services
Costing Committee
Project Manager
Legal & Regulatory committee
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Resource needs
• Support team– Provide support to various committees – Provide research and secretarial support to the committees– Collate written submissions and comments from stakeholders
• Technical experts– Provide technical support to the sub-committees– Technical sign-off
• Core team– Overseeing the work of the committees– Provide secretarial support– Participate in joint planning sessions
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Resource needs
• Steering committee– Approve project deliverables
– Approve scope changes to be presented to sponsor
• Project leader– Develop the TOR together with other project members
– Responsible for management of project process
– Secures acceptance and approval of deliverables from the Steering Committee and Stakeholders
– Ensures project is delivered within budget, on schedule and within scope
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Summary
• HBP that will have UHC impact are much more than lists or technical analyses– Good list is necessary but not sufficient– Effective HBP adjust all other control knobs : financing,
payment, organization, regulation, behavior– Not a one-off consultancy, requires permanent home and
capacity – Multidisciplinary! Health, economics, ethics, governance
• Process is as important as outcome for effectiveness and sustainability– Needs to be (widely perceived as) fair, ethical, transparent,
defensible in court!– With a view to manage not ignore legitimate competing
interests
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Conclusion
• Need resources to fast track the process