NATIONAL HEALTH INSURANCE PILOTS

Forum for Professional Nurse Leaders Conference

Sliverstar Casino, Krugersdorp

8th MAY 2012

Outline

• WHO Dimensions for UHC

• Constitutional Obligation

• Principles of NHI

• NHI Pilots

• Other Preparatory Work

• Conclusion

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DIMENSIONS FOR ACHIEVING UNIVERSAL COVERAGE Source: WHO (World Health Report: 2010)

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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

– The Right to Access Health

– Social Solidarity

– Equity

– Effectiveness

– Efficiency

– Appropriateness

– Affordability

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Piloting of NHI Starts in 2012

• Policy position: Phased-in over a period of 14 years

• First steps towards implementation start in 2012 through piloting

• 10 health districts have been selected for piloting

• Selection of the 10 districts was based on the following factors:

• 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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Pilot Selection Criteria

Burden of Disease

Demographic

Health Service Performance

District Management

Capacity

Socio-Economic

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Selected Pilot Districts and Respective Population Size

Province District Total Population

(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

Kwa-Zulu Natal uMzinyathi 514,840

Kwa-Zulu Natal uMgungundlovu 1,066,150

Western Cape Eden 558,946

North West Dr K Kaunda 807,752

Free State Thabo Mofutsanyane 832,172

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 8

Objectives for NHI Pilots (1)

• To assess utilization patterns (incl. referral systems), costs and affordability of implementing the re-engineered PHC package – Improving access to quality health services particularly in the rural and

previously disadvantaged areas of the country

• To assess the practical, affordable and innovative ways of engaging private sector resources for public health purposes

• To examine the mechanisms needed for introducing a district health system mechanism of funding for health services

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Objectives for NHI Pilots (2)

• To assess the costs of introducing a fully-fledged District Health Authority as Contracting Agency and implications for scaling-up such institutional and administrative arrangements throughout the country

– To test ability of the districts to assume greater responsibilities associated with the purchaser-provider split required under a NHI

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The First 5 Years of the Pilots

• Focus on strengthening the health system in the following areas:

• Management of health facilities and health districts

• Quality improvement

• PHC re-engineering incl. roll-out of three PHC streams

• Infrastructure development

• Medical devices including equipment

• Human Resources planning, development and management

• Information management and systems support

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PILOT INTERVENTIONS

HEA

LTH IN

DIC

ATO

RS

HEA

LTH IN

DIC

ATOR

S

CENTRAL

HOSPITALS

SERVICE DELIVERY

INDICATORS

Ward-Based PHC

Teams

District

Specialist

Support

Teams

School-based

PHC Services

Private

providers (GP &

Teams) Model

7 Hospital Pilot

Revenue

Collection

Package of Services

+ EMS

Delivery

Models

Referral

Networks

Private

Providers (GP &

Teams) Model

Revenue

Retention

Systems

strengthening

HEALTH SYSTEMS

STRENGTHENING

(HR; FINANCING;

INFORMATION

SYSTEMS,

MANAGEMENT,

ADMINISTRATIVE

CAPACITY etc.)

District Health Authority –Contracting Agency

Innovative Financing for health services

Human

Resources

(Norms and

standards)

Contracting,

procurement,

purchasing, IT,

& risk (Fraud

prevention)

engine

Population

Registration

Case

Management

Tools

development HEALTH INDICATORS

NHI Pilot Matrix

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Other Preparatory Work

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Health Facility Audits

• NDOH commissioned an independent audit on quality of health services and conditions under which they are delivered at public health facilities for the period May 2011 – March 2012

• +30 districts have completed (100% facilities audited with data validated) as at end January 2012

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Purpose of the Audits

• To strengthen comprehensive health care delivery at all levels - a process to strengthen the healthcare system

• To support the development and effective implementation of Facility Improvement Plans that respond to audit findings

• To strengthen the capacity for continuous healthcare quality improvements

• To develop a culture for sustained quality healthcare delivery that can be measured

• To initiate foundational work for the NHI

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Facility Audits Scope

• Audit information covers: – Information about bulk service supply, waste

management, opening hours, physical access, etc.

– HR

– Infrastructure

– Services packages

– Performance against national core health standards namely • Availability of medicines and supplies

• Cleanliness

• Patient and staff safety

• Infection prevention and control

• Positive and caring attitudes

• Waiting Times

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Districts Completed (Not All Validated)

Province Districts completed January 2012 Districts completed Feb 2012

Eastern Cape Chris Hani, Alfred Nzo, O R Tambo, Amathole, Cacadu

Free State Motheo, Xhariep, Lejweleptuswa, Thabo Mofutsanyane, Fezile Dabi

Gauteng Sedibeng, Ekhurhuleni, Tshwane, City of JHB West Rand

KwaZulu Natal Umkhanyakude, Uthukela, Ugu, Zululand, Amajuba, Sisonke, Umzinyathi, Umgungundlovu

Uthungulu, iLembe

Limpopo Greater Sekhukhune, Capricorn, Vhembe, Mopani

Mpumalanga Gert Sibande, Ehlanzeni, Nkangala

Northern Cape Frances Baard, Pixley Ka Seme, Siyanda, Namakwa, J T Gaetsewe

North West Ngaka Modiri Molema, Dr Ruth Sekgomotsi Mompati, Bojanala

Kenneth Kaunda

Western Cape Eden, Central Karoo Cape Winelands

Total 40 6 17

Summary of Completion Rate (February 2012)

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Prov. Hosp CHC Clinic Prov .Total Tot Fac

% Completed at the end of February

EC 75 28 612 715 880 81%

FS 31 10 210 251 312 80%

GP 31 35 317 383 453 85%

KZN 69 17 472 558 662 84%

LP 40 25 412 477 504 95%

MP 32 51 232 315 338 93%

NW 24 51 255 330 387 85%

NC 23 35 157 215 235 91%

WC 46 55 234 335 439 76%

Total 371 307 2901 3579 4210 85%

Establishment of HFITs

• Components to focus on Health Systems Strengthening & Clinical Health outcomes

– Financing

– Health Information

– Human Resources

– Medicines (other consumables)

– Quality

• Teams of officials from National and Provincial DOHs plus additional expertise where deemed necessary

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HFITs: Scope of Work

FITs will be district and or facility based and will focus on

• Standards benchmarking

• Human Resources – staffing norms, recruitment and retention

• Staff and community attitudes- caring staff, confident and

proud community

• Clinical care

• Operational and logistical efficiency

• Financial Management

• Health systems strengthening – patient centred care and

management capacity

• Quality

• Infrastructure

• M&E and Information Management

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Domains for Quality Improvement Initiatives

• Patient Rights

• Patient and Staff Safety incl. Clinical Governance and Clinical Care

• Clinical Support Services

• Public Health Programmes

• Operational Management

• Infrastructure Management and Appropriateness

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National Core Standards

• Availability of Medicines & Supplies

• Cleanliness

• Improve Patient and Staff Safety

• Infection Prevention & Control

• Positive & Caring Attitudes

• Waiting Times

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Establishment of the Office of Health Standards and Compliance (OHSC)

• All facilities/establishments to be accredited according to the same set of standards and norms

• Draft Bill on 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

evidence-based principles for standard development to evaluate compliance and to monitor progress

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Human Resources For Health Strategy

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• HRH Strategy finalised and published in 2011

• Numerous consultations with key players to finalise contents and gap analyses – Consultations involved Provincial DOHs, Deans and Heads of

Health Science faculties and Colleges of Medicine, NGO groupings, Department of Higher Education, Professional Representative bodies and labour organizations

• Focuses on 27 professional categories – Training, recruitment and retention matters

– Revitalisation of training platforms

– Access and availability in disadvantaged areas

– HR Intelligence & Planning

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• Nursing summit report finalised and social compact developed with a road map for nursing reform (August 2011)

• Ministerial Nursing Task Team established to

• Elaborate implementation plan for nursing reforms

• Work on policy and plans for nurse education and training by the end of 2011/12 financial year

• Priority infrastructure projects in 2012/13 include renovation, refurbishment and/or the complete rebuilding of about 122 nursing colleges – Enhance student intake and training capacity

– ± R450 m over the MTEF period

Improving Nursing & Increasing Numbers

Primary Health Care (PHC) Re-engineering

• PHC services shall be delivered according to the following three streams:

– District Clinical Specialist Support Teams supporting delivery of priority health care programmes at the district level • Focus: IMR, MMR and CMR (MWCH)

– School Primary Services • Focus: PHC services with the schools environment

– Municipal Ward-based Primary Health Care Agents • Focus: Community outreach programme (promotion +

prevention)

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Improving the Functionality & Management of the Health System

• As part of the overhaul of the health system and improvement of its management, hospitals in South Africa will be re-designated as follows:

• District hospital

• Regional hospital

• Tertiary hospital

• Central hospital

• Specialized hospital

• Each level of hospital designation will be managed at a newly defined level with appropriate qualifications and skills as defined by the National Health Council

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6.1 INFORMATION SYSTEMS…./2

• National Health Information Repository Data Warehouse

• Quality Improvement Initiatives

― Facility Profile on quality issues

― Monitoring of quality issues

― Targeted quality improvement strategies in identified districts (HFIT Programme)

• Integrated Health Facility Planning (PMU)

• Facility catchment population

― Travel Distance mapping

― Emergency Medical Services

• Health Facility Audits >>> baseline data to inform proactive planning and decision making

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Strengthening Planning & Decision Making

Non-Negotiables for Success of the Health System

1. Infection Control Services

2. Medicines and Medical Supplies including Dry Dispensary

3. Cleaning Materials and Services

4. Essential Equipment and Maintenance of Equipment

5. Laboratory Services: National Health Laboratory Services (NHLS)

6. Blood Supply and Services: South African National Blood Services (SANBS) or

Western Province Blood Transfusion Services (WPBTS)

7. Vaccines

8. Food Services and Relevant Supplies

9. Child Health Services (Including Neonatal and Perinatal)

10. Maternal and Reproductive Health Services

11. Registrars

12. Pilot Districts Full Complement of Primary Health Care Teams / Family Care

Teams

13. School Health (Quintile 1 and Quintile 2 Schools)

14. District Specialist Teams

15. Infrastructure Maintenance

16. HIV & AIDS

17. TB

18. Security Services

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Conclusion

• NHI not the only focal area • Multiple programmes and activities

– Systematic approach >>> get the basics right

• Builds on the strengths of the past, addresses current shortfalls

• Strong focus on health system overhaul and laying foundation for future

• Focus: improve performance, address health needs and achieve universal health coverage

“A Long & Health Life for All South Africans”

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Thank You

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