Essential Healthcare Package Proposal

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Essential Healthcare Package Proposal

• R Patel, H Wadee D Pearmain
• Board of Heathcare Funders of Southern Africa
• 2006

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(No Transcript)
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Benefit policy Dichotomy
Primary care
BBP
NDoH
CMS
Hospital care
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Current System Alternate Paradigm
Health Insurance (catastrophic cover) Health benefit for health need
Commodity Social Benefit
Focus Individual Focus Community
Benefits Core Referred care Diagnosis based PMB Algorithms Benefits Core Primary care Benefit category Traditional design EDL
Competition Solidarity
Reference price/ at cost Regulated price
Allocative inefficiencies Coherent system for health services provision
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Why Primary Care as Core benefit?
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Herman A et al. 2002. Tender Doc
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Alma Ata (1978)

• Health for All
• PHC

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WHO

• Primary Care
• most cost effective improve health status
• (Not every primary care service is cost effective)

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Norms and Standards for District Health (2000)

• Starting point towards Equity
• PHC based
• de facto BBP

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Risk EqualisationInternational Review Panel

• Include primary care

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NHA Section 3 (1) (d)South Africa

• The Minister must
• ensure the provision of such essential health
  services, which must at least include primary
  health care services, to the population of the
  Republic as may be prescribed

• Circular 8 of 2006, CMS
• Promote hospital benefit as core benefit
• Inconsistent with NHA

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Health Charter in SA

• In development
• Principles applicable to SADC
• Basic Package of health services

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African Union Conference of Health
Ministers2007

• African Health Strategy 2007-2015
• 34. This Strategy seeks to advocate and promote a
  coherent organisational framework that enhances
  efficiencies and effectiveness through
• Adopt a primary health care approach
• Determining the package of primary health care
  that all citizens can access

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PMB in SA Problematic

• DTP CDL
• 271 conditions including Cancers
• Mainly referred or catastrophic care
• Based on work done in Oregon
• 26 Chronic conditions
• No inclusion and exclusion criteria
• misinterpretation and conflict
• e.g. no definition for life threatening
• At cost (no recommended pricing structure)
• Perpetuate allocative inefficiency
• Predominantly referred care
• Other weaknesses
• BHF paper
• Medscheme paper

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LIMS

• No growth in Medical Scheme membership
• Large group of low income earners currently using
  private private sector e.g. GPs and not on
  Medical aid
• Government service for indigent, private sector
  for those earning
• Target is new members
• Income below R6500.00
• primary care based, EDL and emergency care. No
  private sector hospitalisation and Maternity
• Funding (R150 per beneficiary per month)
• Member
• Employer
• Tax subsidy (R25 at least- best growth potential)
• Provider discounting
• Part of existing MS or new New medical Scheme?

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Limitations of LIMS

• Extra chronic benefit
• 14 diseases (not equitable)

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EHP/BBP
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Guiding principles
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Needs based benefit focus
Adapted from Stolk P et al. Rare essentials
drugs for rare diseases as essential medicine.
WHO Bulletin Sept 2006, 84 (9)
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(No Transcript)
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Burden of disease
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Argentina Brazil Chile Mexico Netherlands South Africa
2004 WHO Report Other Other BBP BBP BBP
Total population 38m 176.2m 15.6m 102m 16.1m 44.8m
GDP per capita (Intl , 2001) 11,920 7,537 11,265 8,903 29,237 7,538
Life expectancy at birth male (years) 70.8 65.7 73,4 71.7 76 48.8
Life expectancy at birth female (years) 78.1 72.3 80 77 81.1 52.6
Healthy life expectancy at birth male (years) 62.5 57.2 64.9 63.4 69.7 43.3
Healthy life expectancy at birth female(years) 68.1 62.4 69.7 67.6 72.6 45.3
Child mortality male (per 1000) 20 42 16 30 6 86
Child mortality female (per 1000) 16 34 13 24 5 81
Adult mortality male (per 1000) 177 246 134 170 94 598
Adult mortality female (per 1000) 90 136 67 97 65 482
Total health expenditure per capita (Intl , 2001) 1,130 573 792 544 2,612 652
Total health expenditure as of GDP (2001) 9.5 7.6 7 6.1 8.9 8.6
Allocative inefficiency
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Health Status of SA

• Equivalent to developing nation
• Essential care required as core
• SADC countries
• Developing countries

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Count of deaths by age band
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South Africa 2000 South Africa 2000 South Africa 2000 South Africa 2000 South Africa 2000 South Africa 2000 South Africa 2000 South Africa 2000
Deaths Deaths YLL YLL DALY DALY
HIV/AIDS 29.8 HIV/AIDS 39.0 HIV/AIDS 32.8
CVD 16.6 Infect Parasites 11.1 Infect Parasites 9.6
Infect Parasites 10.3 Intentional injuries 8.9 Unintentional injuries 8.3
Malignancy 7.5 CVD 7.7 Intentional injuries 7.8
Intentional injuries 7.0 Perinatal conditions 7.6 Perinatal conditions 6.8
Unintentional injuries 5.4 Unintentional injuries 6.7 CVD 6.8
Perinatal conditions 4.9 Malignancy 4.2 Respiratory disease 4.7
Respiratory disease 4.1 Respiratory infections 3.8 Malignancy 3.4
Respiratory infections 4.0 Respiratory disease 2.2 Respiratory infections 3.0
Diabetes 2.4   GIT disease 1.6   CNS disease 2.7
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Draft primary care benefitsLIMS as core

• Consults and
• additional consults mild to mod chr.dx. (1GP
  another) (ECB)
• Full benefit for severe disease (establish
  objective criteria)
• Negative list for ECB
• lt5year age additional consult benefit
• Formulary of GP procedures, side room tests
• Hospital level EDL
• Formulary of pathology and radiology including
  additional tests for ECB
• Conservative dentistry (2 x 2)
• Limited optometry ISO LESO copper plan
• Mental health services (5 treatments)
• Emergency transport and care
• Maternity care benefits _at_ primary care fees

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In hospital benefit

• Public sector appropriate admissions and
  utilisation
• At UPFS
• Private sector
• Maternity and pregnancy states
• Sterilisation and TOP
• AIDS and related
• Trauma
• 4 years
• Notifiable diseases
• Rehabilitation services for above where
  applicable
• Cataracts
• Other incl. CVD depends on cost affordability

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Risk management for referred care benefits

• Care must be evidence based with proven health
  economic benefit.
• Minimum standard of care
• public sector,
• documented guidelines,
• ongoing availability of treatment.
• BHF Principles for PMB funding

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• Primary Care intervention/investigation,
  procedures
• not covered in Referred Care benefit unless
• accompanied with another unlisted serious trauma
  injury or pathology.
• When performed by practitioners, other than GPs
• benefit is limited to the primary care fee for
  the entire service event.
• Maternity care
• is generally considered a essential and primary
  care service.
• Benefit is recommended at primary care rates,
  except for specified complications.

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Referred care
Primary care
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Affordability

• Regulated benefit, regulated fee
• R260 pbpm (2006)
• 4 of R6500 (LIMS)
• 10 of salary divide by 2.5 beneficiaries
• R780 cost per member per month contribution
• 3 beneficiaries
• Member portion R390 (Assume 50 employer
  subsidy)
• Potential tax rebate R1300

1. Solutio 2005. Product costing for 2006

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REF present view
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REF suggestion for EHP
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• Thanks You!