NATIONAL HEALTH INSURANCE AND THE WORKPLACE

1
NATIONAL HEALTH INSURANCE AND THE WORKPLACE

• 25th Annual Labour Law Conference
• Sandton
• Johannesburg

2
Outline

• Baseline Health System Challenges
• Green Paper on National Health Insurance
• Piloting NHI
• Possible implications for the workplace

3
KEY CHALLENGES IN THE HEALTH SYSTEM

• Quadruple Burden of Disease
• Quality of Healthcare
• Distribution of Financial and Human Resource
• High Costs of Health Care
• Out-of-pocket payments and co-payments

4
Baseline

• Poor health outcomes and poor overall performance
  
• IMR, MMR, Life Expectancy, worsening BOD
  (Quadruple)
• Fragmented funding pools
• Rich, healthier funded separately
• Poor, more susceptible to illness reliant on
  State
• Huge exposure to health-related catastrophic
  expenditures
• Hospicentrism and growing commercialism
• Inequitable access to key health resources

5
OVERALL, SOUTH AFRICA GETTING POOR PERFORMANCE
RELATIVE TO COST
Countries sitting above the trend line are
producing relatively better performance for the
cost per capita inputs that they are investing
Performance vs. Cost Comparison, 2008
Bahrain
Sweden
High
Middle East
Australia
Switzerland
Belgium
Africa
Ireland
France
UK
Europe
UAE
Kuwait
New Zealand
Asia Pacific
Germany
Czech Republic
Latin America
Singapore
Spain
Netherlands
South Korea
US Canada
Oman
US
Saudi Arabia
Canada
Poland
Qatar
Slovakia
Performance
Hungary
Italy
Hong Kong
Uruguay
Brazil
Philippines
Israel
Malaysia
Argentina
Russia
Taiwan
Algeria
Chile
China
México
Turkey
Colombia
South Africa
R20.5367
Kenya
Venezuela
Morocco
Peru
Low
India
Namibia
Cost (Spend per capita /Int.)
High
Low
Note Trend line is a polynomial Source Discover
y Health Pool Stream Database, Monitor Analysis
6
Selected Health Statistics, BRICS Countries
7
(No Transcript)
8
(No Transcript)
9
QUALITY IN PUBLIC HEALTH FACILITIES

• Cleanliness
• Safety and security of staff and patients
• Long waiting times
• Staff attitudes
• Infection control
• Drug stock-outs

10
Trends in Total Benefits Paid, 1997 - 2005
Source Council for Medical Schemes
11
Sustainability of Medical Scheme Industry

• A number of medical schemes have collapsed, been
  placed under curatorship or merged
• Registered schemes have reduced from over 140 in
  the year 2001 to under 100 in 2010
• To sustain their financial viability, schemes
  tend to increase premiums at rates higher than
  CPIX
• Declining depth breadth of benefits
• Industry has registered deficits two years
  consecutively

12
There are no simple solutions to the systemic
challenges... 1. Sit back, relax and watch as
system and outcomes worsen ?OR2. Recognise that
we cannot wish our problems away so we must get
up, roll-up our sleeves and take action now ?
13
CONSTITUTIONAL OBLIGATIONTHE BILL OF RIGHTS

• Section 27. Health care, food, water and social
  security
• 1. Everyone has the right to have access to
• health care services, including reproductive
  health care
• sufficient food and water and
• 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.

14
Principles

• The Right to Access Health
• Social Solidarity
• Equity
• Effectiveness
• Efficiency
• Appropriateness
• Affordability

15
THE EVOLUTION OF HEALTH CARE FINANCING IN SOUTH
AFRICA

• Commission on Old Age Pension and National
  Insurance (1928)
• Committee of Enquiry into National Health
  Insurance (1935)
• National Health Service Commission (1942 1944)
• Health Care Finance Committee (1994)
• Committee of Inquiry on National Health Insurance
  (1995)
• The Social Health Insurance Working Group (1997)
• Committee of Inquiry into a Comprehensive Social
  Security for South Africa (2002)
• Ministerial Task Team on Social Health Insurance
  (2002)
• Advisory Committee on National Health Insurance
  (2009)

16
Population Coverage

•  All South Africans and legal permanent residents
  will be covered
• Short-term residents, foreign students and
  tourists required to obtain compulsory travel
  insurance
• Legally required to produce evidence of this upon
  entry into South Africa
• Refugees and asylum seekers will be covered in
  line with provisions of the Refugees Act, 1998
  and International Human Rights Instruments
  ratified by the State
• NB DHA amending this so may be reviewed further

17
Healthcare Benefits under NHI (Illustrative)

• Primary health care services
• Prevention,
• Promotion,
• Curative,
• Community outreach and community-based services
  as well as school-based services
• Inpatient and outpatient hospital care (including
  specialist and rehabilitation services)
• Prescription drugs
• Emergency care
• Mental health services
• Oral health services
• Basic vision care and vision correction
• Appropriate technologies for diagnosis and
  treatment including assistive devices

18
Health System Re-engineering

• Shift emphasis from high cost, curative service
  delivery/provision to health promotion and
  prevention (incl. community outreach)
• Primary health care services shall be delivered
  according to the following three streams
• District-based clinical specialist support teams
  supporting delivery of priority health care
  programmes at the district level
• School-based Primary Health Care services
• Municipal Ward-based Primary Health Care Agents

19
Accreditation of Providers

• All facilities/establishments to be accredited
  according to the same set of standards and norms
• Draft Bill on Office of Health Standards
  Compliance (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

20
Principal Funding Mechanisms

• Combination of sources
• General tax allocations
• Employers
• Individuals
• Revenue base to be as broad as possible
• To achieve the lowest contribution rates
• Generate sufficient funds to supplement the
  general tax allocation to NHI

21
The Role of Medical Schemes

• Medical Schemes will continue to exist within the
  NHI environment
• May provide top-up cover
• No one will be allowed to opt-out of NHI
• Mandatory contributions gtgtgt payroll- or income
  linked
• Technical capacity exists within the sector to
  help with roll-out
• What, how and when....

22
The Ten Point Plan

• Provision of strategic leadership and creation of
  a social compact for better health outcomes
• Implementation of a National Health Insurance
  Plan
• Improving Quality of Services
• Overhauling the health care system and improve
  its management
• Improving Human Resources Management
• Revitalization of physical infrastructure
• Accelerated implementation of HIV and AIDS Plan
  and reduction of mortality due to TB and other
  communicable diseases
• Mass mobilization for better health for the
  population
• Review of the Drug Policy
• Strengthening Research and Development

23
Health System Performance
24
Piloting of NHI Started in 2012 April

• Policy position Phased-in over a period of 14
  years
• First steps towards implementation through
  piloting
• 10 health districts selected for piloting
• Selection of the 10 districts 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

25
Selected Pilot Districts and Respective
Population Numbers
Notes KZN will pilot two (2) districts due to
high population numbers and high disease burden
26
The First 5 Years

• 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 PHC streams
• Infrastructure development
• Medical devices including equipment
• Human Resources planning, development and
  management
• Information management and systems support
• Establishment of the National Health Insurance
  Fund

27
Impact of NHI oN THE WORKPLACE
28
Background

• The 2006 LIMS study attempted to gain insights
  into health in the workplace
• 40 companies surveyed, 8 have all employees
  covered and the rest have variable cover.
• 90 of companies offer medical schemes subsidy
  between 50-66, dependents included max 4.
• Employees should pay 10-15 of salary as premium
  with max of R200/month/employee
• Strong support for low income members to have
  cover given the benefits better employee health,
  leading to increased productivity, reduced
  absenteeism and reduced requests for loans.

29
Bargaining Council Schemes

• Established under the Labour Relations Act (Act
  66 of 1995)
• 27 Bargaining Councils
• 800,000 employees and about 50,000 employers
• Approach is PHC based with panel doctors

30
Occupational Health Facilities

• extensive legislation governing occupational
  health issues in the workplace
• staff-based model or directly-contracted model
• Contracted providers usually employed on a
  part-time consultancy
• Workplace-based occupational health services may
  be engaged in the promotion and maintenance of
  employee health, maintenance of workforce
  efficiency, fulfilment of legal compliance with
  regulations.

31
Mine Health and Safety Act

• Mine - hospital or clinics and nurses, doctors
  and other health professionals are employed by
  mine
• In 1997 there were 66 mine hospitals with a total
  of 6,088 beds - more economical than contracting
  or insurance
• Significant decline in the number of hospitals
  over the next 10 years - decline in the gold
  price, development of more efficient mining
  techniques, and the fact that many gold reserves
  are becoming depleted has led to drastic
  reductions in employed miners.

32
Provision of HIV/AIDS Treatment

• The mines have lead the widespread provision of
  testing and treatment for HIV/AIDS, other have
  since followed
• South African Business Coalition on HIV AIDS
• The mining, metals processing, agribusiness and
  transport sectors are most affected by the
  pandemic, with more than 23 of employees
  infected with HIV/AIDS and with prevalence rates
  two to three times higher among skilled and
  unskilled workers than among supervisors and
  managers.

33
Possible implications under NHI

• Benefits that were available through bargaining
  councils will be replaced by the universal
  healthcare package. Tax based financing as
  opposed to current out of pocket payments on a
  voluntary basis.
• Financing of workplace programmes from the fund
  will reduce the burden on companies since these
  activities will be eligible for funding through
  the NHI. Improved efficiency through central
  purchasing and monitoring

34
Possible implications under NHI (2)

• Provision of ARVs, monitoring and care of HIV
  patients will be funded centrally. Reduced burden
  on the employer and greater efficiency through
  central purchasing.
• Consolidation of healthcare funding for workplace
  injuries such as CCOD. Central fund that will pay
  for all healthcare service. Patients can access
  care at any NHI provider as opposed to the
  current system.

35
FAIRNESS

• Fairness, I believe, is at the heart of our
  ambitions in global health. A quest for greater
  fairness dominates the agenda for this forum.
• We see this in your concern about vulnerable
  populations, and about health systems that
  exclude the poor. We see this in your support for
  global health initiatives and funding mechanisms
  that redistribute some of the worlds riches
  towards health needs of the poor.
• On the issue of fairness, let me again state the
  obvious. Our world is dangerously out of balance,
  also in matters of health. Differences, within
  and between countries, in income levels,
  opportunities and health status are greater today
  than at any time in recent history.
• Part of the world feasts itself into obesity,
  while part of the world fasts and starves for
  want of food. Part of the world thrives into old
  age, while part of the world dies young from
  easily and cheaply preventable causes.
• As the historians tell us, such huge extremes of
  privilege and misery are a precursor for social
  breakdown.
• Is this where the progress of our civilized,
  advanced, high-tech, sophisticated society has
  brought us? To the brink of social breakdown?
• Let me make another obvious point. A health
  system is a social institution. It does not just
  deliver pills and babies the way a post office
  delivers letters. Properly managed and financed,
  a health system that strives for universal
  coverage contributes to social cohesion and
  stability.
• I further believe that a failure to make fairness
  an explicit objective, in policies, in the
  systems that govern the way nations and their
  populations interact, is one reason why the world
  is in such a great big mess.
• Dr Margaret ChanDirector-General of the World
  Health Organization

36
Thank You
36