Social Health Insurance Policy Development

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Social Health Insurance Policy Development
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Presentation

• Policy process to date
• Constitutional mandate
• Policy context
• WHO Ranking
• Key objectives
• Future policy options

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Policy Process

• 1994 Finance Committee
• 1995 National Health Insurance Committee
• 1997 Departmental Task Team
• 2000 Social Security Committee of Inquiry
• Health Subcommittee
• Dept/Council workshops
• Research
• WATP
• Financing research
• Stakeholder reviews

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Constitution

• Everyone has the right to have access to health
  care services, including reproductive health care
  (ss27(1))
• The state must take reasonable legislative and
  other measures, within available resources, to
  achieve the progressive realization of these
  rights (ss27(2))
• No-one may be refused emergency medical treatment
  (ss27(3))

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Current Policy Context

• Public sector
• Private sector

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(No Transcript)
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Per Capita Public Health Expenditure 1996/97 to
2000/2001
Source Department of Health (NHA)
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Public sector

• Link between policy and implementation
• Centralized responsibility and accountability
• Flawed user fee system
• Declining budgets
• Impossible to address inequity

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Private Sector

• Systematic cost increases due to fee-for-service
• Tax subsidy
• Residual risk selection
• Residual adverse selection
• Difficulties in linking to public sector
• Evolving low-cost market limited due to high
  private hospital costs
• Intermediary problems

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Medical Scheme Reimbursement of Public and
Private Hospitals 1988 to 1999 (1995 prices)
Source Council for Medical Schemes
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Per capita health expenditure/outcomes (WHO)
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Research Findings

• Conditional support for SHI
• Improve the public hospitals
• Critical to address inequities
• Ensure additional funding goes to health
• Differential amenities, not clinical services
• Injection of funds into public system

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National Health Insurance

• Only becomes feasible over time
• Is not a substitute for SHI but an end result
• Universal systems only exist in industrialized
  countries
• Middle-income countries typically combine
  tax-funded, contributory systems, and regulated
  voluntary environments

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Key Objectives of Proposed Reforms

• Attract additional resources to social risk pools
• Tax funding
• Contributory (voluntary and mandatory)
• Entrench systems of cross subsidy
• Income-based (equity)
• Risk-based
• Reinforce public provider system
• Decentralize hospital management
• Basic essential services
• Restructure budgeting system

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Phase 1 Development of enabling environment
Phase 2 Implement preparatory reforms
Phase 3 Implement statutory mandates
Phase 4 Implement national health insurance
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Development of Enabling Environment

• Preparation of public health budget system
• Centralization of health budget
• Create unit to manage conditional grants
• Preparation of public hospital system
• Management decentralization
• Coherent enhanced amenities policy
• Financial injection to improve public services
• Creation of minimum norms and standards
• Human resource management improvement
• Consolidation of medical scheme reforms
• Expansion of prescribed minimum benefits
• Review of savings accounts, benefit options and
  late joiner penalties
• Mandatory membership for restricted schemes
• Improved regulation of intermediaries
• Development of policy on universally accessible
  basic essential services
• Development of integrated subsidy system
• Revise the tax subsidy
• review risk equalization
• Implement private sector cost containment
  measures

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Implement preparatory reforms

• Introduce the risk equalization fund
• Implement the revised tax subsidy
• Mandatory cover for civil servants
• State-sponsored medical scheme

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Implement statutory mandates

• Mandate medical scheme membership
• Apply only to high income groups
• Implement voluntary cover for low-income groups
• Move towards pre-payment system for public
  hospitals
• Pre-payment allows access to enhanced amenities
• Non-contributors still entitled to free services

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Final Implementation of National Health Insurance

• Universal coverage
• Choice of provider still available
• Private providers funded via medical schemes
• Public providers funded mainly via Public Sector
  Contributory Fund, but also free to contract with
  medical schemes for additional revenue
• Central Equity Fund to allocate the reformed per
  capita tax subsidy to medical schemes and to the
  Public sector Contributory Fund
• Central Equity Fund to allocate revenue from risk
  equalization contributions back to medical
  schemes, according to their risk profile

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Universal Mandatory contribution
Tax subsidy
Central Equity Fund
Public Sector Contributory Fund
Medical Schemes
Public Health Service Basic Amenities
Public Health Service Enhanced Amenities
Private Health Services
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THE END