A National Health Insurance (NHI) scheme is being piloted in South Africa. Close monitoring will help us decide whether it works and importantly if it will support the implementation of the NSP.

In August 2011 the Department of Health (DoH) published a Green Paper for a proposed National Health Insurance (NHI) scheme in South Africa.The primary goal of which is to “ensure that everyone has access to a defined comprehensive package of healthcare services.” As a result, any developments pertaining to NHI will be of importance to those monitoring the implementation of NSP. NHI should be seen as a key component of broader health reforms currently taking place in South Africa. For example, the new Office for Health Standards Compliance (OHSC) has begun the process of auditing health facilities in South Africa. It’s findings will inform the work of the new Facility Improvement Teams and will aid the development of national norms and standards for ensuring quality of public health facilities. Public comment has also been invited.

While this work is encouraging, the new NHI plans have been criticised for their lack of clarity. This lack of clarity has a bearing on the implementation of the NSP. Precise details about the structure of the system, for example, and how it will function, remain unclear. Two years after the Green Paper was published, an anticipated government White Paper has still not been issued, and operational details remain opaque. How will the NHI administrative structure be organised? What role is envisaged for the private sector (as providers or funders)? What will the NHI actually cost, and who will provide this funding? For the OHSC to succeed, effective community participation is essential. But how the public will be engaged in the development of the NHI scheme remains unclear.

Redesigning the primary healthcare (PHC) system

Achieving universal healthcare coverage will depend on shifting the central focus of health service delivery from the tertiary hospital level to the community level. Particular emphasis must be placed on rural areas and on marginalised and vulnerable groups. A more equal distribution of skilled health workers is also important. At the district level, we need to ensure that there are enough doctors, nurses, specialists, and community health workers to deliver promotional, preventative, curative and rehabilitative services. To support a more comprehensive range of services, including those outlined in the NSP, primary healthcare delivery will need to be integrated, so that different levels within the healthcare system are able to support each other better. Newly-formed District Specialist Teams have started this process by investigating how GPs will be contracted into providing support at PHC facilities, and how school-based PHC services will be re-introduced. Greater levels of civil society engagement will also be required if the new system is to be designed effectively and maintain accountability.

11 NHI pilot districts

In April 2012, piloting of NHI commenced in eleven pilot districts in all nine provinces of South Africa. This initial phase allows the DoH to evaluate the proposed administrative and service delivery reforms necessary to implement an NHI. It also allows for the identification of barriers to efficient healthcare planning and, hopefully, ways to overcome them. Budgeting and management lessons will be evaluated.

But our initial assessment of the pilot phase found little evidence of a coordinated implementation strategy. Most of the district administrators, facility managers and healthcare workers were unclear about what the NHI piloting phase hoped to achieve or what they were expected to do.

At the end of July, the National Department of Health presented its first 12-month progress report of the NHI sites. The findings of the report were based on questionnaires, pilot district reports, and site visits with the District Health Management Teams. While the tone of the report was generally positive, it is evident that there are at least four key weaknesses in the pilot phase.

Budgets spent late

The first of these is the failure of the DoH to provide adequate budget guidance. By the end of the 2012/13 financial year, only 77% of the budget allocated to the pilot districts through conditional grants had been spent. Most problematically, 90% of the available funds were used only in the fourth quarter of the financial year. This, as the report admitted, was because the DoH failed to provide clear guidance about which NHI initiatives the funds could be used for. The surge in spending occurred only after the DoH revised its grant criteria. (Annual district health expenditure reviews were completed. However, the annual report did not include the outcomes of the reviews or indicate if or when they would be made available to the public.)

Budgeting problems are likely to persist. The 2013/14 NHI Pilot District plans have yet to be made available, despite the fact that more than a third of the financial year has already passed. Once again, communities will be unable to monitor the district sites because they do not have the necessary information about what is being implemented in the current financial year and at what cost.

The absence of clear guidance reflects a significant failure on the part of the DoH to comply with the regulations and laws governing public planning and budgeting. This has also negatively impacted both our ability to evaluate the costs of establishing a properly functioning NHI system, and our ability to capture useful managerial insights.

Infrastructural improvements are falling behind

A second significant challenge has been the lack of adequate improvement to the infrastructure in the pilot districts. The report explained that, in some instances, progress was slow because of poor coordination between the National Department of Health and the Department of Public Works. Preparations for the new NHI services and innovations necessarily depend on improvements to the standard of the available facilities and the coordination of functions between the DoH and the Department of Public Works.

As part of its review of the piloting process, the DoH compared the standards of the NHI pilot facilities in 2012/13 with the baseline assessment. In the new assessment, mean scores across most domains had declined, including cleanliness (-6%), the availability of medicines and supplies (-8.7%), staff attitudes (-3.6%) and patient safety (-5.8%). The provision of a comprehensive package of primary healthcare services is the foundation of South Africa’s new NHI scheme. Only a third of NHI pilot site facilities had the necessary staffing levels, infrastructure, pharmacy services, and equipment to support these.

It remains unclear if the size of the budget allocated during the NHI pilot phase is sufficiently large to support the planned service scale-up. The failure of the DoH to discuss this issue in their report was a conspicuous omission.

Uneven progress

A third key problem in the pilot phase of the NHI scheme has been the uneven progress across the districts. The Eden District (Western Cape), Pixley ka Seme District (Northern Cape), Tshwane District (Gauteng) and uMgungundlovu District (KwaZulu-Natal) all significantly outperformed the OR Tambo District (Eastern Cape) and Vhembe District (Limpopo Province). For example, only 2% of primary healthcare facilities in the OR Tambo District and 15% in the Vhembe District were able to provide the full package of primary healthcare services. In contrast, more than 80% of the facilities in the Eden District, 76% of the facilities in the uMgungundlovu District, and 65% of the facilities in the Pixley ka Seme District had sufficient capacity.

This unevenness is mirrored in the larger human resource capacity disparities across the districts. Approximately 90% of all posts for doctors at hospitals in the districts of Eden and uMgungundlovu are filled, compared to 60% in the OR Tambo District, and 29% in the Vhembe District. Similar differences were noted with regard to the nursing posts at hospitals: while 92% of the nursing posts are filled in the Eden District and 97% in the uMgungundlovu District, only 51% and 36% of the nursing posts are filled in the OR Tambo and Gert Sibande Districts respectively.

These disparities extend to the primary care level: 95% of the nursing posts are filled in the districts of Eden and uMgungundlovu, while only 37% and 30% of the nursing posts are filled in the OR Tambo and Vhembe Districts respectively. Even these statistics may not reflect the severity of the organisational problems on the ground: the organisational charts are so out-of-date and so poorly managed, that they do not reflect the current staffing hierarchy at these facilities. They are therefore unlikely to provide any indication of how close the facilities are to meeting the basic requirements of the new NHI scheme.

The fact that the DoH has clearly failed to prioritise or adequately fund outreach services during the pilot phase of the NHI scheme is of particular concern. Based on the DoH’s own assessment, it is clear that little progress has been made to ensure that community health care workers, rehabilitation professionals and nurses have the necessary transport, equipment and support for undertaking home-based care. If primary healthcare is the foundation of the NHI, as the DoH claims, then the resourcing of an effective outreach and referral system should be at the forefront of the piloting process.

Clinic committees and hospital boards

The fourth key weakness evident in the report is the lack of progress in establishing clinic committees and hospital boards. These structures are meant to serve as the principal institutions of community participation in primary healthcare service delivery. While all the districts were reported to have hospital boards and clinic committees, closer scrutiny of the report revealed little detail about how these bodies function and the extent to which they facilitated meaningful community participation.

The available information suggests that there are already unacceptable variations in the quality of the structures which are intended to facilitate public participation. In the Pixley ka Seme District in the Northern Cape for example, four out of thirty-six clinic committees are described as “functioning optimally” in the report. In contrast, in the OR Tambo District, all the hospitals have boards “but functionality is an issue”. The Gert Sibande District has no protocol for the establishment of clinic committees, and has used the provincial protocol for Hospital Boards instead.

Meaningful public participation in the health system is critical. An environment which empowers community members to exert influence and oversight over healthcare can help communities to ensure that health services are tailored to their specific health needs.

The weaknesses and failures noted during the piloting phase can be explained, in part, by the historical neglect of many of the districts. But the purpose of the NHI pilot districts is to determine how reforms under the NHI could be implemented, particularly in deprived and neglected districts in South Africa.

Piloting therefore needs to prioritise reforms and interventions that promote greater equity, efficiency, effectiveness and participation. Thus far, the NHI piloting scheme has largely failed to do so.

Without a coordinated piloting effort which encompasses all levels of the healthcare delivery system we can only ever expect uneven implementation. The involvement of the national, provincial and district level administrations in the pilot scheme requires carefully developed plans. Such plans need to be based on the resource needs of the districts rather than the ability of local interests to negotiate beneficial deals. Future NHI plans must reflect a proper assessment of district requirements with reference to the NSP. Putting such plans in place will help us realise the core objective of the NHI scheme: ensuring that all South Africans are able to lead a long and healthy life.

Daygan Eagar works at the Rural Health Advocacy Project (RHAP) and is the manager of the Rural Proofing Programme; Thokozile Madonko is the coordinator of the Budget Expenditure and Monitoring Forum (BEMF).