The pathway to NHI. Roseanne Murphy da Silva: Sarika Besesar:

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Dwayne Goodwin
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1 The pathway to NHI Roseanne Murphy da Silva: Sarika Besesar:

2 2 The pathway to NHI Universal health coverage South African context Countries selected Key learnings Way forward

3 3 Universal Health Coverage (UHC) Non discriminatory health systems Accessible to all Role of private sector where resources are constrained Themes: Access to care or insurance Coverage Identifiable point of entry Rights-based approach Economic risk protection

4 4 Health Systems Finance Components Revenue Collection Pooling Purchasing Delivery

5 The South African context Medical schemes cover only 16% Private primary care purchased OOP (4.8%) Inequalities perpetuated Pathway to NHI Single fund Publicly financed Comprehensive benefit package Free at point of service Public and private delivery of care

6 Countries in the analysis Low to Middle Income High Income Brazil Chile Ghana Thailand Canada France Netherlands U.K.

7 7 Healthcare Exp. per capita GDP per capita Health Expenditure vs GDP per Capita $7 000 $ $6 000 $ $5 000 $4 000 $3 000 $2 000 $1 000 $ $ $ $ $- Brazil Chile Ghana South Africa Thailand Canada France Netherlands United Kingdom $- Average Health Care Spend per Capita (2012) Average Health Care Spend per Capita PPP adj. (2012) Average GDP per capita (2014)

8 8 Life Expectancy U5MR Health Outcomes (2013) Life Expectancy U5MR per 1000 live births

9 9 Doctors Nurses Human Healthcare Resources Brazil Chile Ghana South Africa Thailand Canada France Netherlands United Kingdom Doctors per 10,000 population ( ) Nurse per 10,000 population ( ) 0

10 10 Low income experience Brazil Chile Ghana Thailand Benefit package Implicit Explicit Explicit Explicit Pooling SUS (Decentralised) AUGE + ISAPRE NHIS (District) Central funds Purchasing Mixed Mixed Mixed Mainly public Financing Taxes - 3 levels. Payroll + VAT Payroll + VAT + Tax alloc General Tax VPHI Duplicative and Supplementary Duplicative and Supplementary Duplicative and Supplementary Duplicative

11 11 OOP & VPHI 50% 45% 40% 35% 30% 25% 20% 15% 10% 05% 00% Brazil Chile Ghana South Africa Thailand Canada France Netherlands United Kingdom OOP as a % of THE (2012) VPHI as % of THE (2012)

12 12 Lessons from Higher Income Countries Unlimited Wants Finite Resources Scarcity The INFINITE DEMAND OF HEALTHCARE RENDERS UHC IMPOSSIBLE

13 Population Coverage Population Coverage 13 Lessons from lower income countries Service Coverage Service Coverage RESEOURCE CONTRAINTS REQUIRE TRADEOFFS IN COVERAGE

14 Benefit package Tradeoff between depth of benefit package and breath of population coverage Explicit definition of services facilitates management and empowers patients Incremental increases to

14 14 Benefit package Tradeoff between depth of benefit package and breath of population coverage Explicit definition of services facilitates management and empowers patients Incremental increases to manage costs Community participation for acceptability An explicit benefit package in SA will limit the NHI s liability, allow for better cost containment and empower patients with entitlement to a set of benefits

15 Delivery Decentralisation Advantages vs Risks Quality Assurance Quality authority Revitalisation of the public sector Private sector contracting Competition

15 15 Delivery Decentralisation Advantages vs Risks Quality Assurance Quality authority Revitalisation of the public sector Private sector contracting Competition Decentralisation is complex but will make the end users closer to NHI structures. Quality assurance is key. Private sector contracting will enhance competition.

16 Pooling Single Funder Inefficiencies Ghana, UK and Canada Competition does not guarantee efficiency Netherlands Innovative designs such as France

16 16 Pooling Single Funder Inefficiencies Ghana, UK and Canada Competition does not guarantee efficiency Netherlands Innovative designs such as France or Thailand with distinct pools inequalities NHI pooling system should ensure income cross-subsidies. The system should be responsive to local needs.

17 Financing Healthcare reform requires additional funding High reliance on OOPs in low income countries In higher income countries, cost containment is a challenge NHI White paper

17 17 Financing Healthcare reform requires additional funding High reliance on OOPs in low income countries In higher income countries, cost containment is a challenge NHI White paper suggests increasing tax in South Africa Mechanisms to raise revenue for the NHI should be progressive with minimal impact on employment. The impact on OOPs and THE must be considered.

18 18 Voluntary Private Health Insurance Demand for VPHI in lower income countries is inevitable. Private sector should complement public sector An opt out private sector enables government resources to be focused on the poor Private duplicative cover in South Africa is appropriate. Role of medical schemes must be defined to ensure it is harmonious with the NHI

19 19 The Way Forward The pathway as important as the destination Infrastructure and human capital more important than finance Success lies in unlocking current inefficiencies Build on current institutions Tackle gross inequalities

20 20 Thank You!

National Treasury. Financing NHI. Pharmaceutical Society SA 24 June 2018

National Treasury. Financing NHI. Pharmaceutical Society SA 24 June 2018 Financing NHI Pharmaceutical Society SA 24 June 2018 1 Principles of National Health Insurance Public purchaser Provision by accredited public and private providers Affordable and sustainable Primary care