National Health Insurance Green Paper
National Health Insurance Green Paper
National Health Insurance Green Paper
Department:
Health
REPUBLIC OF SOUTH AFRICA
NATIONAL HEALTH INSURANCE
IN SOUTH AFRICA
POLICY PAPER
1
Contents
1 . INTRODUCTION ........................................................................................................................ 4
2. PROBLEM STATEMENT ........................................................................................................... 5
2.1 THE BURDEN OF DISEASE IN SOUTH AFRICA .......................................................... .. , ... '?
2.1 .1 H IV/AIDS and TB ......................... .... ... .... .. .. .. .. ... .. .. ..... .. ... :
2.1.2 Maternal, Child and Infant Mortality ....................................................... .......... ,, .. , ..... 8 .
N . . -:0-JYii:_>
2. 1. 3 on-Commumcable D1seases .............................................................. ""''''' ................. 8
. . ,/- ---
2. 1 .4 I n)ury and Violence ...................................................................... y .. :., . ,, , ...................... 8
,;_;, . '/.
2.2 QUALITY OF HEAL THCARE ......................................................... '''" .. :\,;, .. : .. : ....................... 9
>
2.3 HEAL THCARE EXPENDITURE IN SOUTH AFRICA ............. ; ..... , ..... !il\lli!!!: ............................ 9
,fi:, .. "<. /
2.4 DISTRIBUTION OF FINANCIAL AND HUMAN .................................. 10
2.5 MEDICAL SCHEMES INDUSTRY .......................... :: .. , .... :O:l,,11:ti.Yi .......................................... 11
. .
3. HISTORY OF PROPOSALS ON HEAL THCARE FINANCiNG REFORM IN SOUTH
AFRICA ..............................................................
1
...
3.1 Commission on Old Age Pension and (1928) ..................................... 12
3.2 Committee of Enquiry into (1935) ............................................. 12
. q,;_,
3.3 National Health Service Com!)i!j$8{ ' - 1944) ........................................................... 13
z.<t ,,,
3.4 Health Care Finance 1994 ............................................................................... 13
3.5 Committee of Inquiry Insurance (1995) ................................................ 14
3.6 The Social Health Group (1997) ........................................................... 14
--- w'it '
3.7 Committee Comprehensive Social Security for South Africa (2002) ....... 14
3.9 Advisory Committ'l;le on National Health Insurance (2009) ................................................. 15
/-,<----- "<iiRvd:F
4. NATIONAL HEAl:"''H INSURANCE ........................................................................................ 15
41'JJ;;\ ... i
5. OF NATIONAL HEALTH INSURANCE IN SOUTH AFRICA ......................... 16
--- \Yhc -;:
6. OF NATIONAL HEALTH INSURANCE .......................................................... 18
,-1/;;-.> \/., /''.-<
\'27Ji$0CIOECONOMIC BENEFITS OF NATIONAL HEALTH INSURANCE ............................. 19
-
Economic Impact Modelling ............................................................................................. 21
8. THE THREE DIMENSIONS OF UNIVERSAL COVERAGE ................................................. 21
9. POPULATION COVERAGE UNDER NATIONAL HEALTH INSURANCE .......................... 23
10. THE RE-ENGINEERED PRIMARY HEALTH CARE SYSTEM .......................................... 23
1 0.1 District Clinical Specialist Support Teams .......................................................................... 24
2
10.2 School Health Services ........................................................................................................ 25
10.3 Municipal Ward-based Primary Health Care Agents ......................................................... 26
11. HEAL THCARE BENEFITS UNDER NATIONAL HEALTH INSURANCE .......................... 26
11.1 The Service Package within the Context of District Heath Services ................................ 21
f:>,
11.2 Delivery of Primary Health Care Services through Private Providers ...................... ..
11.3 Hospital-Based Benefits .......................................................................................... (;c::'i
L ,
11.4 Designation of Hospitals.................................................................................. . ......... 29
12. ACCREDITATION OF PROVIDERS OF HEALTH CARE SERVICES .
2
,., ....................... 31
.
12.1The Office of Health Standards Compliance ..................................... . ::;.id::: ................... 31
12.2 Accreditation Standards ............................................................. ,.,, . : ... .................... 32
13. PAYMENT OF PROVIDERS UNDER NATIONAL HEAL T
13.1 HEALTHCARE CODING SYSTEMS AND REIMBURS!E
13.2 UNIT OF CONTRACTING PROVIDERS OF HEA
f:'>L: , '
INSI:J
''J:r.:1: ................................... 33
i:i
SERVICES ..................... 34
14. PRINCIPAL FUNDING MECHANISMS EALTH INSURANCE ........... 35
\,
14.1 The Role of Co-Payments under Nation eal!2dnsurance ............................................ 35
15. HOW MUCH WILL NATIONAL HEALTH I RANCE COST .......................................... 36
15.1 Funding Flows ................... .. . ............................................................................... 41
16. THE ESTABLISHMENT OF '"'"'I"\'- HEALTH INSURANCE FUND ................... 41
17. THE ROLE OF MEDI .................................................................................. 43
18. REGISTRATION LATION ............................................................................ 43
NATIONAL HEALTH INSURANCE ............................... 44
20. MIGRATIO
CURRENT HEALTH SYSTEM INTO THE NATIONAL HEALTH
MENT .................................................................................................... 44
'!;' O.F NATIONAL HEALTH INSURANCE .............................................................. 52
, Y ............................................................................................................................ 53
3
1. INTRODUCTION
1. South Africa is in the process of introducing an innovative system of healthcare financing
with far reaching consequences on the health of South Africans. The National Heal
Insurance commonly referred to as NHI will ensure that everyone has
i< \/,
appropriate, efficient and quality health services. It will be phased-in over a p '0J,J#
years. This will entail major changes in the service delivery structures, nd
management systems.
'V;/
2. The NHI is intended to bring about reform that will vision. It will
promote equity and efficiency so as to ensure that all S , ''tci/fls have access to
affordable, quality healthcare services regardless of nomic status.
3. The current system of healthcare financing in is two-tiered, with a relatively
large proportion of funding allocated schemes, various hospital care
plans and out of pocket payments. This arrangement provides cover to
private patients who have with a scheme of their choice or as
a result of their employment
subsidised by their
, only benefits those who are employed and are
State and the private sector. The other portion
mainly for public sector users. This means that those
a choice of providers operating in the private sector
of the population.
with medical
which is not '"'''"nr
financial and human resources for health is located in the private
""'vin.n a minority of the population. Medical schemes are the major
services in the private sector which covers 16.2% of the population (CMS
1
,
public sector is under-resourced relative to the size of the population that it
and the burden of disease. The public sector has disproportionately less human
than the private sector yet it has to manage significantly higher patient
numbers.
1
CMS: Council for Medical Schemes is a statutory body with regulatory oversight for the medical scheme
1
s
industry. It is established by an Act of Parliament, the Medical Schemes Act, 1998
4
5. The South African health system is inequitable, with the privileged few having
disproportionate access to health services. There is recognition that this system is
neither rational nor fair. Therefore, NHI is intended to ensure that all South African
citizens and legal residents will benefit from healthcare financing on an equitable af\d
t<;>,
sustainable basis. NHI will provide coverage to the whole population and
('
burden carried by individuals of paying directly out of pocket for healthcare servJ. &i,Jhis
t&t. -,<_-,;
model of delivering health and healthcare services to the population is well a *d,
described and widely promoted by the World Health Organisation as cove :age.
' \,;
t#J(l;; <c,<J_
6. To successfully implement a healthcare financing mechanisrp
population such as NHI, four key interventions need
\t1;;;:Ffibk::.. \
/"
the whole
i) a
ii) the total
overhaul of the entire healthcare system iii) the raclic;;cll
management iv) the provision of a comprehensive p acl<a'!lre
engineered Primary Health Care.
2. PROBLEM STATEMENT
of administration and
care underpinned by a re-
7. Prior to the 1994 democrati
';,;
kthrough, South Africa had a fragmented health system
designed along ystem was highly resourced and benefitted the white
iJ;-_ '\.,''<
4
'-";;t:;_-
minority. The under-resourced and was for the black majority.
The any form of racial discrimination and guarantees the
principles rights including the right to health.
8. Att?tjt . eal with these disparities and to integrate the fragmented services that
stll(edirom fourteen health departments (serving the four race groups, including the
,antustans) did not fully address the inequities. Problems linked to health financing
,th'at are biased towards the privileged few have not been adequately addressed.
h-
'9. Post 1994 attempts to transform the healthcare system and introduce healthcare
financing reforms were thwarted. This has entrenched a two-tiered health system, public
and private, based on socioeconomic status and it continues to perpetuate inequalities in
5
the current health system. Attempts to reform the health system have not gone far
enough to extend coverage to bring about equity in healthcare.
10. The two-tiered system of healthcare did not and still does not embrace the principles of
equity and access and the current health financing mode does not facilitate the
('
attainment of these noble goals. ,:
11. The 2008 World Health Report of the World Health Organisation three
'''''c;':;
trends that undermine the improvement of health outcomes globally, namely':;
Hospital centrism, which has a strong curative focus
Fragmentation in approach which may be relatedto or service
delivery, and
Uncontrolled commercialism' which underminE!s. of health as a public
good
12. An analogy of the preceding description drawn with the negative attributes of the
South African two-tier healthcare system; whfth are unsustainable, destructive, very
costly and highly curative or hospicentric
3
.
' '%:
13. The national health systehi'''0b?s a myriad of challenges, among these being the
worsening quadruple; of"disease and shortage of key human resources. The
'0. ,;_ \__ ',
public sector has}; filrperforming institutions that have been attributed to poor
\(,
management,
5
unde )!lg, and deteriorating infrastructure.
14.1n many area!laccess has increased in the public sector, but the quality of healthcare
has' deteriorated or remained poor. The public health sector will have to be
sign\ljantly changed so as to shed the image of poor quality services that have been
' \;'
scientifically shown to be a major barrier to access (Bennett & Gilson, 2003).
2
Commercialism -This is a business practice that turns goods and services into products for the sole
of generating profits
Hospi-centric- a health system where the majority of health problems are dealt with at hospital level
when patients already present with serious complications
4
Quadruple Burden of Disease: Refers to HIV/AIDS and TB; Maternal and Child death; Non-
Communicable diseases and Violence and Injuries
6
15. Similarly to the public health system, the private sector also has its own problems albeit
these are of a different nature and mainly relate to the costs of services. This relates to
the pricing and utilisation of services. The high costs are linked to high service tariffs,
provider-induced utilization of services and the continued over-servicing of patients on a
fee-for-service basis. Evidently, the private health sector will not be sustainable ov
medium to long term.
16. To change these types of systems will require transformation of the
model, better regulation of healthcare pricing, improvement in qua/if'f9f as
/
well as the strengthening of the planning, information managem7n /r;iflprovision and
the overhauling of management systems.
2.1 THE BURDEN OF DISEASE IN SOUTH AFRICA
17. The introduction of NHI, should take into account th 'burden of disease the country is
experiencing. South Africa is plagued health problems that have been
described in the Lancet Report as the burden of disease (Coovadia et at,
2009). These are:
HIV/AIDS and TB
Maternal, infant
Injury
South Africa only having 0.7% of the world population it carries 17% of HIV
?\f'/hii- "'> ::> '4,
people in the world. The HIV prevalence is twenty three times the global
t;;:,;:,<r'0>,
";:,average, while the TB infection rate is among the highest in the world. Moreover, the TB
and HIV/AIDS co-infection rate is one of the highest in the world at 73%. As a result life
expectancy in South Africa has declined over a number of years. HIV/AIDS has also
contributed significantly to high maternal and child mortality rates. Failure to intervene
may reverse 50 years of health gains.
7
2.1.2 Maternal, Child and Infant Mortality
19. The maternal mortality ratios
5
, peri-natal mortality" and neonatal mortality' rates in South
Africa are much higher than that of countries of similar socio-economic developmeqt,
fi):-,,
Maternal mortality has increased markedly in our country, and as previously mentioned
HIV/AIDS is the main contributor. However, there are also deaths that are
{_,/ ''<f: -,,
l>:: it> "
preventable and non-AIDS related factors. Similarly, infant and child mortality rales i;l<Jve
,, ' b<>>-
/< tf<'!Y
reached unacceptably high levels not only due to HIV and AIDS but aJsq due to'i'other
preventable causes.
2.1.3 Non-Communicable Diseases
20. Non-communicable diseases such as high diabetes, chronic heart
disease, chronic lung diseases, cancer and mentJ"(Jijnesses contributed to 28% of the
(<?!'<
total burden of disease measured by life years in 2004. They are
largely driven by four risk factors, smoking, poor diet, and lack of
.,, '-'- ;
exercise.
2.1.4 Injury and Violence
-, __ _,
"': __ ;,-;
:;
,_--_ 'i,: '<''
21. Injury and violence are, aiSJl contributing significantly to the burden of disease. Injuries
may be categorised as either intentional or unintentional. Of note is the significant
proportion 6/injury associated with road accidents and inter-personal violence,
against women and children. These are driven largely by high
'<>:_ _,_ ''\,,_
alccihql c'Oil.!;Jilrnption and other social factors such as poverty and unemployment.
Maternal Mortality Ratio- This is the number of women who die due to pregnancy related causes and
is measured per 100,000 live births in a given population. It includes any pregnancy related death and
is measured from the beginning of pregnancy to six weeks after birth or termination of pregnancy.
6
Peri-Natal Mortality Rate- Peri-natal mortality is the death of a baby who was born live after 20 weeks
of pregnancy or dies within ?completed days after birth measured per 1000 births. It includes stillbirths.
7
Neonatal Mortality Rate- refers to the death of a live born baby within 28 days of birth and is
measured per 1.000 live births.
8
2.2 QUALITY OF HEAL. THCARE
22. As mentioned earlier, significant improvements in health services coverage and access
since 1994 have been achieved. However, there are still notable quality problemf\l
Among the commonly cited and experienced by the public are: cleanliness, safet)'
security of staff and patients, long waiting times, staff attitudes, infection
f;;; \i;';, '< :-'
stock-outs. '"
;;>?/.
23. Given that there are concerns about quality at public sector facilities,
by the public for services in the private sector which may largely
v:
is preference
ut of pocket.
Various members of the public cannot afford to make This type of
arrangement is not suitable for the country's level; &y, elopment. Therefore,
',
improvement of quality in the public health system is aqhe,ce tre of the health sector's
reform endeavours.
/ c;
2.3 HEAL. THCARE EXPENDITURE IN
24. The World Health Organisati that countries spend at least 5% of their
GOP on health care. South a already spends 8.5% of its GDP on health, way above
what WHO recommends., Oespite;&this high expenditure the health outcomes remain poor
when compared countries. This poor performance has been
attributed mainly to 'N\JiJlfj;lquities between the public and private sector.
f/1 .. :;: . \cfY
v
25. It has bi , that high-income countries spent an average of 7. 7 percent of their
G9f' ,, omestic Product)' on health whilst middle income countries spent 5.8
>, ' !
and low income countries spent 4. 7 percent (Schieber, et al 2006).
8.3% of GDP spent on health is split as 4.1% in the private sector and 4.2% in the
public sector. The 4.1% spend covers 16.2% of the population, (8.2 million people) who
are largely on medical schemes. The remaining 4.2% is spent on 84% of the population
8
Gross Domestic Product (GDP)- This is the market value of all final products (goods and services)
produced in a country within a given period, usually a financial year.
9
(42 million people) who mainly utilize the public healthcare sector (National Treasury:
Intergovernmental Fiscal Review, 2011 ).
27. Over the past decade, private hospital costs have increased by 121% whilst over the
same period, specialist costs have increased by 120% (CMS Report, 2008). This
that the private healthcare sector will have to accept that the charging of
: --
completely out of proportion to the services provided have to be radically tr nsformed.wlil
'r:A-'
real terms, contribution rates per medical scheme beneficiary have
seven-year period. This has not been proportionate with increased '(!!. services.
Simply put this has meant limited access to needed health serv mainly as a
result of the design of the medical scheme benefit options, oNl arly exhaustion of
benefits. Ji
';
28. In South Africa health care expenditure is derived from sources: public sector
-,_- --- '<\
expenditures financed out of general reVE\Q,\ie, p'fjyi:ite sector expenditures financed
tyJTt:;g; \
through medical schemes, and out of, payments. This is consistent with
expenditure trends as reported by the Bank 2004 ).
2.4 DISTRIBUTION OF FINANC
29. The mal-distributi
distribution of key h
eillhcare resources described above leads to a skewed
'\{L;
re professionals in favour of the private sector.
30. The rec,rit 7 es show that the ratio of patients to health professionals (specialists,
ge pharmacists) is lower in the private sector than in the public sector.
Th '!ilrmore professionals per patient in the private sector than the public sector. The
men! is finalising its human resources for health strategy in order to the shortages
\numan resources .
. The amount spent in the private health sector relative to the total number of people
covered is not justifiable and defeats the principles of social justice and equity. Per capita
annual expenditure for the medical aid group has been estimated at R 11,150.00 in
contrast to public sector dependant population where the per capita annual health
10
expenditure is estimated at R2,766.00. This is not an efficient way of financing
healthcare.
2.5 MEDICAL SCHEMES INDUSTRY
32. Presently the most reliable source of healthcare financing for individuals is in the forrhof
medical schemes and various hospital cash plans. However, over m<my of
them have experienced problems of sustainability. A number of medical have
collapsed, been placed under curatorship or merged. They have over 180
in the year 2001 to about 102 in 2009. This was mainly due to of health care.
33. In a bid to sustain their financial viability, many <scHemes resorted to increasing
premiums, in many cases at rates higher than CPI(<, Wherithis was not successful, the
schemes resorted to decreasing members benefits. This has led to an increasing number
of members exhausting their benefits ortowards the end of the year. This has
been worsened by non-health related
1
!;k\)rbitant administrator's fees, oversupply of
brokers, disproportionate to the membership, and managed care costs. As a result,
increased deductions of medical sctu3me contribution from member's salaries have
resulted in wage inflation.
",;;
-
34. However, it is evident(hat;;theabove measures did not improve or have worsened the
'
cost-escalation because at the centre of this problem is the uncontrolled commercialism
of by the World Health Organisation. The intervention by the
Competition Commission was also clearly based on the understanding that the scenario
is above. Clearly something completely different is needed in the South
-q:,j'
Afrii:<lh health sector .
. 2.6 OUT OF POCKET PAYMENTS AND CO-PAYMENTS
35. Out of pocket payment accounts for a significant part of total health expenditure and this
could be in the form of co-payments, or direct payment to private providers particularly by
those who are not covered by medical schemes. Even for those who are covered by
medical schemes, the extent of co-payments confirms that the current system does not
11
provide full cover. However, for those who are not on medical aid this could have
catastrophic
9
effects.
36. Payment for health care, particularly for those who cannot afford and who pay out of
pocket cannot be planned in advance and this lack of predictability is what
households to financial hardships.
"Pi:
37. Evidence has demonstrated that those who are not adequately any of
health insurance are among others women; children; the elderly; .groups etc.
fY'<
It is for this reason that coverage should be extended to all these (Meng,
2011 ).
3. HISTORY OF PROPOSALS ON HEAL THCARE
AFRICA
-(;!;
IN SOUTH
38. Contrary to common belief, the history qf reforming the healthcare financing system in
South Africa actually dates back more th:oM8.P years:
3.1 Commission on Old Age B;nd National Insurance (1928)
"-,' ;::';, \ ',, '
.
39. A Commission on Old Aga.Pension'and National Insurance recommended that a health
' \
insurance scheme to cover medical, maternity and funeral benefits
Y, '
for all low income formal, sector employees in urban areas.
3.2 Committee Of Enquiry into National Health Insurance (1935)
'
/i:h'"
',' \ ": \'
40. A of Enquiry into National Health Insurance recommended in 1935 similar
proposals as those made in 1928. Neither of the proposals of these two Committees was
'' ' /
forward.
9
Catastrophic health expenditure- health care expenditure resulting from severe illness/ injury that
usually requires prolonged hospitalisation and involves high costs for hospitals, doctors and medicines
leading to impoverishment or total financial collapse of the household.
12
3.3 National Health Service Commission (1942 -1944)
41. A Commission led by Dr. Henry Gluckman was set up in this period. It was called the
National Health Service Commission. It recommended the implementation of a Nationr,
Health Tax to ensure that health services could be provided free at the point of
for all South Africans. The aim was to bring health services "within reach of all s ./ SQf
the population, according to their needs, and without regard to race, colour,
station in life". Health centres, prov-iding comprehensive primary
,,_-v:;,_,
proposed as a core component of the health system. ,,
42. Although the Gluckman Commission proposals were accept
General Jan Smuts, it was decided to implement them .as of measures rather
than in a single step. The introduction of . res was taken forward
\;-.-._ 'j'?,
with 44 centres being in operation within two aspects of the proposals
\ ,-<--- "''
,,_, //--
were never implemented. Any gains from Jtle GIL!ckman Commission process were
reversed after the National Party (NP) by General DF Malan was elected
in 1948.
3.4 Health Care Finance
form of mandata
' Y,'-, ,
again turned to the possibility of introducing some
Msurance and after the 1994 elections; there were several
policy initiat.ivEl.S tha onsidered either social or national health insurance. The
Healthcirlt Committee of 1994 recommended that all formally employed
their immediate dependents should initially form the core membership of
arrangements with a view to expanding coverage to other groups
';Y
time.
"A
Mill was also suggested that there should be a multi-funder (or multi-payer) environment
and that private funders, namely medical schemes, should act as financial intermediaries
for channelling funds to providers. It was also proposed that there should be a risk-
13
equalization
10
mechanism between individual insurers to help stabilise the medical
schemes industry. It was further recommended that a comprehensive set of services be
covered under such a system and that both public and private providers will be involved
in the delivery and provision of these services. The main challenge with respect to these
sets of recommendations was the inability of the State to fully finance the recomm\lpded
;\{;/
package of services. 1:\:1 \;"
<zzx::t
3.5 Committee of Inquiry on National Health Insurance (1995)
45. The 1994 Finance Committee was followed by the 1995 Col[lrrir$sion of Enquiry on
"%i,-
National Health Insurance which fully supported the of the Health
; , ::.- , .
Finance Committee. The key difference was on the This committee as
well as the healthcare finance committee made a stropg pase for primary health care
'' , ''t:;'};LG'
services.
t---'''\t
i-,, b:<
3.6 The Social Health Insurance Working Grou"p (1997)
46. In 1997 the Social Health Group developed the regulatory framework
that resulted in the the :Medical Schemes Act in 1998. This Act was meant
c "f; .
to regulate the private :he;"ilth insurance as well as to entrench the principles of open
enrolment, comm "ting, prescribed minimum benefits and better governance of
medical schemes. wer, despite the introduction of the Act and the supporting
principles of coverage for the national population has remained below 16
. Ws::: \r:
to the relatively well-off.
3.7 Comrftjttee of Inquiry into a Comprehensive Social Security for South Africa
./ \ (2002) .
' '
;;_ In 2002, Department of Social Development appointed Professor Vivienne Taylor to chair
the Committee of Inquiry into a Comprehensive Social Security for South Africa. The
Commission recommended that there must be mandatory cover for all those in the formal
10
Risk Equalisation- This is a mechanism that is applied to equalise the risk profiles of separate insurance pools
in order to avoid loading premiums on the insured members based on some pre-determined health factors
14
sector earning above a given tax threshold and that contributions should be income-
related and collected as a dedicated tax for health. The Committee also recommended
that the State should create a national health fund through which resources should be
channelled to public facilities through the government budget processes.
3.8 Ministerial Task Team on Social Health Insurance (2002)
48. To implement the recommendations of the TaylorCommittee, the of 'Health
established the Ministerial Task Team on Social Health Insurance . draft an
implementation plan with concrete proposals on how to health
insurance and to create supporting legislative and i s that will in
the long term result in the realisation of National H in South Africa.
However, the path to achieving universal coverage I health insurance
model was not widely supported and the implemen
stalled.
supporting proposals thus
' .
3.9 Advisory Committee on Natio1nal Healtli'!nsurance (2009)
49. In August 2009, the Mir1isll
established which had
Committee on National Health Insurance was
with providing the Minister of Health and the
Department of Heal ommendations regarding the relevant health system
reforms and a J to the design and roll-out of National Health Insurance. This
was to carry arJ'\tfilil Resolution passed at the ruling party's (ANC) Conference in
will be fair and rational. The term 'benefit package' describes how different
pes of services are organized into different levels of care in the public sector (J
oherty, 201 0). It also defines the types of services that are considered as achievable
for the country commensurate with its resources.
80. The National Department of Health (NDOH) has over the number of years developed
'benefit packages,' for primary health care, district hospital services, regional hospital
26
services and tertiary services. Despite this, barriers to accessing these packages still
exist.
81. In the design of these packages, certain considerations should be made to overcome the
identified barriers to access. A review of the international evidence on high-level
i
strategies to promote health and health equity found that comprehensive benefit
packages should be determined first by considering which interventions are importantfh
improving access, offering financial protection to less advantaged enhancing
' ';,
redistribution of healthcare services. The comprehensiveness of the packagi3';of services
to be provided must also demonstrate how well the health is performing, and
ensure timely referral of patients at different levels of care.
82. The norms and standards for the package to be providE'ld in the district will assist in
outlining precisely the measurable targets which must D-e and the acceptable
standards of care which providers must comply wlt,f\. These will enable managers at
facility, district, provincial and national l!il\fels to compare performance and challenges
->-
between individual and groups of similar fadilities.
11.1 The Service Package within the Context of District Heath Services
83. Services provided withirlr:fi\e<context of the district health system have shown mixed
. .
results purely because they have been viewed as a once off process of granting authority
to lower levels<ot administration in a decentralised manner. Evidence shows that this
must be a planned process that requires good administrative systems with
innoyative service delivery approaches that would bring about efficiency, improved
,
including financial management.
.84,_Adistrict health package of public health and clinical interventions, which are highly cost-
. effective and deal with major sources of disease burden, through the three PHC streams
involving various teams, can be provided in South Africa at reasonable cost. Properly
delivered through the primary health care streams, this package could eliminate 21% to
38% of the burden of premature mortality and disability in children under 15-years of age,
and 10% to 18% of the burden in adults (Bobadilla, 1994).The district health package is
designed to meet the needs of the population. Some of the issues to be addressed are:
27
Availability of health services at adequately convenient hours with enough
professional staff to attend to their needs
Consideration of the user's privacy, confidentiality, fair treatment by staff
and ensuring the user's dignity is respected at all times
Compliance with core quality standards
11.2 Delivery of Primary Health Care Services through Private Provid
(,"
85. In addition to the three streams, PHC services will be ccredited and
contracted private providers practicing within a District. of the
population in the country uses private providers for their
" "\;;."
often than not it involves substantial out of pocket
-:;; ',
are needs and more
\;;;,_,t:;1:::;
86. There are several ways in which private participate in providing PHC
services to the population. The salient of contracting private providers in the
delivery of primary health care servicenUJ the specification of the range of
services that will be provided. Tg.&lse services by the general practitioners to
patients who must get the primary care services required in one facility or
comparable arrangement ich does not inconvenience or require travel costs on the
part of the patient.
11.3 .Benefits
f,-_ :
J--
87. rendered at the hospital level will be based on a defined comprehensive
\;'_" "'VY
.. that is appropriate to the level of care and referral systems
13
. The National
'\ ____ ',d:>__ '-
Insurance will provide an evidenced-based comprehensive package of health
1
slr'Vices which includes all levels of care namely: primary, secondary, tertiary and
//
quaternary health care services.
13
The channelling of a patient to another level of care, either a higher or lower level for continuity of care. It is a process in
which the treating health practitioner at a particular level of health service channels a patient to a different level of care.
28
11.4 Designation of Hospitals
88. As part of the overhaul of the health system and improvement of its management,
hospitals in South Africa will be re-designated as follows:
District hospital;
Regional hospital;
Tertiary hospital;
Central hospital; and
Specialized hospital.
appropriate qualifications and skills as defined by the Nation th Council.
\;
89. It is recognized that health care services in South rendered at different levels
of care with specific core packages.