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Integration of the public and private sectors under the NHI and other research

Integration of the public and private sectors under the NHI and other research. Mariné Erasmus 21 September 2010 IRF Conference - Sandton. Public Healthcare Providers. Healthcare Service Delivery. Provider Contracting and Payment. Healthcare Service Delivery. Contribu - tions.

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Integration of the public and private sectors under the NHI and other research

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  1. Integration of the public and private sectors under the NHI and other research Mariné Erasmus 21 September 2010 IRF Conference - Sandton

  2. Public Healthcare Providers Healthcare Service Delivery Provider Contracting and Payment Healthcare Service Delivery Contribu-tions Non-contributing Individuals Contributing Individuals National Health Insurance Authority Healthcare Service Delivery Healthcare Service Delivery Provider Contracting and Payment Private Healthcare Providers Key features of the current proposal

  3. Current research • Series of research notes on general health reform • Importance of primary care • Accreditation • Integration of public/private sectors • Human resource requirements • Reimbursement levels and models • Freedom of choice • Earmarked tax for NHI • Other practical issues

  4. Role of Primary Healthcare in Health Reform • Health Minister Motsoaledi’s turnaround strategy: renewed focus on PHC • Evidence of improved affordability & accessibility of public healthcare by poor households since 1994 • Quality remains a concern • Waiting times • MDG 4: reduce child mortality • MDG 5: reduce maternal mortality • Assuring quality through accreditation

  5. Percentage of people who experienced the following problems while visiting a public hospital or clinic, GHS 2008

  6. Maternal mortality ratio(maternal deaths per 100,000 live births)

  7. PHC in South Africa • “South Africa is regarded as a superpower in health on the continent. Yet, the irony lies in the fact that most of these countries that turn to South Africa for hi-tech healthcare have low infant and maternal mortality rates.” Minister Motsoaledi • Focus on delivery of PHC will have large impact on poor & vulnerable communities • PHC facilitates less costly and more equitable healthcare • But in SA: • Higher detection rates at PHC level implies greater costs in short to medium term • Expect cost decreases in long term • Implies major changes to current private sector delivery model

  8. Integration of the public and private healthcare sectors • Contracting? • Payment mechanisms & levels? • Referral system? • Choice of provider? • Service delivery models? • Current promise: • Universal coverage • Free choice of provider at PHC level (although restricted to geographical area) • Capitation at PHC level, global budgets for hospitals

  9. Integration of the public and private healthcare sectors (continued) Private sector: • GPs & specialists paid on fee-for-service basis at the moment • Not employed by hospitals • Large out-of-pocket payments by medical scheme beneficiaries and non-members • Free choice & direct access to specialists in most cases • Demand rationed by price Proposed comprehensive PHC approach: • Integrated, holistic & more preventative • Outreach beyond hospitals, analysis of upstream factors • Focus on family, not just individual • Task-shifting (multi-disciplinary practices/ health teams: CHWs, nurses, doctor)

  10. Integration of the public and private healthcare sectors (continued) • Only limited excess capacity in private sector (±20%) • 32% of population already use private out-of-hospital services (DBSA Roadmap study) • 36.7% of population depends on private sector for PHC (McIntyre et. al.) • GPs & specialists (CMSA 2009) • Private GPs: 0.44 per 1,000 population • Public GPs: 0.35 per 1,000 population

  11. Integration of the public and private healthcare sectors (continued) • Private sector players will only contract with NHIA if beneficial to them • Quality differences, implicit rationing • Possible perpetuation of current system at higher costs • Conversion to higher private sector prices if no differential payment structures

  12. Patient choice & referral • Rationing choice is inevitable • GP gatekeeper model (across the world) • South African proposal • Will restrict choice • Current rationing in public sector vs. private sector • Limited resources vs. to keep system affordable • Need clearly defined referral guidelines • Geographical inequalities affect choice & referral • Information systems • Other practical concerns

  13. Provider payment systems • Single-payer system with monopsony powers • Different payment options with associated incentives • BUT unique SA situation • Quality differences • Shortage of doctors • HPCSA rules • Private insurers (medical schemes)

  14. Concluding remarks • To deliver on the promise of quality care for all South Africans (under a NHI system), integration between public & private sectors must happen • Many practical concerns, including: • Service delivery model • Referral mechanisms • Contracting & payment • HR requirements • Information systems, etc. • Theoretically, if the hurdles could be overcome, access, affordability, quality & health outcomes (life expectancy, etc.) should improve over the long run • Further research needed

  15. Thank you.

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