South African Medical Association



PP4U: Actuary, Christoff Raath addresses the South African National Health Insurance proposals in the international context and



Actuary, Christoff Raath addresses the South African National Health Insurance proposals in the international context and their relevance to medical practitioners

Christoff Raath, Actuary at Insight Actuaries and Consultants, presented on the Many Faces of Universal health Cover.

Christoff conceded that although the NHI Bill is controversial, at least the policy uncertainty around universal health coverage (UHC) in South Africa is diminishing, and there is now a proposed direction to begin interacting with.

Globally, there is no single best solution to achieving UHC, and NHI is just one way to try to achieve UHC. Christoff then took us through several other country examples to demonstrate experiences in other systems trying to implement UHC.

What is clear from the World Health Organisation UHC framework is that the NHI journey will never be complete and these reforms will not be a once-off process.

Just over half of the South African population live in a household where the breadwinner earns less than R4200 per month. Medical scheme coverage is simply unaffordable for most. In addition there is also a large amount of out of pocket payment in the private sector by inunsyred patients who can afford to pay cash for some services.

Christoff also stressed that there is no country in the world that has no private health sector at all, although the need for this depends a lot on the performance of the publicly funded sector.

In all countries, equity, efficiency, sustainability remain challenges. Amongst middle income countries there are very few examples of a single-payer model as proposed in South Africa.

Additionally, most countries have cost-sharing and co-payment models for many services including hospital care, medicines, dental care, optometry, and sometimes specialist services.

Gate keeping is used to contain costs, often with penalties, as in envisioned in the South African NHI Bill, which imposes no payment for services at all, if patients do not follow prescribed referral pathways.

Countries with the most successful systems tend to decentralize and devolve systems, and there is a myriad of governance structures, delivery models and reimbursement models to facilitate this.

Contracting is a key issue for practitioners in the private sector. The fact that practices and practitioners will have to be accredited implies that a contract will need to be in place, which means participation for practitioners will be voluntary. It is not yet clear as to whether, if practitioner is contracted to the NHI, he/she will also be able to consult with patients on a private basis.

In addition, the Bill is ambiguous on whether it will be “reimbursed” or “reimbursable” benefits which cannot be provided as complementary cover through medical scheme benefits. Christoff stressed that these terms are not equivalent, but are used as such in the Bill. It is still unclear what services would be considered “complementary” to those in the NHI Benefit Package.

Many practitioners accept differential fees for low income versus higher income patients, and pharmaceutical companies may also cross-subsidize their public sector tender prices through income from medicine sales in the private sector.

Ultimately, the existence of privately funded patients may well be necessary to cross-subsidize the NHI patients to keep reforms sustainable.

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