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B) Public Health Medicine > Health care Financing and National Health Insurance (NHI) > Flashcards

Health care Financing and National Health Insurance (NHI) Flashcards

1
Q

What is health care financing?

A

Health financing - “function of a health system mobilization, accumulation
and allocation of money to cover the health needs of the people, individually and collectively, in the health system…

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2
Q

Updated definition of Health financing.

A

A good health financing system raises adequate funds for health, so that people can use needed services protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient”

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3
Q

Healthcare financing - in South Africa

A

Divided into Public and Private sectors. Over 8% of GDP goes towards health services [one of the highest globally]

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4
Q

Pooling risks

A

The accumulation and management of revenues in a way as to avoid large, unpredictable health expenditures

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5
Q

Purchasing goods and services

A

The mechanisms used to secure services from public and private providers

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6
Q

Two characteristics of Good health financing

A
  1. Raises adequate funds for health to ensure that peoples get to use needed services
  2. People who use health services are shielded from financial catastrophe or impoverishment associated with having to pay for them
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7
Q

The goals of health financing.

A
  1. Ensure adequate spending on health
  2. Raising sufficient funds for health
  3. Using funds for health efficiently and equitably
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8
Q

Mechanisms of Health Financing:

A 
>general revenue or earmarked taxes
>social insurance contributions
>private insurance premiums
>community financing
>direct out of pocket payments.
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9
Q

Each mechanism of health financing is meant for?

A
  1. Distributing the financial burdens and benefits differently
  2. Access to healthcare
  3. Financial protection
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10
Q

General revenue or earmarked taxes

A
  • the most traditional way of financing health care

finance a major portion of the health care (especially in low income countries)

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11
Q

Social insurance

A
  • Is compulsory
  • Everyone in the eligible group must enroll and pay a specific premium contribution in exchange for a set of benefits.
    Social insurance premiums and benefits are described in social compacts established through legislation. Premiums or benefits can be altered only through a formal political process
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12
Q

Private insurance

A

-Is Voluntary
- private contract offered by an insurer to exchange a set of benefits for a payment of a specified premium
-offered on individual and group basis. Under individual insurance the premium is based on that individuals risk characteristics.
major concern in private insurance is buyer’s adverse selection

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13
Q

Community based funding**

A

-are based on three principles: community cooperation, local self reliance and pre payment.

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14
Q

Direct out of pocket

A

made by patients to private providers at the time a service is rendered
user fees refer to fees the patients have to pay to public hospitals, clinics, and health posts not to private sector providers.
proponents of user fees believe that the fee can increase revenue to improve the quality of public health services and expand coverage
major objection raised against user fees had been on equity grounds

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15
Q

Factors for success of community funding **

A

> Technical strength and institutional capacity of the local group
Financial control as part of the broader strategy in local management and control of health care services
Support received from outside organizations and individuals
Links with other local organizations
Diversity of funding
Responding to other (non-health) development needs of the community
Ability to adapt to a changing environment

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16
Q

South African Public sector

A
  • It is funded largely through general tax revenue
  • Over 80% of the population totally dependent on this sector
  • Three tier public hospital structure (Tertiary, regional, and district) –> the primary health care system
  • This sector accounts for about 40% of total health care expenditure
  • Less that 50 % of both financial and human resources.
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17
Q

South African Private sector

A
  • Funded largely by private medical scheme [private health insurance]
  • Serves [mainly] less than 20 % of the population with private health insurance
  • Comprises a range of providers - GP, specialists, pharmacies, private hospitals, etc
  • More than 50 % of both financial and human resources
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18
Q

What is National Health Insurance

A

NHI is a health financing mechanism that will move us towards universal health coverage (UHC)

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19
Q

What is the goal of the National Health Insurance ?

A

NHI is aimed at ensuring that:

  • all South Africans have access to quality health care irrespective of their socio-economic status
  • health services are delivered equitably
  • the population does not pay for accessing health services at the point of use • the population has financial risk protection against catastrophic health expenditure.
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20
Q

What is the purpose of the National Health Insurance Act?

A
  • To establish and maintain a National Health Insurance Fund
  • Funded through mandatory prepayment that aims to achieve sustainable and affordable universal access to quality health care services
  • Single purchaser and single payer of health care services in order to ensure the equitable and fair distribution and use of health care services;
  • strategic purchasing of health care services, medicines, health goods and health related products from accredited and contracted health care service providers.
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21
Q

What are the 7 Principles of National Health Insurance?

A
  1. Universal access
  2. Mandatory pre-payment of health care
  3. Comprehensive services
  4. Financial risk protection
  5. Single fund
  6. Strategic purchaser
  7. Single payer.
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22
Q

What are the 7 Principles of National Health Insurance?

A
  1. Universal access
  2. Mandatory pre-payment of health care
  3. Comprehensive services
  4. Single fund
  5. Financial risk protection
  6. Strategic purchaser
  7. Single-payer
23
Q

What are the 7 Principles of National Health Insurance?

A
  1. Universal access
  2. Mandatory pre-payment of health care
  3. Comprehensive services
  4. Financial risk protection
  5. Single fund
  6. Strategic purchaser
  7. Single-payer
24
Q

NHI 1. Universal access

A

All South Africans will have access to needed promotive, preventive, curative, rehabilitative and palliative health services that are of sufficient quality and are affordable without exposing them to financial hardships.
The right to access quality health services will be on the basis of need and not socioeconomic status.

25
Q

NHI 2. Mandatory pre-payment of health care

A

NHI will be financed through mandatory prepayment which is distinct from other modes of payment such as voluntary prepayment and OOP payments.

26
Q

NHI 3. Comprehensive services

A

NHI will cover a comprehensive set of health services that will provide a continuum of care from community outreach, health promotion and prevention to other levels of care

27
Q

NHI 4. Financial risk protection

A

NHI will ensure that individuals and households do not suffer financial hardship and/or are not deterred from accessing and utilising needed health services.
It involves eliminating various forms of direct payments such as user charges, co-payments and direct OOP payments to accredited health service providers

28
Q

NHI 5. Single fund

A

This refers to integrating all sources of funding into a unified health financing pool that caters for the needs of the population.

29
Q

NHI 6. Strategic purchaser

A

In order to purchase services for all, there should be an entity that actively utilizes its power as a single purchaser to proactively identify population health needs and determine the most appropriate, efficient and effective mechanisms for drawing on existing health service providers.

30
Q

NHI 7. Single-payer

A

This refers to an entity that pays for all health care costs on behalf of the population. A single-payer contracts for health care services from providers. The term “single-payer” describes the funding mechanism and not the type of provider.

31
Q

Population coverage - [who gets the health care services] is determined by the Benefits Advisory Committee, on behalf of?

A
  • South African citizens;
  • Permanent residents;
  • refugees;
  • inmates and
  • certain categories or individual foreigners determined by the Minister of Home Affairs
32
Q

In the case of an asylum seeker or illegal foreigner, they are only entitled to?

A

emergency medical services; and
services for notifiable conditions of public health concern.
All children, including children of asylum seekers or illegal migrants, are entitled to basic health care services.

33
Q

Registering as a user of NHI. You need?

A

Register at an accredited health care service provider or health establishment.
-Must provide Biometrics including fingerprints, photographs, proof of habitual place of residence and—
an identity card as defined in the Identification Act, 1997 (Act No. 68 of 1997);
an original birth certificate; or
a refugee identity card issued in terms of the Refugees Act.

34
Q

What are the rights of the users? [NHI]

A

Patients rights as per patient right charter plus
To purchase health care services that are not covered by the Fund through a complementary voluntary medical insurance scheme registered in terms of the Medical Schemes Act, any other private health insurance scheme or out of pocket payments, as the case may be.

35
Q

Health services coverage steps [referral pathways] or requirements as determined by the Benefits Advisory Committee

A

=must first access health care services at a primary health care level as the entry into the health system;

=must adhere to the referral pathways prescribed for health care service providers or health establishments; and

=is not entitled to health care services purchased by the Fund if he or she fails to adhere to the prescribed referral pathways

36
Q

A person or user must PAY for health care services rendered that:

A

One is not entitled to health care services purchased by the Fund if the person
fails to comply with referral pathways prescribed by a health care service provider or health establishment;
seeks services that are not deemed medically necessary by the Benefits Advisory Committee; or
seeks treatment that is not included in the Formulary

37
Q

What do we mean by Free at the point of care?

A

-It means that a person will Receive the health care services purchased on his or her behalf by the Fund from an accredited health care service provider or health establishment. Provided that they follow all pathways and protocols.

38
Q

National Insurance Fund

A

Pool the allocated resources in order to actively purchase and procure health care services, medicines, health goods and health related products from health care service providers, health establishments and suppliers that are certified and accredited in accordance with the provisions of this Act, the National Health Act and the Public Finance Management Act.

39
Q

Role of medical schemes in the future

A

Medical schemes may only offer complementary cover to services not reimbursable by the Fund

40
Q

National Health Insurance Fund

A 
Procurement- Contracting 
Re-imbursement
Re-imbursement rates
Information management- quality and accreditation
Research, monitoring and evaluation
41
Q

The purchasing of the Health services

A

The Fund must actively and strategically purchase health care services on behalf of users in accordance with need.
The Fund must transfer funds directly to accredited and contracted central, provincial, regional, specialised and district hospitals based on a global budget or Diagnosis Related Groups.
Funds for primary health care services must be transferred to Contracting Units for Primary Health Care at the sub-district level
Emergency medical services provided by accredited and contracted public and private health care service providers must be reimbursed on a capped case-based fee basis with adjustments made for case severity, where necessary.
Public ambulance services must be reimbursed through the provincial equitable allocation.

42
Q

Accreditation of Service Providers

A

Be in possession of and produce proof of certification by the Office of Health Standards Compliance and proof of registration by a recognized statutory health professional council.

43
Q

More on how Services providers are accredited.

A

Provision of the minimum required range of personal health care services published in Gazette from time to time as required;
Allocation of the appropriate number and mix of health care professionals, in accordance with guidelines, to deliver the health care services
Adherence to treatment protocols and guidelines, including prescribing medicines and procuring health products from the Formulary;
Adherence to health care referral pathways;
Submission of information to the national health information system to ensure portability and continuity of health care services in the Republic and performance monitoring and evaluation; and
Adherence to the national pricing regimen for services delivered.

44
Q

What does it mean to say accreditation of service providers is performance based?

A

Performance based- management of patients, the volume and quality of services delivered and access to services.

45
Q

Payment of health service providers

A

The Fund, in consultation with the Minister, must determine the nature of provider payment mechanisms
Accredited primary health care service provider must be contracted and remunerated by a Contracting Unit for Primary Health Care
specialist and hospital services, payments must be all-inclusive and based on the performance of the health care service provider, health establishment or supplier of health goods,
Emergency medical services must be reimbursed on a capped case-based fee basis with adjustments made for case severity

46
Q

Funding of the National Health Insurance.

A 
general tax revenue, including the shifting funds from the provincial equitable share and conditional grants into the Fund;
reallocation of funding for medical scheme tax credits paid to various medical schemes towards the funding of National Health Insurance;
payroll tax (employer and employee); and
surcharge on personal income tax, introduced through a money Bill by the Minister of Finance and earmarked for use by the Fund,
47
Q

Transitional arrangements

A

National Health Insurance must be gradually phased in using a progressive and programmatic approach based on financial resource availability

48
Q

What is Phase 1 [2017-2022]?

A

continue with the implementation of health system strengthening initiatives, including alignment of human resources
The development of National Health Insurance legislation and amendments to other legislation;
Undertaking of initiatives which are aimed at establishing institutions that must be the foundation for a fully functional Fund; and
include the purchasing of personal health care services for vulnerable groups such as children, women, people with disabilities and the elderly

49
Q

What is phase 2 [2022-2026]?

A

the continuation of health system strengthening initiatives on an on-going basis;
the mobilisation of additional resources where necessary; and
the selective contracting of health care services from private providers

50
Q

Phase 1 objectives

A

migration of central hospitals that are funded, governed, and managed nationally as semi-autonomous entities;

-the purchasing of health care service benefits, which include personal health services such as primary health care services, maternity, and child health care services including school health services, health care services for the aged, people with disabilities, and rural communities

  • The purchasing of hospital services and other clinical support services, which must be—
    (i) funded by the Fund;
    (ii) an expansion of the personal health services purchased; and
    (iii) from higher levels of care from public hospitals (central, tertiary, regional, and district hospitals) including emergency medical services and pathology services provided by National Health Laboratory Services;
51
Q

Potential of NHI if well implemented

A

Increased efficiency of health service
Integration of private and public
Less duplication of services
Distinction between service delivery role and Assurance role

52
Q

Aspects that stand out about the NHI

A

Centralisation of services- Role of Provinces
No clear mention of role of private hospitals
Separation of curative services from health promotion services

53
Q

Current status

A

The new NHI office est. 2019. National department of health budget.

  • Need additional 33 bil annually for 2025
  • covid-19 imposed some adjustments NHI grant not spared, revised down by 6% for 2020 to contribute to covid-19 response.

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B) Public Health Medicine (14 decks)

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