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Public Health > Into to Health Systems > Flashcards

Into to Health Systems Flashcards

1
Q

What is National Health Insurance

A

NHI is a health financing system that pools all the funds we spend on our personal health care to provide equitable access to quality health services for all South Africans based on our health needs, irrespective of our socio-economic status. NHI is intended to ensure that health services do not result in financial hardships for individuals and their families. Services are paid for us from the single pool, which we pre-finance through our taxes.

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2
Q

WHO definition of health

A

Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity

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3
Q

Three spheres of government

A

local government
provincial government
national government

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4
Q

local government

A

Responsible for local amenities, markets, municipal abattoirs, municipal roads, noise pollution and street trading

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5
Q

provincial government

A

Responsible for ambulance services, provincial planning, provincial cultural matters, provincial roads and traffic

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6
Q

national government

A

Responsible for policy formulation and making, developing national standards and norms, and rules and regulations

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7
Q

What does the SA Constitution declare about these structures?

A

Distinctive:
Each sphere has its own unique area of operation

Interdependent:
The three spheres are required to co-operate and acknowledge each other’s area of jurisdiction

Interrelated:
There should be a system of co-operative governance and intergovernmental relations among the three spheres

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8
Q

Legislature (law markers) in each sphere

A

local- council
provincial- legislature
national- parliament

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9
Q

executives
(Cabinets/Councils/Committees

A

local- Mayor and Mayoral Committee

provincial- Premier and Members of Executive Council (MEC)

national- President and Cabinet Ministers

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10
Q

administration of health system in each sphere

A

local- Municipal Manager, Heads of Municipal Health Services

provincial- Heads of Provincial Departments of Health

national- Director General and
National Department of Health

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11
Q

National Health Act, 2003: Health as a Human Right

A

-No one may be refused emergency medical treatment;
-Every child has the right to basic health care services;
-Everyone has the right to an environment that is not harmful to their health or well-being;
-Local Government is responsible for Municipal Health Services
-Provincial Government can assign any provincial function to Local gov if Local gov has capacity to perform the function

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12
Q

What is a District?

A

-Total of 52 districts in SA
-A geographical demarcation
-Well-defined population: Communities/People
-A delineated administrative area (urban/rural)
Homes
Schools
Work places etc

Smaller geographic area urban districts tend to have large single local municipalities
Larger geographic area rural districts tend to have multiple local municipalities

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13
Q

What is a system?

A

A set of things working together as parts of a mechanism or an interconnecting network and forms a complex whole

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14
Q

What is a Health System

A

Health systems are part of government structures of delivering healthcare services to its people/ citizens
World Health Organization describes as:
All organizations, people and action whose primary intent is to promote, restore or maintain health

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15
Q

The WHO health systems framework system building blocks

A
  1. leadership/ governance
  2. healthcare financing
  3. health workforce
  4. medical products, technologies
  5. information and research
  6. service delivery
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16
Q

WHO health systems framework

A
  1. Delivers quality services to all, when and where they need them.
  2. Requires a robust financing system to offer above services.
  3. Well trained and adequately paid workforce
  4. Reliable information on which to base decisions and policies
  5. Deliver quality medicines and technologies
  6. Leadership and governance
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17
Q

Goals for the WHO framework

A
  • improved health (level and equity)
  • responsiveness
  • financial risk protection
  • improved efficiency
18
Q

What are the Health system building blocks?

A

people
governance
information
financing
service delivery
human resources
medicine and technologies

19
Q

What is a District Health System?

A

WHO defines it as a network of PHC facilities that deliver a comprehensive range of promotive, preventive and curative health care services to a defined population with active participation of the community

DHS are managed by District hospitals (where PHC facilities refer to) and District Health Management Teams (DHMTs)

20
Q

Universal Health Coverage

A

Global agenda for all health systems :
“Ensuring that all people can use the…health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship

21
Q

Three dimensions of UHC

A
  1. Financial risk protection for all (cost)
  2. Enabling access for use of needed health services for all (population)
  3. Ensuring the appropriate services are provided at an appropriate quality (services)
22
Q
  1. Financial risk protection for all
A

If people have to pay the entire costs out of their own pockets, the poor will be unable to obtain most of the services they need and even the “rich” will be exposed to financial hardship in the event of severe or long term illness.

Forms of financial risk protection that pool funds:
Through tax
Other government revenues, and/or
Insurance contributions
Spreads the financial risks of illness across the population, and allow for cross subsidy from rich to poor and from healthy to ill, increase access to both needed services and financial risk protection

23
Q

How UHC works

A

single payer
mandatory insurance
national health insurance

24
Q
  1. Enabling access for use of needed health services for all
A

Population – the people who need the services

Challenges:
Urban vs Rural access
Old vs Young
Rich vs Poor
Employed vs Unemployed

25
Q

Ensuring the appropriate services are provided at an appropriate quality

A

The services axis depicts the quality health services they need across the major causes of ill health – including:
-The unfinished agenda of the MDGs
-Non-communicable diseases
-Mental health
-Injuries

This is not solely treatment though

UHC must also include prevention, promotion (personal and nonpersonal), rehabilitation and palliative services, and population-based interventions e.g. reduce tobacco consumption, alcohol harms etc

26
Q

What is the problem with NHI

A

The multiplicity of funders in the private sector add an estimated 15% to the cost of the private sector (administrative costs)
Access to quality health care services determined by race, gender, geographic location, SES. Two-tiered health system perpetuates inequality
Only those with financial means / employer assisted health benefits have access to healthcare paid through medical aids

A family with a household income of R20 000 per month will spend ~ R3800 on an average medical scheme package (excl. co-payments and levies)
This is 19% of their disposable income
Medical scheme premiums increasing above inflation, this proportion of income is likely to rise
At least ¼ of population pays for private health care services out of pocket.
Even those with medical schemes often pay additional out-of-pocket payments through co-payments or when benefits have run out

27
Q

How is SA public health system currently funded?

A

revenue collection: SARS

distribution of funds: treasury

purchasing and provision of services: Provinces, local government

28
Q

What are the current challenges to financing the public health system?

A
  • Disincentives to efficiency and cost-saving.
    -Multiple purchasers = drives up prices.
    -No clear package of services which the public can expect.
29
Q

What is the NHI proposed solution?

A

Proposed SA Health care financing model to achieve Universal Health Coverage (UHC)
-Financing tool to fund health services for all South Africans
-Single national fund, huge purchasing power to negotiate fair and affordable payments with healthcare providers
-Financial protection in costing of healthcare

30
Q

What are the features of NHI?

A

Publicly Administered (loosely likened to one big medical scheme for all)

Mandatory Prepayment (primarily through tax)

NHI fund is a Single Purchaser of defined comprehensive health services f

31
Q

What are the financing mechanisms of NHI

A

revenue collection:
-Raises revenue for the health system (Tax)
-Relates to fund sources, funding structures and the means by which funds are collected.

pooling of funds
-Accumulation & Management of revenue (Single Fund NHI Fund)
-Risk for healthcare borne by all members

purchasing of services
-Transfer of pooled resources to health service providers by NHI Fund
-Provision of appropriate and efficient services for the population DOH

32
Q

When and how will NHI come into operation?

A

1st phase (initiated in 2018): legislative framework / refining clinical protocols and treatment guidelines / reimbursement strategies / accreditation processes.

2nd Phase: Implementation of NHI fund with governance structures. Shifting & mobilizing revenue, expanding contracting of services from Private GP and rehab services and Private and Public Hospitals, continuing certification and accreditation.

3rd Phase: Expanding certification and Accreditation to all the remaining private and public hospitals and introduction of mandatory prepayment based on ability to pay.

33
Q

Where will the funding for the NHI come from?

A

1.National Treasury will determine the sources of funding for NHI and be approved by Cabinet. Treasury will also determine when any dedicated NHI contributions are introduced or changed in line with the fiscal and economic environment.

  1. NHI will be funded through a mandatory pre-payment system and other forms of taxes collected by SARS and allocated to the Fund by Parliament.
  2. Based on the NHI Bill, NHI will be predominantly funded through general revenue allocations, supplemented by: (1) a payroll tax payable by employers and employees and (2) a surcharge on individuals’ taxable income.
  3. The financial impact of the NHI taxation system must not create an increased burden on households compared to the current system. There will be no option for opting out of NHI for eligible people.
  4. Out-of-pocket payments such as co-payments and user fees will not be used to generate additional funding for comprehensive health care services to be covered under NHI. This ensures that healthcare services are delivered free of charge at the point of service and that the most vulnerable are not denied access.
34
Q

What is the role of private providers in the NHI?

A
  1. Private health care providers will continue to operate privately under the NHI dispensation. Contrary to some public narrative, the NHI is not going to abolish or do away with private health providers.
  2. NHI will not allow health care providers to set their own fees for NHI funded benefits. The Fund will set the fees that it will pay to private doctors, hospitals and others on your behalf.
  3. Private General Practitioners will be a part of multi-disciplinary networks in their communities and will be paid by the NHI Fund using a capitation model.
  4. The private health sector providers will benefit from the opportunity to contract with NHI to provide health services to the broader public, rather than the small proportion for which they currently provide services. They will be able to provide services to patients throughout the year not worried about depletion of funds of patients at any stage.
  5. Private hospitals will see patients referred by primary health care providers in both public and private sectors and the NHI Fund will settle the bill at the prescribed rates.
35
Q

How can I qualify to be an accredited healthcare provider under the NHI?

A
  1. Every health care provider may be contracted by the NHI Fund. This will be initiated by the provider and once the provider meets the accreditation requirements they will be contracted. There will be no tenders for services.
  2. Every health care provider (public and private) must be certified by the Office of Health Standards Compliance.
  3. It will take some time for all health care providers to obtain certification, so the law makes provision for a transitional period of conditional accreditation by the Fund. The tools for health care provider compliance have been developed but NHI Fund accreditation and contracting requirements are still being developed.
  4. The health care provider must agree to, and comply with, the requirements of the NHI Fund to be accredited and contracted with the Fund. This includes connection to the Fund digital systems and reporting.
  5. A primary health care provider will be assigned a designated population that will be under their care and will be paid on a capitation basis. The details are being developed and will include a performance-based portion
36
Q

Will private providers be forced to contract with NHI?

A

Not at all. Contracting with NHI Fund gives the health care provider opportunity to offer health care services to a designated population (significantly more patients than currently). The provider will not have to worry about the patients’ affordability as the Fund would have paid a capitation fee for the designated population. Patients who consult with providers who are not contracted with NHI will pay cash for the providers’ services. Patients will only be able to use their medical schemes to pay for benefits not covered by the Fund with non-NHI contracted providers.

37
Q

How will corruption be prevented?

A
  1. The Fund will have a Board and various governance structures as required by the PFMA and King IV that will have the responsibility of ensuring that there are institutionalised systems, policies and procedures that proactively prevent, detect, investigate and correct incidents/acts of fraud and corruption.
  2. The Fund is required by law to establish and operate units that focus on fraud prevention, detection, investigation and correction of fraud and corruption.
  3. All employees of the NHI Fund will be responsible for preventing and detecting fraud in the execution of their assigned roles and responsibilities.
  4. The department, in collaboration with the Health Sector Anti-Corruption Forum (HSACF) and the Special Investigating Unit (SIU), is currently engaged in a process of risk identification, analysis and mitigation of all fraud and corruption risks that may affect the Fund.
  5. Control measures and mitigating strategies are currently being implemented in the design and development process of the NHI Fund.
  6. The public will have opportunity to anonymously report corrupt activities to law enforcement agencies and the HSACF which has been established by the President.
  7. The design of the NHI is far less complicated than the present myriad of departments and medical schemes. Everything that the fund does, all the contracts with providers and suppliers, and the common set of funded benefits, will be fully transparent. Since every person will be entitled to the same benefits and treated the same way, there is far less incentive for fraud and corruption.
38
Q

What is a Law?

A

Law is a system of rules, usually enforced through a set of institutions to regulate human conduct.

39
Q

How a Law is Made

A

Parliament is the national legislature (law-making body) of South Africa. As such, one of its major functions is to pass new laws, to amend existing laws, and to repeal or abolish (cancel) old laws. This function is guided by the Constitution of South Africa, which governs and applies to all law and conduct within South Africa.

40
Q

Who Makes the Laws?

A

Both Houses of Parliament, the National Assembly (NA) and the National Council of Provinces (NCOP), play a role in the process of making laws.

41
Q

How is legislation developed and how might this process be influenced?

A

green paper
white paper
bill
act

Public Health (16 decks)

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