What the National Health Insurance will cover

South Africa is grappling with the immense task of transforming what have historically been two parallel health systems – public and private – into a unified health system that serves all South Africans and accelerates progress towards universal health coverage. 

The policy driving this transformation is National Health Insurance (NHI).

From the start, it was intended that the NHI would be phased in; however, progress has been slower than anticipated. 

Arguably, one of the reasons has been the absence of a list of conditions and healthcare services to be covered under NHI and provided by the public and private sectors. Internationally, this list of conditions and treatments is often known as a “health benefits package.” In South Africa, it has come to be known as the NHI “service benefits”.

The national health department has developed a service benefits framework. Developed over a number of years, this framework has guided the development of a repository of the current services delivered, and that can serve as the basis for determining the services the NHI covers and how. 

The framework reflects the conditions, services, and care pathways reflected in existing national clinical guidelines. It also includes the average associated resources required to provide care for the conditions listed as per existing policies. 

Government has already committed to ensuring that services under an NHI will be no less than those currently available in the public sector.

The framework and current content of the repository is a start. 

From here, it can be used to ensure national guidelines and policies align. Part of this will mean looking at the services and conditions contained in the framework and analysing them alongside data on, for instance, disease burden, cost-effectiveness analysis, and societal preferences. This, in turn, will support financial and operational planning, now and as we transition to a fully implemented NHI.

For instance, it will help us predict everything from how many nurses we’ll need to how much medicines or equipment the National Health Insurance Fund might need to budget for. It will also provide a baseline against which to implement routine review through a defined and transparent priority-setting process.

Ultimately the information in this framework can be made available publicly to allow, for instance, public and private healthcare providers to understand cost assumptions underlying how reimbursement rates are calculated. For medical schemes,  it can help define what complementary services they will cover in the short term. For the wider medical technology industry, it will provide market certainty and a focus for research and development in cost-effective interventions.

Finally, the public will be able to use the service benefit framework to look up what services are available and where.

It will also ensure that everyone understands policy and guidelines, and in so doing support broad participation in discussions and debates about how these NHI service benefits change over time.

How did South Africa develop a service benefits package framework for the NHI?

Former health minister Aaron Motsoaledi established six workstreams, each focusing on a different aspect of the NHI. Between 2015 and 2017, one of these teams worked to develop an approach to health benefits, drawing on established best practice as well as ways to evaluate new health technologies that might one day be part of those benefits. 

In 18 months, the expert group delivered a first draft of the NHI service benefits framework. The group also proposed scenarios for developing a national health technology assessment body and estimated how much this might cost. Following this, the service benefit framework was expanded and refined in consultation with the medical scheme regulator, the Council for Medical Schemes (CMS) and the committee revising the country’s existing Prescribed Minimum Benefits. 

The process began with a review of all available national clinical guidelines to see if any existing document could form a foundation for the framework. Researchers found more than 100 national clinical guidelines for primary healthcare services in existence variously developed, adopted or endorsed by the national health department.

Ultimately, the country’s Standard Treatment Guidelines for Primary Healthcare was chosen for three reasons: First, this single guideline provided for the widest set of conditions at primary healthcare. Secondly, it — as with the standard treatment guidelines for all levels — had been developed to support practical implementation of South Africa’s list of essential medicines, which itself had been developed through a priority-setting process.

Lastly, it was thought that the amount of detail contained in the guidelines would help the health department link treatment to required resource inputs and thus the expected costs for the South African health sector. But, it was acknowledged that these treatment guidelines would have to be supplemented by the content of the other national clinical guidelines which listed further services for primary healthcare-related to prevention, treatment and palliative care, as well as rehabilitation services.

Next, experts worked from these guidelines to link each condition with the types of people who would be most at risk for developing them based on age, sex or life stage, for example. Then they mapped out what care would look like in a way that anyone in the health sector — regardless if they had a medical degree or not — could understand them: Think managers at a district office, for instance. 

Once this team of experts finally had a set of primary healthcare benefits, they could move onto figuring out the resource requirements needed per patient in terms of medicines, tests or other resources, using national policies. 

Next, researchers will be working to attach the unit costs to calculate what providing each of these per patient service benefits looks like right now, using existing tenders and personnel costs based on the Department of Public Service and Administration rates.

Plugging the service benefits data alongside population figures and disease burdens into forecasting models will then enable the estimation of the cost of delivering the current service for different target levels of coverage. It will help highlight where the NHI Fund can help South Africa save money or be more efficient and where, with limited resources, tough decisions need to be made regarding priorities. This methodology will have to be adjusted when they begin to look at patients with more than one illness. Also, until there is more certainty about the NHI’s final management structure, the methodology will need to factor in additional costs such as those related to overhead or administration.

In time, it is anticipated that the NHI service benefits framework will extend beyond facility-based primary healthcare to include community-based and hospital services. 

We have an idea of what benefits under the NHI could look like, now what?

There are three early lessons in building the country’s framework for what the NHI service benefits will be. First, creating unified systems and classifications for healthcare data will be crucial to supporting service coordination. Similarly, processes to develop national policies, strategies and guidelines will also have to align as will the health information systems that support their implementation.

Finally, broad-reaching consultations both within and outside of the national health department have been and will continue to be important. When it comes to the private sector, this will mean navigating a fragmented group of players both geographically and in allegiance. The different types of private actors will, for example, need to come together to discuss how their current benefits will align to those under the NHI. This will require balancing the need to ensure existing medical scheme members are not disenfranchised while recognising that the current mode of private sector service delivery and cost structures are unsustainable.

Private and public healthcare workers and facilities must also have a voice given their role in delivering the service benefits. And stakeholder engagements will not be complete without establishing a research agenda to answer questions relating to the service benefits, but also to help us monitor, evaluate, learn and adapt along the way. 

Finally, everyone in South Africa has a stake in the NHI and the first group to be engaged should be South African citizens, who ought to know what healthcare services they can expect under NHI. 

But the authors highlight that broad participation too holds its own brand of challenges. In the United Kingdom, priorities for the National Health Service are set by the National Institute for Health and Care Excellence (NICE). The institute has had a dedicated budget line for public engagement since it was established in 1999, research published in 2005 in the journal Healthcare Quarterly points.

Although public engagement has played a major role in the institute, it can also — perhaps counter-intuitively —  threaten the legitimacy of the process. 

A 2019 study published in the British Medical Journal found that almost 80% of the financial interests of public and patient organisations actively contributing to NICE guidance were not known to NICE decision-making committees.

Amid increasing pressure on the UK’s National Health Service to do more with less, NICE seems to have backed away from its longstanding commitment to explicitly acknowledging societal values in its decision-making process, argue researchers in a 2019 commentary in the Journal of the Royal Society of Medicine.

The UK’s NICE example may be a cautionary tale for a country like South Africa with fewer resources and a deeply rooted sense of solidarity and commitment to equity as to how best to design and sustainably finance stakeholder engagement processes.

Today, South Africa still remains saddled with one of the most enduring structural legacies of apartheid: South Africa’s two-tiered health system. It is a system that remains a key factor underlying South Africa’s status as the country with the highest level of inequality in the world. The NHI remains a critical step in addressing this. DM

Jeanne-Marie Tucker is a senior technical adviser with the Clinton Health Access Initiative. Kalipso Chalkidou is the director of Global Health Policy and a Senior Fellow at the Centre for Global Development and Yogan Pillay is the national health department’s deputy director-general for communicable and noncommunicable diseases. 

This is an extract edited by the Bhekisisa Centre for Health Journalism of their recent chapter entitled, Establishing the NHI Service Benefits Framework: lessons learnt and stakeholder engagement published in the latest edition of Health Systems Trust's South African Health Review. Read the full chapter. 

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