In the lead up to the Hospital Association of South Africa (HASA) 2017 Conference taking place in Cape Town from the 25-27 September, Healthcare Actuary at Insight Actuaries & Consultants and invited speaker, Shivani Ranchod, explains why we need to think differently about National Health Insurance (NHI) in order to achieve universal healthcare coverage (UHC).

NHI is not a single, simple reform. It extends beyond financial restructuring or the introduction of a national insurance fund with tax implications. NHI is a very complex set of reforms which impact every aspect of the health system – including the purchasing and delivery of care.

But despite the challenges, the reform work is necessary because our healthcare system as it stands is not optimal. Our history has given rise to an expensive private sector and an overburdened, under-resourced public sector. NHI is an opportunity to reflect on and action how to redesign the current healthcare system to ensure that it provides quality healthcare to all South Africans.

Access vs access to quality care

As it stands the public sector currently provides (largely) free healthcare. But the reason this does not translate into UHC is because the system currently does not provide access to quality care. We have to conceptualise what we mean by quality and determine how we can get the best quality with our limited resources, both financial and human. A good place to start when improving the quality of care is by reducing waste and over servicing, and improving efficiency to address shortages and leverage our resources.

There will always be a trade-off between what we want in terms of features and benefits of a national health insurance, and what we can afford. Therefore, the design of our new healthcare system under NHI should ideally be an iterative process supported by strong technical work.

A simplified example of the importance of reform sequencing is the interplay between overhauling both risk cross-subsidies and income cross-subsidies within the system. The impact differs depending on whether we were to change income cross-subsidies before risk cross-subsidies or vice versa. Technical modelling to predict the impact and to weigh up the different outcomes is essential.

Of course affordability matters – it is essential to long term sustainability. Not knowing all of the answers to affordability should not translate into inaction. It is unacceptable to say that we can’t afford to provide healthcare to the people of South Africa. We have to be able to afford something, and we have to figure out what that something is and how to best design it so that we make optimal use of our resources. As an actuary, it’s my role to help build those tools to help us figure out the trade-offs and the cost of the various policy decisions.

Following different pathways

Because NHI is a complex set of reforms it isn’t conceivable that there is just a single pathway to be followed. We have to be open and have an innovative, experimental mind-set so that we can try different things and reflect on the outcomes in order to make improvements and adjustments. Unlike the first draft, the latest version of the NHI White Paper is open to multiple pathways, which is significant because NHI is now transitioning to a more realistic plan.

I’m an advocate of pluralistic approaches, and in particular pluralistic purchasing and financing. We must give careful consideration to how we transition from the current two-tier healthcare system to a future state of collaboration. As a resource-constrained country, we have to leverage the valuable resources we have in the private sector, including the existing medical aid schemes, high quality healthcare facilities and medical specialists. We have to do so in such a way that limits damage, but also does not cause inertia.

With the release of the updated NHI White paper the vision behind NHI is becoming more tangible with a range of possible roles for the private sector going forward. However, there’s still an enormous amount of work that needs to be done and structural impediments that need to be overcome. We hope that the HASA 2017 Conference will generate further engagement between the different stakeholders and help us move towards improving our healthcare system under NHI.

The HASA 2017 Conference will feature a number of international and local speakers who will together explore how to respond to the global healthcare puzzle through integrating healthcare. The world-class conference and exhibition will take place from Monday, 25 September to Wednesday, 27 September 2017 at the Cape Town International Convention Centre (CTICC). More information about the event can be found here.

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