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National Health insurance in south africa: User Guide: GET INFORMED AND PARTICIPATE !
National Health insurance in south africa:
User Guide:
Get informed and ParticiPate !
1
creditS
title: User Guide 3: National Health Insurance in South Africa: Get informed and Participate!
Published: May2013
design: LUMOwww.lumo.co.za
contributors from
monash University: ProfessorKeitshepileGeoffreySetswe,JacquelineWitthuhnandRavayiMarindo
copyright: Oxfamgivespermissionforexcerptsfromthisbooktobephotocopiedorreproduced
providedthatthesourceisclearlyandproperlyacknowledged.
disclaimer: Theviewsinthispublicationarethoseoftherespectiveauthorsanddonotnecessarily
representthoseofOxfamoranyfundingagency.
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Tel:+27(0)312010865
Monash South Africa
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Tel:+27(0)119504329
about the oxfam-monash University Partnership project:
MonashUniversity,(Monash)andOxfamAustralia,(Oxfam)inMelbourne,Australiahavebeencollaboratingonvariousactivitiessince2008inordertofurther
theirsharedaimsofengagingtheworldandhelpingimprovethehumancondition.InMay2011,OxfamandMonashreceivedfundstosupportandstrengthen
theirpartnership.ThefundswillbedirectedtowardssignificantlyincreasingOxfamandMonash’scollectiveimpactonglobalpoverty,bybringingtogetherthe
knowledgethatOxfamcanprovide,coupledwithMonash’sacademicexpertise.
TheOxfam-MonashUniversityPartnershipprojectinvolvesaprogramofactionwhichisbeingimplementedinstagesforaninitialperiodoffiveyearsfrom2010to
2015.Inthenewphaseofthepartnership,OxfamandMonashwillcollaborateonresearchandthenapplytheresultstonewprojects,communications,advocacy
andcurriculumdevelopment.ThepartnershipwillbuildonOxfam’sexistingagendabyfocusinginitiallyonthreeareas:accountability,climatechangeadaptation
andgenderequality.
ThroughtheOxfam/MonashPartnership,ajointresearchproposalwhichseesthecollaborationbetweenOxfam’sSouthAfricancountryoffice,theGlobalHealth
UnitatMonashinMelbourneandtheSchoolofHealthSciencesatMonashSouthAfrica(MSA),receivedfundingforaproject.Thisproject,knownasGovernance
andAccountabilityintheHealthSector:Apeople’spolicyforhealthinSouthAfrica,aimstoexaminethecapacityofcommunitiestoengagewithgovernment
abouttheirhealthneedsandhowthisistranslatedintoaresponsiveandeffectivehealthpolicy.Ascontextforthework,thisprojectwillusetheNationalHealth
Insurance(NHI)processthatSouthAfricaisproposingtoimplement.
Theprojectwillexploreandtestamodelofpublicpolicyengagementtoincreaseawarenessof,andaccessibilityto,policyatalocallevel.Itisenvisagedthatthe
projectwillenhancecitizen’scapacitytoactivelyparticipateintheprocessofpolicydevelopmentbydemystifyingthepolicyprocessandcontent.
2 PHOTO©MatthewWillman|Oxfam
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contentS
Introduction 5
HowdidtheconceptoftheNHIdevelopinSouthAfrica? 5
Whatdoes“healthinsurance”meanintheNHI? 5
WhatistheNHIallabout? 6
WhydoweneedtheNHI? 6
HowwilltheNHIwork? 9
WhowillpayforNHI? 9
Ifpeoplecanaffordtobuyprivatehealthcare,willtheyhavetoparticipateinNHI? 10
WhereistheNHIgoingtobesituated? 10
Whataboutmycurrentmedicalaid? 10
WhatkindofserviceswilltheNHIoffer? 12
Whatisexpectedofmycommunity? 12
PHOTO©MatthewWillman|Oxfam
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introdUction
InSouthAfricaaNationalHealthInsurance(NHI)isbeingproposedassupportforthecurrenthealthcare
system.GiventhemultitudeofchallengesfacedbySouthAfrica’shealthcaresystem,anNHIisimportantfor
itsrestructuringandoverhauling.TheNHIaimstoimprovethehealthsystembychangingthewayfinancial
andhumanresourcesareused,makingthesystemmoreequitableasawhole.Atpresent,morethanhalfof
themoneyspentonhealthinSouthAfricaisspentintheprivatehealthsystemwhichservicesonlyasmall
proportionofpeopleinSouthAfrica.Onthe11thofAugust2011theSouthAfricangovernmentreleasedtheGreen
Paper1ontheNationalHealthInsurance,whichseekstoprovidebetterhealthcareforSouthAfricancitizensand
legalresidents.TheprincipleoftheNHIsystemisbasedonhealthcarebeingarighttowhicheverycitizenshould
haveaccess.SouthAfrica’shealthsystemisalreadyundergoingatransformationthatwillseeashiftfromthe
currenthospitalbasedcurativeapproach,toacommunityandclinic-basedprimaryhealthcaresystem.There
aremanybuildingblocksthatneedtobeputinplaceaspartofthishealthcaretransformationprocess.Central
tothesuccessoftheNHIistheneedtoeducateourselvesabouttheNHIsothatwecaninformthedesignand
developmentofanNHIthatmeetsourhealthneeds.
ThereleaseoftheGreenPaperfordiscussionmarkedthebeginningofaconsultationprocessbetween
governmentandvarioussectionsofthepopulationwhichwillcontinuefortheforeseeablefuture.Engagement
anddialoguefromcivilsocietyashealthcareend-usersiscrucialduringthisstageoftheNHIpolicydevelopment
process.ToensurethattheNHIisresponsivetotheneedsofthemajorityofSouthAfricansandachievesits
potentialtobeamajorsteptowardsqualityhealthcareforallinSouthAfrica,healthcareend-usersshouldbe
givenanopportunitytoparticipateandcontributemeaningfullyinshapinghowtheNHIshouldbeimplemented.
Thisinformationbookletiswrittenasareader-friendlyguidethatprovidesbasicinformation2ontheNHItohelp
facilitatemeaningfulcontributionstowardsalllevelsofdebateonitsdevelopmentandimplementation.
TheaimofthisdocumentistoprovideyouthereaderwithbasicinformationontheNationalHealthInsurance
(NHI)sothatyouarebetterabletoparticipateinandholddiscussionsanddialoguesontheNHIwithinyour
households,communitiesandpublicparticipationstructures.DuringthelaunchoftheGreenPaperontheNHI,
theMinisterindicatedtheimportanceofthepublic’sparticipationinthedevelopmentandimplementationofthe
NHI.ThisbookletprovidesbasicinformationontheNHItoenableyoutocontributemeaningfullytodebateson
thedevelopmentandimplementationoftheNHI.
ItisimportanttohighlightthatthecontentforthisdocumentwasgatheredfromsourcessuchastheNHIGreen
Paper3whichwaspublishedon11August2011andpubliceducationmaterialsontheNHIthatappearonthe
NationalDepartmentofHealth’swebsite.4Thisinformationbookletiswritteninaquestionandanswerformatso
thatitisreader-friendlyandcanbeusedtofacilitatediscussionswithpeopleatalllevels.
1. South Africa (2011) The National Health Insurance in South Africa - Policy Paper. Government gazette Vol 554, August 12 (No 34523)
2. Content for this document was gathered from sources such as the NHI Green Paper, published on the 11th of August 2011 and public education materials on
the NHI from the National Department of Health.
3. http://www.doh.gov.za/docs/notices/2011/not34523.pdf
4. http://www.doh.gov.za/docs/publicity/2011/nhi_english.pdf
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HoW did tHe concePt of tHe nHi deVeLoP in SoUtH africa?
• ThedevelopmentoftheNHIhasbeenunderdiscussionformanyyears.
• AschemeforaNationalHealthServiceforSouthAfricawasfirstdiscussedinthe1940s.Itwasproposed
thatSouthAfricashouldadoptaschemethatprovidedfreehealthcare,withanetworkofcommunity
centresandgeneralpractitionersasareferralsystem—whichwassimilartotheBritishmodel.However
thiswasneverimplemented.
• ThecurrentNationalHealthreformhasitsoriginsintheANChealthplanof1994,whichincludedthe
introductionofamandatoryinsurancesystem.
WHat doeS “HeaLtH inSUrance” mean in tHe nHi?
• InsuranceintheNHIisdifferentfromtheinsurancewearefamiliarwithsuchaslifeinsuranceorfuneral
coveretc.Thesetypesofinsuranceprovidefinancialhelptoyourfamilywhensomeonepassesaway(life
insurance)orcoverthecostsofthefuneral(funeralpolicies).
• TheNHIwillnotprovidefinancialhelptopeoplewhohavelostrelatives,anditwillnotcoverfuneralcosts.
HowevertheNHIFundwillpayforyourmedicalexpensesifyougetsick.
• Withhealthinsurance,aperson’sbasichealthrequirementisensured.Thismeansthatifaperson
becomesill,theirmedicaltreatmentinrelationtothispackagewillbepaidbytheNHIFund.
WHat iS tHe nHi aLL aBoUt?
• TheNationalHealthInsurance(NHI)isasystemthatwillusefundscollectedfromgeneraltaxation,aswell
asspecialcontributionsfromindividualswhoearnaboveacertainspecifiedlevel,toensurethatall
citizensofSouthAfrica(andlegallong-termresidents)areprovidedwithfreeessentialhealthcare.
• Thishealthcarewillbeprovidedtoall,whetheryouareemployedorunemployed,andevenifyoucannot
makeadirectmonetarycontributiontotheNHIFund.
• TheNHIisdesignedtoenableSouthAfricancitizens(andlegallong-termresidents)toreceivegoodquality
healthcareatanytimetheyrequireit.
• TheNHIwillallowpeopletohaveequalandfairaccesstoskilledhealthprofessionalsandequalandfair
accesstofinanceforhealthcare.
• Boththerichandthepoorwillreceiveproperhealthcareofthesamequality.
• TheNHIFundwillbelongtothepublicsohospitalsandhealthcareprofessionalscanbepaidforthe
servicetheyprovide.Hospitalsandhealthcareprofessionalswillbefairlypaidfortheirservices
(butnotatunreasonablecosts).
• TheNHIisgovernment’splantotakecareofeveryone’shealthinthefuture.Itwilltake14yearstofully
complete.ThismeansthatthereistimeforeveryonetoknowasmuchastheycanabouttheNHIandto
askallthequestionstheywantandgetanacceptableanswer.Itiseveryperson’srighttoknow
andtoaskquestions.
7PHOTO©MatthewWillman|Oxfam
PHOTO©MatthewWillman|Oxfam
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WHY do We need tHe nHi?
• Ourconstitutionstatesthataccesstohealthcareisahumanright.ThroughtheNHIitispossibleforSouth
Africatoprovidehealthcaretoall.
• Becauseofourhistory,wecomefromasystemwheretherichpaidtohaveverygoodhealthcarewhile
manypoorcouldnotaffordtohavehealthcare.
• Therearemanypeopleespeciallythepoorandthoseinruralareaswhoarenotabletoobtaingood
healthcare.Eventhoseincitiescomplainaboutthequalityofservicesinpublichospitals.Somesaythere
aretoofewqualifiedhealthprofessionalsandalsopoorequipmentinpublichospitals.
• Atthepresentmomentalthoughtheprivatesectorprovideshealthcareforonlyasmallnumberofpeople
(about14%ofthepopulation),ithasthelargestnumberofhealthcareprofessionals
(morethan60%ofdoctors).
• TheNHIwillchangeallthisbychangingthewayourcountrypaysforhealthcare:itwillprovideuswith
ahealthcaresystemthatisfairandequal.BecauseallhealthcareneedswillbepaidforthroughtheNHI,it
meansthequalityofserviceswillbealmostthesamethroughoutthewholecountry.
• ThroughtheNHI,SouthAfricanswillbehealthier.ThisisbecauseundertheNHImorewillbedoneto
preventillnessandpeoplewillreceivetreatmentatearlystagesofillness.Boththerichandthepoorwill
havemorechoiceofhealthservicesunderNHI.
• Inajustworld,thesickestpeoplenottherichestshouldreceivethelargestshareofhealthcare.Thisis
whattheNHIwilltrytoensure.
HoW WiLL tHe nHi WorK?
• TheNHIFundwillprovidefinanceforhealthcare.Itwillcreateasinglepoolofmoneyandprivateandpublic
healthcareproviderswillbothbepaidfromthissamepooloffunding.Privateandpublichealthcare
providerswillreceivepaymentonexactlythesamebasis.
• TheNHIFundwillenterintocontractswithpublicandprivatehospitals,specialistsandprivategeneral
practitioners(GPs)todeliverhealthservicesfreeofchargetoeverySouthAfricancitizenandlegal
resident.ThestatewillpayhealthcareprovidersfromtheNHIFund,andsothepatientwillnotneedtopay
forthehealthcareservicestheyreceive.
• Thesamestandardofcarewillbeexpectedfromprivateandfrompublichealthcareproviders:theNHIwill
ensurethatserviceprovidersareoftherequiredstandard.
• AllNHIpatientswillenterthehealthcaresystematprimaryhealthcarelevel—thatisatcliniclevelorGP
level.Theprimaryhealthcareprofessionalwillthenreferthepatienttoaspecialistorhospitalifneeded.
• Itisimportantthatallpatientsbeproperlyreferredforthesystemtowork.TheNHIwillnotpayforpatients
whohavenotbeenreferredthroughtheproperchannels.
• Thegovernmentwillalsowithinthenextfewyearsupgradehospitalsandotherhealthcaresystemsto
ensurethatthestandardsofthesefacilitiesaregoodenoughtosatisfythestandardexpectedbytheNHI.
Thereisalsomoneybeingputintothetrainingofhealthprofessionals.Thisisimportantbecausewith
goodinfrastructureandwellskilledprofessionals,theNHIwillbesuccessful.
• TheNHIwillimprovepreventivehealthcareandcareintheearlystagesofillness.Itwilldothisby
introducingfamilyhealthteamsinneighbourhoodswhichwillprovidepreventivehealthservicesand
home-basedcare.Itwillalsoleadtotheexpansionofprimaryhealthcareservices(publicclinicsandGP
practices)soeveryonewillhavebetteraccesstoahealthserviceproviderstopreventillnessandinthe
earlystagesofillness.
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WHo WiLL PaY for nHi?
TheNHIwillgetmoneyfromthegeneraltaxrevenueandfromspecialcontributionsofindividualswhoearnabove
acertainspecifiedlevelandtheiremployers.Itwillnotbepossibletooptoutofthisresponsibility.
• Alargeamountofthefundingwillcomefromgeneraltaxessoallofuswhopaytaxeswillcontributetothe
NHI.Thiswillnotmeanpayingadditionaltaxontopofwhatwepaynow(unlessyouearnabove
aspecifiedamount).
• Thosewhoearnmorewillcontributemore.Everypersonwhoearnsoveracertainspecifiedamountwillbe
requiredbylawtomakeaspecialmonthlypaymenttotheNHIFund(calledthe“NHIcontribution”).
• EmployersofthosewhoearnabovethespecifiedamountwillassisttheNHIFundbyensuringthattheir
workers’“NHIcontributions”arecollectedandsubmittedinamannersimilartopensionfunds.
• Employerswillalsomatchtheiremployees’contributions.Thismeansthatemployersarealsorequiredto
payamonthlyamounttotheNHI,foreveryworker.
if PeoPLe can afford to BUY PriVate HeaLtHcare, WiLL tHeY HaVe to ParticiPate in nHi?
• ThereisadistinctionbetweenacitizenparticipatingintheNHIasacontributorandacitizen
participatinginNHIasapatient.Ifyouearnaboveacertainincomeyouwillberequiredbylawto
makeacontributiontotheNHIFund.Itwillnotbepossibletooptoutofthisresponsibility.
• However,asapatient,ifyouwishtomakeuseofservicesofahealthcareproviderwhoisnot
accreditedand/orwhochoosesnottocontracttoNHI,youwouldhavetoa)paytheproviderdirectly
orelseb)maintainmedicalschemecover.Youwouldalsostillneedtomakeyourmonthly
contributiontotheNHI.
WHere iS tHe nHi GoinG to Be SitUated?
• TherewillbeanofficehandlingalltheNHIpaymentstohealthcareproviders.Butyoudonotneed
toworryaboutthis.
• WhatisimportanttoknowisthattheNHIwillbeeffectiveinthewholeofSouthAfrica,ruralareas,urban
areas,peri-urbanareas,richareas,andpoorareasinthenext14years.
• BecausetheNHIissuchahugeundertaking,theprocessofcoveringthewholecountrywilltakeabout14
yearsandwillalsobeinsteps.
• ThegovernmentwillfirststarttoimplementtheNHIinsmallareaswhicharecalledpilotsites,toseehow
itwillwork.Atthemomentwedonotknowwhichareasthesewillbeandhowtheyhavebeenselected.
• AtthemomentthegovernmentisputtinginplacelawsthatwillsupporttheNHI.
WHat aBoUt mY cUrrent medicaL aid?
• Somepeoplebelievethattheircurrentmedicalaidisverygoodandworryaboutwhetheritwillcontinue
toexist.ItisimportanttonotethatmedicalschemescancontinuetoexistalongsidetheNHI,butthose
whochoosetocontinuewiththeircurrentmedicalaidwillhavetomakeadoublepayment.Thismeans
theywouldpayboththeNHIcontributionandtheirmedicalschemecontribution.
PHOTO©MatthewWillman|Oxfam
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• Itispossiblethatmedicalschemeswillbegintoprovidenewoptionsfocussinglessonfullcoverandmore
ontoppingupthecareofferedbyNHI.Butthisissomethingthatisstillunderdiscussion.
• Peoplemayalsowishtoknowiftheycancontinuetopayaparticularhealthcareproviderdirectly/
privately.Theanswerisyes:participationintheNHIwillbevoluntaryforhealthcareproviders.Theycan
continuetoservethosepatientswhochoosetopaythemprivately.Insomecaseshealthcareproviders
willbeseeingpatientswhoarepaidforbytheNHI,aswellasseeingotherpatientswhoarepayingfrom
theirownpocketsbychoice,atthesametime.
WHat Kind of SerViceS WiLL tHe nHi offer?
• TheNHIwillclearlydefineapackageofservicesthateverypersonisentitledtoreceive.
• Thepackagewillcoverallthenecessarytypesofhealthcareincludinghospitalcare.
• Youwillnotbetoldthatyourbenefitshaverunout.
• Youwillnotbeaskedtosharethecostoftreatment.
• HealthprofessionalswilltreatyouaccordingtonationalguidelinesthatareapprovedbytheNHI.
• TheNHIwillnotpayforproceduresthatarenotrequiredforhealthreasons(forexampleitwillnot
payforcosmeticprocedures).
• Itisimportanttorememberthattohaveaccesstotheseservices,youhavetofollowtheproperreferral
procedurewehavealreadydiscussedabove(thepatientmustenterthehealthcaresystematprimary
healthcarelevel—thatisatclinicorGPlevel.Theprimaryhealthcareprofessionalwillthenreferthe
patienttoaspecialistorhospitalifneeded).
WHat iS eXPected of mY commUnitY?
Nowwecometotheimportantpart,whatyourcommunitycancontributetotheprocess.
Therearemanywaysinwhichcommunitieshaveparticipatedinthepolicyprocessinthepast.Thebestidea
ofcommunityparticipationisanopenandaccountableprocessthroughwhichindividualsandgroupswithin
selectedcommunitiescanexchangeviewsandinfluencedecisionmaking.
Toreallyinfluencedecisionmakingmeansthatyourcommunitymustparticipatefromthebeginning,bygetting
asmuchknowledgeabouttheprocessofNHIaspossible.
ManydocumentshavebeenwrittenbythegovernmentandotherpeopleontheNHI.Thegovernmenthasput
togetherasmuchusefulinformationaspossibletoallowpeopletogetinformedabouttheNHI.5
Communitiesmustaskquestionsanddemandclarificationforwhattheydonotunderstand,andindividualsin
communitiesmusttakeinitiativestofindoutmoreandseehowtheycanteachothers.
Everybodyhastherighttoaskquestionsandtogetanacceptableanswer.Talkinthecommunityaboutthe
healthcareservicesyouneedandwantandcommunicateyourideas.
5. You can find public education materials on the NHI at http://www.doh.gov.za/docs/publicity/2011/nhi_english.pdf
PrePared BY: oXfam–monaSH UniVerSitY PartnerSHiP ProJect
2013
