Milestones in the implementation of National Health Insurance
IN AUGUST 2011, government published its Green Paper on National Health Insurance. The paper started a round of detailed consultations and discussions across the country with a wide variety of groups including academia, the private sector, civil society, national and international health experts. This included 150 written submissions and 168 consultative meetings with over 59 000 attendees.
NHI White Paper and legislative process
This has focused on preparing the White Paper on National Health Insurance for public consultation and preparing draft legislation. The Department of Health and the Treasury have been in close consultation on the final policy, including how to take forward the next phase to prepare for NHI implementation.
Hospital reimbursement reform
Regulations have been published on Hospital Revenue Retention, and efforts made to improve the ability of public sector hospitals to receive payments from patients with medical scheme cover. As a result of these efforts, hospitals for the last three financial years have retained R1.6 billion of which R1.3 billion was in the NHI pilots. This is now being taken forward through a process called ‘Diagnosis-related Groupers (DRGs)’ and related Coding Schema. DRGs is an internationally recognised system for classifying hospital cases into one of a set of diagnostic groups for reimbursement purposes and encourages cost containment initiatives. It will also be used to improve quality of care, provide statistics for national monitoring, and provide a management tool for resource allocation and monitoring quality of services, outcomes and value for money. As part of the implementation process, more than 25 000 patient files from eight central hospitals have been analysed to review current weaknesses in case classification and to map out how to proceed with DRG introduction. The department is also currently undertaking Phase 2 implementation of the International Classification of Diseases-version 10 (ICD 10) Coding system, in line with best practice as recommended by WHO.
Establishment of the Office of Health Standards Compliance (OHSC)
The OHSC was established as an independent statutory body in 2013. The board of the OHSC was appointed in January 2014. The office aims to protect and promote the health and safety of users of health services by (i) monitoring and enforcing compliance by health establishments with norms and standards prescribed by the Minister of Health; and (ii) responding to complaints relating to non-compliance. The OHSC will cover both public and private healthcare establishments including hospitals and primary healthcare clinics and extends to emergency medical services, hospices, private medical practices and institutions offering frail care. More than forty inspectors have been trained and appointed and 1 229 public sector facilities have been inspected by the OHSC since 2013. Public health facility audit, quality improvement and certification
The department undertook facility audits of 3 800 public sector facilities and these were completed in 2012 with the results available on the Department of Health website. This helped prioritise efforts and led to facility improvement teams being deployed in all nine provinces with an emphasis on the pilot districts. This coincided with the completion of the national core standards for health facilities. To provide a systematic response to achieving the standards and responding to the results of the OHSC inspections, the Department of Health started work on an “Ideal Clinic” for delivering primary healthcare services. The purpose of this was to ensure that every aspect of strengthening a PHC service was covered including maintaining standards once it achieved accreditation by the OHSC. Priority actions under the initiative focus on infrastructure maintenance decreasing of waiting times, appointment of clinic committees, and training of PHC facility managers. The initiative has also tested an online monitoring and evaluation system. This is being rolled out to all 52 districts.
Appointment of district clinical specialist support teams
Following on the recommendations of a Ministerial Task Team on maternal and child mortality, district clinical specialist teams (DCSTs) were established from the end of 2011. Their composition is envisaged to comprise seven team members with a nursedoctor team in three key disciplines: family medicine (family physician and PHC nurse), obstetrics and gynaecology (obstetrician and/or gynaecologist and advanced midwife), paediatrics (paediatrician and paediatric nurse), and anaesthetics. Their role is principally to support district facilities and health staff to improve the quality of maternal and child health services. However their role is still developing across the country. As of mid-2015 a total of 214 district clinical specialists have been appointed throughout the country, which is 60 percent of the specialists needed. The teams are now present in 45 of 52 districts in the country.
Municipal-ward-based primary healthcare services (PHC) agents
As part of the re-engineering of primary healthcare, PHC agents are providing community-based health services and mobilising communities across the country on disease prevention and health promotion. About 17 316 PHC agents have been trained across the whole country to date, and 2483 PHC teams or ward-based PHC outreach teams (WBPHCOTs), each with six PHC agents, have been established throughout the country. Given that these workers came from many different backgrounds, a process of consolidating their roles and building their skills continues across the country.
Integrated school-based PHC services
Following the launch of the integrated school health programme (ISHP) by the Departments of Education and Health in 2012, efforts have focused on establishing a database of school health nurses including retired nurses. The leadership of school health services is through the availability of school health nurses and retired nurses to ensure learner coverage through health screening, onsite services and health information. This has been used to improve the health of school-going children through screening for barriers to learning and addressing learning challenges with a priority given to quintile 1 and quintile 2 schools, where needs are greatest A total of 444 school nurses have been employed. All schools have been mapped to health districts and subdistrict ISHP teams. The department has deployed 76 school mobiles in all pilot districts to provide general, oral health services, eye health services and referrals to other allied health services such as audiology and speech problems and PHC trucks to identify and treat minor cases on site. The number of learners seen through school mobiles in schools for grades 1, 4, 8 & 10 were 380 929 in 2013 and 497 933 in 2014.
Public hospital infrastructure and equipment
The Health Infrastructure Grant and the Nursing Infrastructure Grant were established in November 2011. These aim to refurbish 122 nursing colleges as well as other public facilities such as adding 102 GP consulting rooms and refurbishing PHC clinics to attract general practitioners (GPs) to the public sector. In addition, FET Colleges have been contracted to repair and maintain clinics in various NHI pilot districts. A total of six flagship programmes are underway focusing on:
- King Edward VIII Academic (KZN)
- Dr George Mukhari Academic (Gauteng)
- Nelson Mandela Academic (E Cape)
- Chris Hani Baragwanath Academic (Gauteng)
- Polokwane Academic (Limpopo)
- Nelspruit Tertiary (Mpumalanga)
Human resources for health (HRH)
The HRH Strategy was finalised and launched in October 2011 and is currently being implemented. The workload indicator for staffing norms (WISN) tool was used to assess staff requirements nationally and to set norms for the country on staffing. Individual health facilities are having their needs assessed, with approximately 2 000 already covered. A national nursing strategy has helped to overcome the previous fragmentation of nurse training and development. A chief nursing officer was appointed in 2014. An audit of the profile and capacity of nurse educators has shown the need for an increased focus on PHC skills and more integrated care. The department is assisting public nursing colleges to offer NQF-aligned nursing qualifications. The annual intake of medical students has increased by a total of 2 931, with local universities increasing their intake by 429 since 2011 and with an increased intake of the Cuban student programme by 3 001 since 2012.
Information management and systems support
The national health information repository and data-warehouse (NHIRD) is one of the key components in the revamping of our health management information system, with a data warehouse and repository that allows for the display of data and information in the form of tables, graphs and thematic health maps demonstrating the current status of the SA population’s health - including social determinants of health - as well as the status of health services and health-related initiatives. At present, the system is divided into three major components, namely the graphical information system (GIS), the webreporter & information visualisation component as well as the data warehouse (containing aggregated and indicator data).
Together these components make up the NHIRD. Web-based access to this data and information is offered to managers at national, provincial and district levels. The NHIRD is established by the National Department of Health and with the health information systems programme (HISP-SA) as technical partners. The NHIRD currently provides upto-date information not only on routine national indicator/data sets (NIDS) data and indicators, but also to provide a unified and integrated repository for data such as the national facility base audit, the annual HIV and syphilis survey, demography and health surveys, child health and HCT campaigns.
It is envisaged that the NHIRD will also offer aggregated financial data from the basic accounting system and municipal financial systems, human resource data from PERSAL and municipal HR systems, and a range of data sets from other government departments (eg StatsSA, Rural Development, Housing, etc), the HSRC, MRC and national/international development partners. The NHIRD in reality is a “data warehouse” integrating data from the various specialist information systems that exist so as to be able to develop composite indicators (eg staffing workloads, HR cost per patient seen, etc and to compare and understand the status of health services from multiple perspectives). Currently 359 provincial technical support officers (PTSOs) have been appointed on contract since May 2013. These include: 128 ICT PTSOs; 109 Human Resources PTSOs; and 122 Financial Management PTSOs.
Build capacity to manage NHI through strengthening of DHS
To ensure capacity in the provinces and districts, provincial project (or facility improvement) managers were appointed in seven provinces. In 2011 and 2012, NHI pilot districts were selected to pilot various health system strengthening initiatives to prepare for the NHI.
NHI conditional grant to support piloting of initial work in 10 districts
The NHI conditional grant was established in February 2012 for health systems strengthening initiatives, for contracting GPs in PHC clinics, and for the central chronic medicine dispensing and distribution programme (CCMDD). The CCMDD target is 500 000 patients, with 200 000 patients currently registered through 421 facilities. GP contracting has been undertaken as an essential step in strengthening PHC and ensuring integrated services through contracting private GPs into our public health facilities at the PHC level.
GPs were slow in signing up for the GP contracting initiative because of concerns that the state of our health facilities will hamper their quality of work. Their concerns are being addressed through the “ideal clinic” initiative, and an increasing number are providing positive feedback on the conditions in many clinics. At the end of March 2014, the department had 119 GPs working to complement permanent staff in public health facilities. This number has since increased to 256 at the end of March 2015. Population registration
The department, in partnership with the Department of Science and Technology and the CSIR developed the health patient registration system (HPRS) using the South African identification number as the unique identifier. The number of patients registered in the first four months of piloting was 345 870. A total of 200 000 patients have also been registered on the CCMDD. To allow these and other innovations to take place, the department has also installed hardware in 700 facilities (3 370 computers) rolling out to a further 1 400 facilities involving 8 137 computers in PHC facilities.
Information communication and technology
The department has developed norms and standards for ICT. To standardise the systems, the department, working with the CSIR, has tested all systems at PHC facilities and found 22 out of 37 being compliant with required norms and standards. Within the pilot districts, out of 700 facilities the total quantity of ICT hardware installed for administration functions is 1 642, with an additional 1 642 for consulting rooms. An assessment of hospital ICT systems is now underway.
Department of Health Media Statement, 30 November 2015