What NHI might look like for the average South African

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The NHI Bill will drive a major strengthening of community-based, primary healthcare and reduces that unnecessary hospital-based care that currently wastes so many resources in both the private and public sectors.

The principles of a PHC system built on the joint, integrated work of community clinics, general practitioners (GP) and local hospitals will lead to patients in the system getting treated at the right level of care, relative to their illness.

A routine part of good PHC practice today uses electronic health records to guide health checks, plan care and collect data that is used to understand all members of their local population. This information can be used to illustrate each patient’s relative ‘case mix’ i.e. how sick are they, which leads to good planning for their care.

Combined for everyone together, we get a measure of the case mix of the whole population. This information helps us understand if the overall costs and outcomes are as we would expect - if the PHC team is doing a fantastic job, or if there has been a lack of needed care and wasted resources.

The likely structure of the NHI for the average medically insured person:

• You will get an NHI card with a unique member number, from the NHI funds central beneficiary database. Using this, you will be able to access a list of accredited providers who have met the required standards to get a contract as an NHI healthcare provider in your area. Getting services from these providers is free, as the NHI fund fully pays them for you.
• All registered NHI members must enroll with their local PHC provider of choice. This gives full access to the doctor-led team and their facilities, as well as a range of allied health care professionals and services such as for social welfare and mental health services.
• Your PHC provider is also the way you access medication, laboratory tests, and some clinic procedures, as well as a range of preventative services such as family planning and immunisations.
• One of the key jobs of your PHC provider is to help you to navigate the rest of the healthcare system when your illness needs additional help, to make sure you get continuous care. This includes the need for a referral to hospital, including the preparation before and the ongoing care afterwards.

This model can effectively deliver high volumes of good quality care at an affordable cost. The NHI system will reduce the over servicing of the population that currently characterises our private sector, through strong management by a multidisciplinary care team. Using an integrated and community-orientated approach to their shared patients, these teams will be able to manage problems in the community and focus on good health promotion.

The purchasing of care by the NHI is done by District Management Offices (DMO) that contract with both local hospitals and ‘contracting units for PHC’ – so called CUPs – which coordinate the PHC cover for sub-districts by local providers. The DMOs and the CUPs are familiar with the needs of their population, in charge of reviewing and purchasing doctors’ and hospital services.

These offices will contract with accredited publicly owned clinics, private GPs, non-government organisations and academic institutions, who will act as primary healthcare units for members of the fund. The combined service for patients is now delivered by a grouping of providers who agree to work together in a seamless system.The funding contract reflects their relative case mix and the outcomes they produce for the patient population.