NHI Bill being pushed for elections?

November 27, 2018

The Presidency and Health Minister Aaron Motsoaledi seem intent on pushing the National Health Insurance (NHI) Bill through Parliament before next year’s election despite major unanswered questions.

The revised NHI Bill was presented to Cabinet’s social cluster sub-committee on 27 November 2018  before going to Cabinet, according to the health department.

However, the department failed to answer a number of other questions including why it was pushing the Bill through the legislative pipeline so fast – when even Health Director-General Precious Matsoso admitted last week that she had not seen the latest draft.

Civil society organisations have called on Cabinet to “send the NHI Bill back to the Department of Health and to require a proper and thorough consultation process and consideration of options available for improvement of access to and quality of health care services in the country”.

Professor Olive Shisana, the NHI advisor in the Presidency, is driving the NHI process and has allegedly changed a number of clauses, according to insiders.

The Bill has not been discussed in the National Health Council established by the National Health Act to advise the Minister of Health on policy and on proposed health legislation.

Acting Director General Ismail Momoniat wrote a letter to Shisana last week saying that Treasury could not support the latest version of the Bill as it had been “very substantively amended in October”, removing various agreements reached between the Ministers of Finance and Health.

Treasury was particularly concerned about amendments to the powers of provinces to deliver healthcare, inadequate costing of functions and the relegation of medical schemes to a complementary role which was “premature” and opened the Bill to legal challenges.

However, after the letter was leaked to the media, Treasury issued a statement describing it as “part of the vibrant and ongoing engagement to ensure policy coherence”.

“We have made substantial progress on key areas and have reached agreement on most of the major issues,” added Treasury. “Many of the issues raised by Treasury have been substantively addressed. We are confident that we will soon publish this important Bill for tabling in Parliament.”

But Treasury stressed that “the NHI must be adequately funded and successfully implemented while reducing the risks involved in the implementation of such a large and complex programme”.

Civil society organisations claim that the draft Bill was prepared even before a Presidential Summit that was supposedly called to consult various parties about the NHI.

“Public comments on the NHI over the past decade do not appear to have been taken into account, either between the Green and White Papers and the Bill or after the draft Bill was published for public comment,” according to a statement from Treatment Action Campaign (TAC), SECTION27, Rural Health Advocacy Project (RHAP), People’s Health Movement (PHM) and Lawyers for Human Rights (LHR).

“This makes a mockery of public consultation as required by the Constitution and opens the Bill up to future attack and delay on these grounds.”

The organisations also argue that the current Bill “risks damage to the functional elements of the health system – public and private” and that “government needs to focus on fixing the crises in private and public health rather than on hastily passing legislation that, in its current state, takes the country in the wrong direction”.

While the health department failed to respond to the civil society statement, last week Treasury said that “the implementation of the NHI and improvements in the quality of the health system go hand in hand and are therefore being addressed concurrently.” – Health-e News

Systemic reform necessary to cure SA health system

Friday, October 19, 2018

Deputy President David Mabuza says nothing short of a systemic overhaul is required to pull the country’s ailing health system out of the status quo.

“We all agree that our health system is in crisis and needs urgent attention,” Mabuza said on Friday at the inaugural Presidential Health Summit.

Delegates ranging from government officials, academics, labour to social activists are gathering in Ekurhuleni, Gauteng, over the next two days to thrash out pressing matters beleaguering the country’s strained health system.

Where does it hurt?

Before any steps can be taken, Deputy President Mabuza said, the country must collectively get to the root cause of the crisis.

“According to the World Health Organisation (WHO), one of the six building blocks of a healthy and resilient healthcare system is the health workforce or human resources for health.

“Over the past few months, there has been a serious outcry from all corners of our country about the shortages of the workforce in the public sector. Whereas the President has agreed to inject a certain number of the health workforce as part of his stimulus package, this is just but a temporary measure for immediate relief,” he said.

As part of the stimulus package, President Ramaphosa announced in September that Minister of Health and the National Health Council would immediately fill 2 200 critical medical posts, including nurses and interns. Funding would also be made available immediately to buy beds and linen.

On Friday, Mabuza said the summit had to come up with lasting solutions.

“The gross inequalities that have developed in the provision of human resources between the public and the private health sectors need to be faced head-on and resolved speedily,” he said.

The Deputy President said the country needed to urgently produce a national human resource operational plan that each level of health care can use in planning service provision.

The second major cause of problems in the provision of good quality healthcare, Mabuza said, is poor procurement or supply chain management systems that make it impossible to have adequate pharmaceuticals and other vital health commodities.

Although the country has essential medical equipment and medicine lists, which were accompanied by the delivery of chronic medicines distribution programme, challenges emanating from inadequate maintenance of equipment and stock-outs of medicines are still experienced.

“To ensure quality, safe and relevant technologies, we need to involve the end-users, primarily the health workers, in the procurement of equipment to ensure they can be used effectively and efficiently,” Mabuza said.

The Deputy President said the State needs to work with civil society groups to monitor the availability of medicines and other commodities in the healthcare system.

“The public needs to keep us on our toes to ensure that the population gets what is due to them.”

Health services provision is another area that requires urgent attention, Mabuza said, as this would ensure that every South African has access to care that is affordable.

“It must also be comprehensive and include preventive, curative, palliative, rehabilitative and health promotion services. At the moment, the primary health care component of our healthcare system is very weak and is found wanting.

“Our healthcare system is by and large curative, hospicentric and unable to provide comprehensive healthcare.”

Mabuza conceded that public facilities were congested, inappropriately staffed and plagued by long queues of patients, among them too many repeat visits.

NHI

With regards to the National Health Insurance (NHI) scheme, which is set to be phased in from 2019, the Deputy President said health facilities had to meet the set standards in order to be accredited.

Government is in the process of establishing learning centres to implement these standards.

“At facility level, we need to ensure that agreed quality standards are met in the provision of health care services. This must be supported by the recruitment and deployment of appropriately skilled personnel to ensure quality service delivery,” he said.

There is an urgent need to prioritise the development of new infrastructure in previously underserviced areas, and ensure that existing infrastructure is properly maintained to meet the required standards.

“The drastic shortage of appropriate infrastructure means that people with a mental health condition are often hospitalised in non-mental patient wards, and male and female patients are hospitalised in the same ward,” Mabuza lamented.

Funding and meeting infrastructure needs

In response to these challenges, the Deputy President said government must develop a consistent 10-year infrastructure plan, using identified and ring-fenced infrastructure resources that might benefit from the President Cyril Ramaphosa’s R400 billion infrastructure stimulus package.

“Our response to the health sector challenges will be incomplete if this summit does not provide targeted solutions to inadequate health systems financing and management,” he said.

The Deputy President said the financing of South Africa’s healthcare was inequitable across the board.

The private sector, he said, uses a higher proportion of the GDP but only serves only 16% of the population, when the public sector uses a lower proportion of the GDP, while it services 84% of South Africans.

“These inequities need to be identified and corrected in budget allocations.”

In an effort to address some of the challenges, the Office of the President will be re-costing health system funding “to provide more realistic figures on the cost of this health system and estimate a better model of allocation depending on the burden of disease per district”.

“The challenges in healthcare are also found in the private sector, although they vary in nature,” said Mabuza.

The private sector provision costs are unacceptably high and affordable only to a few, as proved by the Health Market Inquiry headed by former Chief Justice Sandile Ngcobo.

Mabuza bemoaned how most medical schemes were unsustainable, as they had high premiums that often increase faster than inflation.

“Medical scheme benefits are often exhausted before year-end, which forces patients to have no cover and many end up using the public health sector.”

He said challenges in both the public and private health sectors require a new approach to serve all South Africans.

“We need a publicly financed health system where services are provided by both the public and private facilities delivered according to improved standards of care. An integrated unitary health system under NHI does not negate the existence of medical schemes for those who desire additional care that complements services provided under NHI.”

He urged both the public and private arms of the sector to address the challenges in commissions over the next two days.

“We must work on a system based on solidarity to give all of our people the best that we can offer as a nation. It is within our power to make quality health care accessible to all.

“As we enhance collaboration in our entire health system, we need to build coordinated, integrated and shared health information systems.”

Checka Impilo

Mabuza used the summit to launch Checka Impilo, a national wellness campaign that focuses on testing and treating people who have HIV, TB, sexually transmitted infections and non-communicable diseases (NCDs) such as diabetes and hypertension.

The campaign will focus on the provision of comprehensive health and wellness services targeted at men, adolescent girls and young women, as well as key and vulnerable population groups.

The success of the campaign, Mabuza said, depends on coordinated collaboration among all social partners in respect to planning, implementation and monitoring.

Checka Impilo is a call to action for South Africans to move from a curative response to health to preventative approaches and the adoption of healthy lifestyles.

The campaign will focus on increased information, education and communication activities, promotion of HIV testing, widespread distribution of condoms, and provision of pre- and post-exposure prophylaxis against HIV.

“All of us must, therefore, go out in great numbers to test for HIV and screen for STIs, TB and NCDs such as diabetes and hypertension.

“Within 24 months of this campaign, we must have found and put two million more people on ARVs. We must also have found and put at least 80 000 more people with TB on anti-TB treatment. We must also have identified thousands more with diabetes, high blood pressure and cancer, and put them on treatment,” Mabuza said. – SAnews.gov.za

Health Summit and other mixed messaging

This is billed as being about the Checka Impilo or National Wellness Campaign … but some how it got to be more about a failing health system. Take a look.

 Checka Impilo

Source SAnews.gov.za

Deputy President Mabuza used the Health Summit to launch Checka Impilo, a national wellness campaign that focuses on testing and treating people who have HIV, TB, sexually transmitted infections and non-communicable diseases such as diabetes and hypertension.

The campaign will focus on the provision of comprehensive health and wellness services targeted at men, adolescent girls and young women, as well as key and vulnerable population groups.

The success of the campaign, Mabuza said, depends on coordinated collaboration among all social partners in respect to planning, implementation and monitoring.

Checka Impilo is a call to action for South Africans to move from a curative response to health to preventative approaches and the adoption of healthy lifestyles.

The campaign will focus on increased information, education and communication activities, promotion of HIV testing, widespread distribution of condoms, and provision of pre- and post-exposure prophylaxis against HIV.

“All of us must, therefore, go out in great numbers to test for HIV and screen for STIs, TB and non-communicable diseases such as diabetes and hypertension.

“Within 24 months of this campaign, we must have found and put two million more people on ARVs. We must also have found and put at least 80 000 more people with TB on anti-TB treatment. We must also have identified thousands more with diabetes, high blood pressure and cancer, and put them on treatment,” Mabuza said.

1st-ever WHO list of essential diagnostic tests

Summary: 1st WHO essential diagnostic list focusing on mainly communicable diseases with a recommendation to include more NCDs in a future edition. PHC and facility level essential package.   Vicki Pinkney-Atkinson

Improving NCDs diagnosis & treatment outcomes

Today, many people are unable to get tested for diseases because they cannot access diagnostic services. Many are incorrectly diagnosed. As a result, they do not receive the treatment they need and, in some cases, may actually receive the wrong treatment.

For example, an estimated 46% of adults with Type 2 diabetes worldwide are undiagnosed, risking serious health complications and higher health costs. Late diagnosis of infectious diseases such as HIV and TB increases the risk of spread and makes them more difficult to treat.

Essential Diagnostics  List (EDL)

To address this gap, WHO today published its first Essential Diagnostics List (EDL), a catalogue of the tests needed to diagnose the most common conditions as well as a number of global priority diseases.

“An accurate diagnosis is the first step to getting effective treatment ….No one should suffer or die because of a lack of diagnostic services, or because the right tests were not available.”
Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

The list concentrates on in vitro tests – i.e. tests of human specimens like blood and urine. It contains 113 products: 58 tests are listed for detection and diagnosis of a wide range of common conditions, providing an essential package that can form the basis for screening and management of patients. The remaining 55 tests are designed for the detection, diagnosis and monitoring of “priority” diseases such as HIV, TB, malaria, hepatitis B and C, human papillomavirus and syphilis.

Some of the tests are particularly suitable for PHC facilities, where laboratory services are often poorly resourced and sometimes non-existent; for example, tests that can rapidly diagnose a child for acute malaria or glucometers to test diabetes. These tests do not require electricity or trained personnel. Other tests are more sophisticated and therefore intended for larger medical facilities.

“Our aim is to provide a tool that can be useful to all countries, to test and treat better, but also to use health funds more efficiently by concentrating on the truly essential tests,” says Mariângela Simão, WHO Assistant Director-General for Access to Medicines, Vaccines and Pharmaceuticals. “Our other goal is to signal to countries and developers that the tests in the list must be of good quality, safe and affordable.”

For each category of test, the EDL specifies the type of test and intended use, format, and if appropriate for primary health care or for health facilities with laboratories. The list also provides links to WHO Guidelines or publications and, when available, to prequalified products.

Similar to the WHO Essential Medicines List, which has been in use for four decades, the EDL is intended to serve as a reference for countries to update or develop their own list of essential diagnostics. In order to truly benefit patients, national governments will need to ensure appropriate and quality-assured supplies, training of healthcare workers and safe use. To that end, WHO will provide support to countries as they adapt the list to the local context.

The EDL was developed following an extensive consultation within WHO and externally. The draft list was then considered for review by WHO’s Strategic Advisory Group of Experts on In-Vitro Diagnostics – a group of 19 experts with global representation. For more information see WHO website.

WHO will update the Essential Diagnostics List on a regular basis. In the coming months, WHO will issue a call for applications to add categories to the next edition. The list will expand significantly over the next few years, as it incorporates other important areas including antimicrobial resistance, emerging pathogens, neglected tropical diseases and additional NCDs.

6 EnoughNCDs campaign priorities with South African spin

This post puts the UN High-level Meeting for NCDs priorities in a South African context. It does not dilute the global call but pegs the South Africa response.

1  Put people first

People living with, at risk of and affected by NCDs (PLWNCDs), young people, and civil society must be at the heart of the NCDs response.

For over 20 years the South African policy of Batho Pele  or “people first.” The Life Esidimeni  mental health tragedy it is clear that much more needs to be done to include us.  No more talk. #EnoughNCDs. 

Empowering and involving PLWNCDs and young people has been neglected. The knowledge held by PLWNCDs is undervalued in NCDs programme development, implementation and policy-making. They are under-represented as leaders and in organisations they are largely silent in decision-making processes. Let’s correct this state of affairs to realise the rights and responsibilities of PLWNCDs , which require supportive political, legal, and social environments that give all people the opportunity to speak up, especially those most vulnerable and disenfranchised. Let’s start with the South Africa National Health Commission as a key NHI platform for multisectoral stakeholder engagement and policy coherence.

A close connection with communities, civil society organisations (CSOs) provide people affected by NCDs with an essential voice in decision-making processes. CSOs raise public demand and engage with and apply concerted pressure on governments to ensure that resources and services reach and benefit affected communities, as well as hold governments and other sectors to account. Investing in civil society must be recognised as part of the global public good agenda.

2 Boost NCD investment

Scaling up investment for NCDs is a critical priority to achieve the 2025 NCD targets & the SDGs.

Sustainable and adequate resources for NCDs are severely lacking and remain a bottleneck in the response. NCDs receive just 1.3% of development assistance for health, making NCDs the only major global health priority without international financing. Closing the resource gap will require multiple financing sources, depending on the country-specific context. The expected result will be a blended stream of financing, including creating and optimising fiscal space for NCD investment domestically, exploring innovating financing mechanisms (such as taxation of unhealthy commodities), multilateral/bilateral funding, private sector engagement, and catalytic mechanisms, in line with the recommendations from the Third International Conference on Financing for Development in 2015. While domestic resource mobilisation is critical, for low-income countries allocating less than 5% of the gross domestic product to health, progress on NCDs will be impossible without catalytic funding from donors.
At a NDoH level the

3  Step up action against all forms of childhood malnutrition including obesity 

Childhood obesity is an issue with a clear health and economic imperative for action. 

In Africa this priority has to be balanced and weighed against the SDG goal 2 to end hunger and food insecurity and nutrition. 

Global political targets exist to ensure a ‘zero increase in overweight in under 5s’ and a ‘zero increase in obesity and diabetes’, and a WHO Implementation Plan to End Childhood Obesity to guide the response, centering around a set of population-based interventions. With insufficient progress to date and driven by unsustainable, unhealthy food systems and environments, childhood obesity is a major challenge that extends well beyond the health sector and demands political attention at the highest political level.

 

4 Adopt smart fiscal policies that promote health

 South Africa has implemented tobacco, alcohol and sugar sweetened beverage taxes. 

The tax on sugar sweetened beverages, the Health Promotion Levy (HPL) came into effect on less than a month ago and took 2 years of negotiations and activism. The tax is instituted with compromise 2,1 c per gram of sugar per 100 ml of the drink. A portion of the HPL is to be used for health promotion and treatment, hence the name.

In the 2018/19 financial year, Treasury has allocated R100 million to the National Department of Health from the HPL. Dr Yogan Pillay (Deputy Director General NDoH Programmes) confirmed, in a meeting this month, that R93 million is to be allocated for human resources to treat people living with cancer. The remaining R7 million is set to be used for a health promotion campaign for cancer prevention.

Alcohol and tobacco taxes taxes go into the broader fiscus with no directed health allocation.  In the health budget on Furthermore, the money needs to be spent in the right places tackling the largest burden NCDs facing the country.In South Africa, we have adopted 3 major healthy lifestyle taxes to curb NCD risk factors and utilise the money collected to benefit the broader population.  

5  Save lives through equitable access to NCD treatment & NHI

Access to prevention and treatment is a fundamental human right so that we can achieve the highest possible standard of physical and mental health and well-being.

Section 27 of the South African constitution entrenches the right to health and care. a number of law cases have upheld this view. The NHI programme for universal health coverage and access (UHC+A) is in Phase 2 of its roll out.  NCDs prevention and treatment needs firm embedding. 

Availability and access to lifesaving treatment, care and support for PLWNCDs is still out of reach for millions of African people almost all of whom live low- and middle-income countries LMICs).

This is despite global targets for 2025 to ensure 80% availability of essential medicines and technologies for NCDs. In South Africa for example, there is no state procurement of diabetes blood testing equipment and strips. Sadly the leading the leading cause of death in women and the group combination of diabetes, heart and vascular disease the number 1 killer over.

Access challenges relate to weak health systems in many LMICs, including the lack of adequate preparation and training of the health workforce, insufficient financial resources, poor procurement policies and weak supply chains, inefficient information systems, and lack of patient education and low health literacy.

Reducing the burden of NCDs is essential to achieve SDG UHC+A (Target 3.8)  and the SDGs,  goals focus on ending poverty in all forms everywhere and reducing inequalities within and among countries. Integration of NCD prevention and treatment the NHI programme and a strong focus on equity is fundamental to strengthen health systems to deliver for NCDs throughout the life-course and protect against financial hardship.

 6  Improve accountability for progress, results & resources

Accountability is a crucial force for political and programmatic change.

Accountability is cyclical process of monitoring, review and action, accountability enables the tracking of commitments, resources, and results and provides information on what works and why, what needs improving, and that requires increased attention.

Accountability ensures that decision-makers have the information required to 

meet the health needs and realise the rights of all people at risk of or living with NCDs. Multiple sets of commitments and targets for NCDs exist at the global level, as set out in the WHO Global NCD Action Plan and Monitoring Framework on NCDs, the 2014 UN Review Outcome Document, and the SDGs. Existing WHO and UN accountability mechanisms for NCDs can be complemented by independent accountability mechanisms, and at the national level, there is a need to strengthen accountability mechanisms, national targets, and improve data collection and surveillance systems.

The SA NDoH 2013-2017 NCDs strategic plan expired over a year ago and requires multisectoral evaluation. The South African NCDs Alliance conducted a review of progress NCDs policy implementation. Since then key indicators for diabetes, high blood pressure and mental health still require operationaliation with a standard operating procedure. PLWNCDs need to be part of the multisectoral evaluation team.  Provincial NCDs budgets and guidelines for expenditure should be transparent.