The National Health Insurance Scheme (NHIS) – the first implementation phase of which is supposedly set to begin in 2012 – will make scheme membership compulsory for all South Africans.

However it remains to be seen to what extent current policy thinking and target dates will be modified in the release of the eagerly-awaited Government White Paper on the NHIS, now expected around September this year at the earliest, according to healthcare insiders. 

Payment for the NHIS will come from a levy or tax deducted from the salaries of formal sector employees, and by the State for the unemployed.  

Says Neil Kirby, director and Health, Pharmaceutical & Life Sciences Practice Area head at Werksmans Attorneys: "The NHI concept is nothing new in larger, wealthier democracies. The question is whether such a system is a good fit for South Africa."

He points out that the Obama administration in the US and the South African government are currently proceeding down similar paths in terms of proposed healthcare reform. 

"The big difference between the US and SA on this is that the American legislation made it mandatory for all US citizens to purchase private health insurance, whereas in South Africa, there is no such obligation to join a medical scheme."

Within SA, says Kirby, much of what constitutes the NHI scheme is already in place and, "it's just a matter of connecting the dots". The basic concept is that all South Africans, rich and poor, are entitled access to healthcare services. This principle is also enshrined in the South African Bill of Rights.

Over the past decade a raft of often inter-twining legislative amendments touching on all aspects of healthcare access have been made, Kirby adds. Amendments to the 1967 Medical Schemes Act, for example, were aimed at removing risk-rating and providing more equitable entry criteria for medical scheme admission, so increasing the accessibility of private healthcare benefits.

Among other important changes were amendments to pharmacy legislation designed to provide healthcare services in areas under-serviced by pharmaceutical services. In tandem with this was the admission of corporate ownership for pharmacies, to allow larger corporations to enter the pharmaceutical industry.

"In theory," says Kirby, "this would have enabled them to use their economic muscle to provide cheaper pharmacy services through an established network of retail outlets, thus reducing overhead costs and making pharmaceutical products cheaper and more accessible." However, as healthcare analysts have observed, the debate around affordable medicine and the availability and advisability of generic alternatives still rages today. 

Kirby says one of the pillars of the NHIS is the National Health Act of 2003, which will introduce the concept of accreditation of healthcare providers, with healthcare services being available only from specifically accredited providers.

Also introduced was the national health reference price list – a list of prices that was supposed to be used to establish charges for all healthcare services – which in effect, says Kirby, was a definitive list of what healthcare services should cost.  However, this list failed as the legislation underlying it was found wanting by the North Gauteng High Court in Pretoria.

In essence, Kirby suggests, "the NHIS is basically a large medical scheme - to be governed by a board of trustees in the form of an authority to be created by legislation - and making available only a prescribed set of benefits. These will be provided by a prescribed but legally-accredited set of healthcare providers, including doctors and hospitals for a cost negotiated between the State and the healthcare providers."

This formula is already in place, in a micro-cosmism form, in the substance of the Government Employees Medical Scheme (GEMS) which, due to its membership and affiliation to the public service, is "a model of the NHIS," says Kirby. He describes the present NHIS concept as, "the tin man without a promises access, but access to what? 

"Providing universal access is laudable and is a constitutional directive, but we must be certain that we have our eyes fixed on the goal - efficacious and quality healthcare - and not just the promise of it.

"Hopefully the eagerly-awaited Government White Paper on healthcare reform will provide us with some much-needed specifics on planned NHIS implementation," Kirby says.

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