How the quality of healthcare to be accessed through the government's proposed National Health Insurance Scheme (NHIS) is measured and defined – and the extent to which this meets the government's constitutional obligations on healthcare provision – could be key to the roll-out and success of such a system in South Africa.

The government last month (August, 2011) released a Green Paper on the NHIS – updating its stance on certain of the scheme's key principles. This brings the introduction of the NHIS, to be phased in over a 14-year period, a step nearer reality.  

Neil Kirby, director at Werksmans Attorneys and head of the firm's Health, Pharmaceuticals and Life Sciences Practice, points out that much of the emphasis in the discourse on a NHIS centres on the need to provide accessible healthcare for all (a constitutional right, along with access to emergency medical services.)

"But the issue of quality healthcare is much more difficult to define and achieve."

He notes that quality healthcare is defined by individuals based on the outcome of the healthcare service that they receive: a good outcome is normally equated with good quality care and a bad outcome is equated with bad quality care. 

"This makes defining a generally-accepted normative quality of care difficult, if not impossible, and renders it controversial within the current debate on access to healthcare – at least in the NHIS paradigm in which we currently find ourselves," says Kirby.  

Kirby believes that crucial factors in making quality healthcare practical, workable and just in its implementation could be the obligations laid down in the South African Constitution, including the Bill of Rights.  

Says Kirby: "These obligations effectively represent a social contract between the citizens of South Africa as a whole with their government.  Accordingly, the Bill of Rights may be the best place to start in relation to what quality of healthcare should be in our NHIS."   

He submits that measuring quality of care in relation to health outcomes is only one way of assessing whether or not the level of healthcare in an NHIS would meet the State's obligations. 

"A more effective means may be to judge whether the NHIS, when it is finally implemented, treats the users of the scheme in such a manner that their other rights contained within the Bill of Rights are respected in a democracy built on equality, freedom and dignity." 

Such rights may include: the right to dignity; the right to life; the right to equality; the right to proper and procedurally fair administrative justice; and the right to information. These rights may collectively spell out what it is that quality care consists of within the NHIS, once it is established, Kirby suggests.    

"Certainly, pronouncements by our courts already indicate that a great deal of respect is to be accorded to individuals when making decisions concerning their healthcare." This is fundamentally a matter of self determination or choice in the pursuit of an individual's healthcare priorities, says Kirby, including choices to smoke, to abuse substances, to exercise, drive recklessly or engage in potentially dangerous sports, among others.  

He says it is unlikely that the collective impact of these rights has ever been assessed in trying to determine whether 'quality care' would be available to individuals through an NHIS, "but they are a powerful platform on which to champion quality care." 

"Quality is especially important when one considers the social ends that a co-ordinated healthcare system such as an NHIS must be designed to achieve in the context of a South African democracy – one that is premised upon the Constitution and the Bill of Rights." 

Kirby advises that the debate concerning quality of care and its role in an NHIS should be concluded before the scheme is implemented. "The role of quality in the ultimate deployment of an NHIS in South Africa cannot be underestimated and it carries constitutional weight."

"Certainly, South Africa may learn from the experience of other countries that have dealt with, or are dealing with, the implementation of a NHIS.  Quality of care issues have arisen in such jurisdictions, but after the implementation of such systems." 

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