OPINION PIECE

 

Unpacking the NHI Bill recently passed by parliament in May 2023: Implications for oral health

 

 

Y Malele-Kolisa

Head: Department of Community Dentistry, University of the Witwatersrand, Johannesburg, South Africa24358 ORCID: 0000-0003-3368-9193

Correspondence

 

 

"The Portfolio Committee on Health, having considered the subject of the National Health Insurance Bill [B11-2019] (National Assembly - sec 76)], referred to it and classified by the Joint Tagging Mechanism as a section 76 Bill, reports the Bill with amendments [B11B-2019]. " (pg.91).

The journey to enacting a policy is a lengthy but worthy process. It was first the green paper in 2012, then the white paper NHI discussions in 2015, then NHI policy in 2017 and incorporated universal health coverage concepts. From 2019 it was passed into an NHI Bill, went for public comment and was debated at length, with, understandably, many concerns. The Bill must be approved by parliament -by both the national assembly (NA) and the nation council of provinces (NCOP) - before being sent to the president to sign into law - NHI Act of 2023 [or 2024]. The Covid-19 pandemic delayed the process but also brought concerns from the already sceptical public about the intended reform.

Throughout the process, stakeholder engagement was paramount as it changed the form and structure of the intended reform. Even after the Bill is passed, stakeholder engagement is still paramount in shaping the final enactment and the implementation processes.

The process is on track as, according to the white paper, it was going to be phased in over a period of 14 years from 2012 to 2026. Now the details are important - the real work in operationalising the activities from now to 2026 must be clear. The reasons behind the reform are not in dispute. The discourse and discordance are around the nuts and bolts for full implementation processes by both proponents and adversaries. The governance is a source concern where the minister will appoint a board and the board will run this, as is customary of all state-owned entities (SOEs). Slight changes have been made to the proposed Act where the minister will no longer appoint the board on his or her own but must do so in or after consultation with the cabinet and with the cabinet's approval.

Another great concern for the working public is possible funding. The current response to funding is the Finance Minister and the Treasury have at their disposal various mechanisms to raise taxes. These are:

• Raise taxes, most notably personal tax

• Company tax

• Payroll tax expense appropriate at the time

Currently the equitable share from Treasury is allocated to provinces to fund health care and this filters down to hospital and districts. Now, with the proposed Act, the equitable share will go to the NHI Fund to accredited hospitals in all categories (provincial, regional, district public or private), as well as the district health management office, then to the contracting units for primary health care (CUPs). The provincial governments as they are currently will become agents.

• NHI Fund will buy and pay for services [including oral health care] based on own pricing and reimbursement through the CUPs in districts and provinces.

• The CUPs will purchase and pay for health from all forms of clinics, ward-based outreach teams, contracted general practitioners, community health centres and district hospitals.

• The Fund will also buy and pay for services from accredited private hospitals, regional hospitals, district hospitals, specialised hospitals and emergency services.

The proposed Act needs to be clear on:

• The role of the provinces.

• The role and functioning of the CUPs in relation to the functions of the board.

Oral health should be part of the panel of multidisciplinary experts in:

• Benefits Advisory Committee (BAC) - formulary, benefits package, complementary list

• Budget

• Health Care Benefits Pricing Committee - pricing health care

• Stakeholder advisory committee

• Office of Health Standards ComplianceOffice of Health Products Procurement

• District Health Management Offices (DHMO)Contracting Units for Primary Health Care (CUPs)

• Oversee transition until legislation enactment

The oral health care implementation plans now supported by legislation should be specific on the role of dental practitioners in the public and private sectors. The accreditation, licencing, contracting guidelines and plans should be finalised for private dental practitioners and entities. For the public sector practitioners, it will be business as usual from the practitioner point of view; however, management should oversee accreditation of institutions to be CUP registered. Researchers, opinion makers and many stakeholders often cite the impending NHI's universal health coverage as impetus for research, human resource for health realignment and programme initiation. The opponents warn of the huge task ahead. Indeed, in my opinion, the initial four important facets of NHI still needs to occur. The total overhaul of the facilities cannot be downplayed and the reengineered PHC are necessary to provide the nest for the UHC/NHI to germinate, cocoon and blossom. Radical change in management and the transformation of service delivery are imperative.

The gap, I believe, is the "mandatoriness" of the membership. It is not clear how this will be enforced. This should be a relief for those not in favour as it will be business as usual for them if they don't enlist.

The medical aid system will still be important but will be "changed" to top-up schemes which will cover whatever is not covered by the NHI. Thiswillbethe bulkof services which are excluded in the basic package of oral health service. Currently, the basic PHC package may include emergency consultations, extractions, basic restorations, preventive services and basic acrylic dentures. Communities, should they wish, will continue to insure themselves for complementary services not provided by the NHI Fund outside the basic PHC package.

The reform has the potential to alleviate the problems as initially underscored. There are lessons to be considered from other settings and these can't be ignored lest they end up being just stories instead of lessons.

This article is the opinion of the author, Prof Y Malele-Kolisa, Head of Clinical Department of Community Dentistry at the Wits Oral Health Centre/School of Oral Health Sciences

 

REFERENCE

1. Report of the Portfolio Committee on Health on the National Health Insurance Bill [B11 - 2019] (National Assembly - sec 76)], dated 26 May 2023 https://www.parliament.gov.za/storage/app/media/Bills/2019/B11_2019_National_Health_Insurance_Bill/ATC-73-2023-05-26-ENG.pdf        [ Links ]

 

 

Correspondence:
Prof Y Malele-Kolisa
Email: yolanda.kolisa@wits.ac.za

 

 

Author's contribution
Concept, design, intellectual content, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing and review