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These are the six lessons the NHI pilot projects have taught us

Team leaders, funding, planning and budgeting are how the health department can improve on its National Health Insurance (NHI) pilot projects.  On Friday, the NHI bill was handed over to parliament to be debated among lawmakers, as announced in the Government Gazette.  The evaluation report based on a year of research on NHI pilots projects and led by Genesis Analytics consultancy had the following suggestions:

1. The ward-based outreach teams that go out into areas to find and refer sick people to clinics need “regular and appropriate supervision”. One comment from a staff member of the national department of health said the team leaders needed to be “competent” and have “confidence”: “They [ward-based primary health care team leaders] cannot be just school leavers.” The other suggestion was that transport and equipment for teams needed to be planned and adequately budgeted for.

2. The suggestion was that before expanding the school health programme, there needed to be a system to ensure children got transport to get the treatment they needed or it should be provided at schools by a mobile clinic.  Former health minister Aaron Motsoaledi in his budget vote in 2011 had promised the NHI school health programme would provide treatment.  “This stream of primary health care will deal with basic health issues like eyecare problems, dental problems, hearing problems, as well as immunisation programmes in our schools,” he said. But there was no measure of how many children who needed glasses, hearing aids or dental appointments got the help.

3. The report suggested that school health teams should provide sexual and reproductive health services at high schools rather than the same screening they had offered at primary schools.  Eight years ago, that was what Motsoaledi had promised the school health teams would address. “It ... will include issues such as teenage pregnancy ... contraception, as well as HIV and Aids programmes ... drugs and alcohol.”

4. GPs’ salaries should be benchmarked and standardised to reduce costs. The high cost of hiring GPs to work at nurse-run clinics made it one of the most expensive NHI programmes.  This, however, contradicts claims that NHI was supposed to save money. Motsoaledi had said: “We will introduce price regulation ... ” As GPs were not paid for out of the normal department of the health budget, the report suggested some doctors inflated their charges for travel to clinics. In some cases, full-time doctors at state clinics quit in order to work as part-time GPs so they could earn more money doing the same job.  The report also recommended better supervision to prevent fraudulent GP claims.

5. The pilot projects suggested a complete review of the district health intervention, where a team of specialists oversaw an area, suggesting it was very costly, not effective and needed to be adapted. In 2011, Motsoaledi said teams of specialists would work in NHI districts to reduce “maternal and child mortality”.  “These teams will consist of an obstetrician, paediatrician, family physician, an advanced midwife and a senior primary care nurse ... “They will follow up on every case of [baby and mother] mortality to ... deal with the cause at hospital level immediately.” In fact what happened was, state staff, working as specialists in the district handed over their leadership and quality control tasks to the district teams, but many of those were short-staffed.  “The unintended outcome was that clinicians, who are understood to have the ability to implement clinical governance, stepped back from this because it was now thought to be designated to the teams,” the former health minister said.

6. The “most successful” programme was the chronic medicine dispensing scheme, with more than two million patients picking up monthly drugs at 855 pickup points and avoiding long queues at clinics and reducing congestion. “This is an important programme with potential as long as costs can be managed.”