The views of public service managers on the implementation of National Health Insurance in primary care: a case of Johannesburg Health District, Gauteng Province, Republic of South Africa

Abstract

Background The South African government is implementing National Health Insurance (NHI) as a monopsony health care financing mechanism to drive the country towards Universal Health Coverage (UHC). Strategic purchasing, with separation of funder, purchaser and provider, underpins this initiative. The NHI plans Contracting Units for Primary healthcare (PHC) Services (CUPS) to function as either independent sub-district purchasers or public providers and District Health Management Offices (DHMOs) to support and monitor these CUPS. This decentralised operational unit of PHC, the heartbeat of NHI, is critical to the success of NHI. The views of district-level managers, who are responsible for these units, are fundamental to this NHI implementation. This qualitative study aimed to explore district and sub-district managerial views on NHI and their role in its implementation. Methods Purposive sampling was used to identify key respondents from a major urban district in Gauteng, South Africa, for participation in in-depth interviews. This study used framework analysis methodology within MaxQDA software. Results Three main themes were identified: managerial engagement in NHI policy development (with two sub-themes), managerial views on NHI (with three sub-themes) and perceptions of current NHI implementation (with six sub-themes). The managers viewed NHI as a social and moral imperative but lacked clarity and insight into the NHI Bill as well as the associated implementation strategies. The majority of respondents had not had the opportunity to engage in NHI policy formulation. Managers cited several pitfalls in current organisational operations. The respondents felt that national and provincial governments continue to function in a detached and rigid top-down hierarchy. Managers highlighted the need for their inclusion in NHI policy formulation and training and development for them to oversee the implementation strategies. Conclusions It appears that strategic purchasing is not being operationalised in PHC. NHI policy implementation appears to function in a rigid top-down hierarchy that excludes key stakeholders in the NHI implementation strategy. The findings of this study suggest an inadequate decentralisation of healthcare governance within the public sector necessary to attain UHC. District managers need to be engaged and capacitated to operationalise the planned decentralised purchasing-provision function of the DHS within the NHI Bill.

Healthcare disparity and its associations with cytomegalovirus disease in pediatric liver transplant recipients in South Africa

“…Resources lacking in the public sector, such as transplant surgeons and interventional radiologists, were ameliorated by the PPP. Although SA is an upper middle‐income country, it remains one of the most unequal societies in the world, especially regarding its fragmented healthcare system, in which more than 80% of the allocation of healthcare services benefits the highest socioeconomic sectors 12,43 . The South African government has recognized this disparity, and plans are underway to implement a new healthcare financing and service delivery system called National Health Insurance (NHI) to reorganize healthcare and achieve universal equal health coverage for all South Africans.…”

“…The implementation of NHI by the SA government and addressing factors that impact the social determinants of health may lead to the resolution of healthcare-associated disparities, thus decreasing the burden of diseases, 43 including CMV, as seen in our cohort of PLT recipients.…”

Multimorbid life expectancy across race, socioeconomic status, and gender in South Africa

“…The health system evolved from highly fragmented region-specific systems during apartheid to a mixed and highly unequal pluralistic system post-apartheid, in which only the wealthy could afford higher quality private care (Kon and Lackan 2008). From 2012-2017, South Africa piloted the first phase of their National Health Insurance system as a step towards achieving universal health coverage and addressing the existing disparities, however the results were mixed (Murphy and Moosa 2021). While coverage increased, the main issue was the lack of decentralized governance and consequently, compliance in primary healthcare clinics and a lack of transparency and accountability (Day and Zondi 2019).…”

“…This demonstrates that the racial and socioeconomic hierarchies in place during apartheid have had lasting impacts on life course health disparities, highlighting entrenched structural inequalities. As South Africa is beginning to implement a national health insurance system(Murphy and Moosa 2021;Pauw 2021), it is timely for actions to be taken to address these inequalities. Existing systems tend to be fragmented and were built to treat acute diseases, but people with non-communicable diseases and multimorbidity require different types of care (Basto-Farmer, P.E.…”

Newborn and infant hearing screening at primary healthcare clinics in South Africa designated as National Health Insurance pilot sites: An exploratory study

“…Similarly, general practitioners at one of the Tshwane district pilot sites expressed frustration at the lack of infrastructure and equipment (Surender, Van Niekerk, & Alfers, 2016). The lack of communication and exclusion in NHI policy formulation was also expressed in recent findings from in-depth interviews with public service managers in the Johannesburg health district (Murphy & Moosa, 2021).…”