The NHI Bill, palliative care and a call for a systems lens

This article has been written by Dr Jodi Wishnia, CEO of Zazen Respite Care based in Johannesburg, Gauteng. 

There has been so much written about the recent signing into law of the National Health Insurance (NHI) Bill by President Ramaphosa. Perhaps the most palpable feeling is one of anxiety: that South Africa can’t afford this reform, about the timelines, and most notably, that access to quality healthcare will be further throttled.

If you lift your head from the noise though, you will find that most reasonable people agree that our current inequitable health system cannot continue and that affordable access to quality healthcare must improve. These desires are reflective of the use of a ‘systems’ lens to think about healthcare and the coming NHI. A systems lens means that instead of focusing on specific events or phenomena, you are able to take a ‘birds-eye view’ of a situation and recognise patterns and trends that give rise to individual phenomena/events.

The best good for the most people

When one is a specialist in a particular area, it is tempting to look at the specific phenomena rather than the system. For example, child health advocates may argue for more budget for child health programmes or palliative care specialists may advocate for palliative care medical specialist posts in the public health sector. While the intention is right, by advocating for specific diseases or populations, there is a disconnect from the overall picture of a patient – an adult with an advanced cancer was once a child who required immunisations. Both services are critical, but with a finite health budget, rational decisions that allow for the ‘best good for the most people’ (the core of public health philosophy) must be prioritized.

How can we use the NHI Act to push us to think about our healthcare system? First, is to realise that the Act is only about the funding mechanisms and governance structures, it tells us nothing of the ‘benefits’ package. We know that in the public health sector, while there are comprehensive benefits, often access to these services is throttled due to a lack of funding: personnel or equipment. For example, even though hip replacements form part of the benefit package in our public health sector, the waiting lists for orthopaedic surgeries run into the thousands in some provinces.

Unlikely to become available early in the rollout

So, let’s talk about the benefits package under NHI. The NHI Act does reflect palliative care as part of the continuum of care, as it does rehabilitative care. But we know that currently access to allied health professionals (occupational therapists, physiotherapists and speech therapists) is severely constrained^[1] in the public sector. There are many cases similar to this, from medication to services, that technically form part of the public health service package but are not actually available due to resource constraints. So, while it’s positive that palliative care is already recognised as part of the continuum of care, given that it is defacto not available in the public health sector now, it is unlikely to become available in the early phases of the NHI rollout.

Therefore, as a specialist in the palliative space, one might feel compelled to advocate for availability of palliative care in the public service (now and under then NHI) and this is understandable, but it sets us up against other disease areas and groups, essentially asking the Government to choose between services based on which ‘lobby group’ has the loudest voice.

Shifting the conversation 

So, the question is, how can we shift the conversation in Government from a zero-sum game to one where the value of and ‘return on investment’ for palliative care makes its inclusion more compelling (rather than just another line in the already strained health budget).

A systems-oriented approach to this conundrum would be for us as a palliative care community to advocate for ‘health technology assessments’ (HTA) to be used to guide healthcare spending. HTA is a methodology that uses evidence and data to determine the cost-effectiveness of a particular healthcare service or treatment. It is used routinely in the United Kingdom’s National Health Service (NHS).

Providing in-depth data on cost, benefit and need for palliative care

HTA forms part of the NHI Act and plan but there is still much work to be done to generate the data required for regular assessments. This is where we can add the most value, in my opinion. We each have data from our practices, hospices, hospitals and palliative care centres which can provide in-depth data on the cost, benefit and need for palliative care. This will allow the Government to conduct proper analysis and accurately estimate the budget required for a comprehensive palliative care service. This is also what some of the medical schemes in South Africa have done to increase palliative care benefits to the insured population.

Therefore, the palliative care community needs to start identifying palliative data indicators worth tracking, collecting this data routinely and then making the data publicly available for use by government, patients and the broader palliative care community for research, decision making and planning for the NHI. This is the only way we can ensure we build a healthcare system that is holistic, cost-efficient and based on the true need for services. The benefits will be felt not only in our community but also for the health system as a whole.

[1] District Health Barometer 2024. Chapter 4: Service Capacity and Access. Section 4.3: Human Resources for Health: Wishnia, Gomes and Khalawan.