NATIONAL HEALTH INSURANCE – IMPLICATIONS FOR REHABILITATION PROFESSIONALS AND SERVICE DELIVERY

Correspondence Author: Dr Hellen Myezwa Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa Email: hellen.myezwa@wits.ac.za Van.niekerk@wits.ac.za ABSTRACT: This paper reviews the National Health Insurance (NHI) in view of what is proposed and authors suggest how it may impact on the rehabilitation sector namely occupational therapy, physiotherapy, speech and language therapy and audiology. A review of the basic description of the NHI and the different elements is presented. Particular attention is paid to how much interface and mention is made of rehabilitation. The current status of rehabilitation service provision and its response to the needs of the population, in particular the burden of disease and the related finance models are discussed. Suggestions are presented for the way forward to ensure rehabilitation professionals and services rendered are not caught flat footed.


INTRODUCTION
The motivation for National Health In surance (NHI) is driven by the inequali ties that exist in the provision of health in South Africa (Department of Health 2011a).The NHI is in its early phase of development and rehabilitation pro fessionals need to engage and respond proactively.An important starting point is to examine the full intent of the NHI.
Our objectives have several dimen sions: 1) To examine and assess the Na tional Health Insurance (NHI) and the points at which it addresses rehabilita tion issues.2) Identify gaps in the NHI pertinent to rehabilitation.3) Analyze our current situation in terms of staffing service delivery and response to cur rent needs.4) Provide recommendations for inclusion of rehabilitation services shows that SA exceeds the WHO recommended level of expenditure (Department of Health 2011a).In spite of this, expenditure for health in South Africa is still inverted with 16% of the population having 4.1% of the GDP spent on their health needs while an almost equal percentage of GDP is spent on 84% of the country's population, as illustrated by Figure 1.
An interesting historical perspective found in the NHI Green Paper is that the proposals to reform the model to finance within the NHI.Epidemiological data to inform rehabilitation service is in its infancy (Jelsma et al 2002) and therefore we acknowledge the lack of cohesive data for rehabilitation.

REVIEW OF THE NHI
The green paper on the NHI outlines the allocation of resources to heath care delivery and how it is at odds with the quality of care provided.A comparison of the percentage of Gross Domestic Product (GDP) spent on health care and efficiency.As such, the NHI has undertaken to review and strengthen the PHC system i.e.Primary Health Care reengineering which includes systems strengthening.
The systems for service delivery that have been targeted are the district, school based PHC services and the municipal ward based service.Delivery of services within these streams involves distinct proposed approaches such as strengthening administrative systems, cost effective interventions with adequate professional staff, ethical service delivery, adhering to set quality standards and adherence to clinical guidelines.
Public and private partnership link ages are proposed to enhance service delivery.Provision of service by contracted private practitioners and models to provide services may be through defining a selected number of services at primary and hospital care.Rehabilitation is mentioned in the provision of services only under the district hospital.It is seemingly not embedded in the description of services anywhere else but mentioned under the definition of health benefits, the discussion on underfunding, the use of pooled resources and in the definition of universal coverage.However, includ ing rehabilitation at the appropriate servicedelivery levels (e.g.PHC level and hospital settings) is important, as reference to this document for implementation by policy makers will health systems is not a new phenomena and has its roots as early as 1928 with a commission on old age pension and national insurance.Subsequent efforts included a committee of enquiry into National Health Insurance (1935), the Gluckman commission 19421944. Two committees in 1994 and1995 respectively investigated reforms in healthcare funding, which were fol lowed by various inquiries into social health insurance between 1997and 2002(DOH 2011a)).Finally, a Ministerial advisory committee on national health insurance was established, which made recommendations regarding reforms to the healthcare system, effectively implementing Resolution 53 made at the ANC's 2007 Polokwane Conference (ANC 2010).This was the first time that the work of a commission or committee resulted in implementation of a plan to address the inequities in health care service delivery.The NHI's main aim is to improve access to health.It further aims to subsidise people, across the different population groups, who cannot afford health care and links contribu tions to the scheme to people's ability to pay.It also aims to procure services on behalf of the populace and to improve and rehabilitate the public health system.
Prioritising health interventions and staffing is based on the country's health needs, as expressed by the burden of disease.The NHI green paper empha sises that the public health sector services the bulk of the population, and carries the greatest burden of disease (Department of Health 2011a).Burden of disease relates to information about the mortality, morbidity, injuries, disabilities and related risk factors (Econex 2009) and provides important information for health planning to address any persistent gaps to ensure better health for the population (Bradshaw et al 2003).The NHI aims to achieve this by establishing a committed, accountable and skilled force of health care workers, ensuring sustainable and equitable access to health care for all in South Africa (emphasising communitybased promotion and prevention services), and ensuring responsible leadership (Kleinert & Horton 2009:760; Matsotso et al 2013:1).Burden of disease information is based on three figures: years of life lost due to premature death (YLLs) and years of life lived with disability (ies) (YLDs).When combined, these figures form the disabilityadjusted life year (DALY) (Bradshaw et al 2003:682;Econex 2009:1) which is indicative of nonlethal health outcomes and premature death (Jelsma et al 2002).Globally, the burden of disease is presented in terms of three categories of conditions: 1) pretransitional causes of death, including communicable diseases, maternal conditions, prenatal condition and nutritional deficits, 2) noncommunicable conditions (e.g.diseases of lifestyle such as hypertension and diabetes) and 3) injuries.In global analyses, HIV/AIDS and tuberculosis form part of the first group, as they are communicable diseases.In South Africa, however, their contribution to the burden of disease is so significant that the data are kept separate, giving South Africa a quadruple burden of disease (Bradshaw et al 2003).Many of the guiding principles of NHI are similar to those of Primary Health Care (PHC) and include the right to access, social solidarity, effectiveness, appropriateness, equity, affordability of disease in terms of disabilityadjusted life years as expressed in Table 2.
Figures based on DALYs are important to therapists as these figures are indi cative of the need for rehabilitation in a country's population.

CURRENT RESPONSE TO REHABILI-TATION NEEDS
Two methods have been used to assess the current rehabilitation response to health needs, namely: an assessment of published papers in the local journals and an analysis of the common con ditions seen by therapists.The pattern of publications represents by proxy the current focus of demand, service deli very and research within the professions, while conditions that are captured in statistics will reflect professional activity.Arksey and O'Malley (2005:21  22 The ratio of health workers across the board to 100000 population is not optimal with physiotherapists at a ratio of 12 and occupational therapists 7 (HST 2013).The same could be said of the ratio of doctors and nurses to patients, which although better stands at 55 doctors and 361 nurses to 100000 (DoH 2011).Across all professions discrepancies exist across public and private, urban and rural and across types of service (George et al 2012).It has been pointed out that the debate around human resources should not be reduced to one of numerical shortage but should extend to appropriate use of the existing personnel (George 2012).
In order for the rehabilitation professions to remain relevant, they need to address the burden of disease, which reflects the demands for health care (Econex 2009).In order to ensure effective service delivery, staffing and the supply of health care services should relate with the need as expressed by the DALYs (Econex 2009).
The MRCstudy highlighted the top 20 contributors to South Africa's burden literature is important as it provides information at a glance to amongst others, policy makers.Three studies assessing publications to show the focus for research in physiotherapy have been published (Mothabeng 2003;Mothabeng 2006;Frantz et al 2011).Two of these studies assessed the relevancy of the papers to the country's needs.The authors con cluded that there is some relevancy to the country's needs.Mothabeng (2003Mothabeng ( , 2006) ) iden tified gaps such as HIV, health promotion and human resources which in the later review (Frantz et al 2011) reflected progress.Though the bulk of the research was in clinical practice areas, 60% in 2002 and 45% in the period 19892003 the author did not give detail on the type of conditions covered.Between 20022010 the most published clinical areas were muscu loskeletal (47), education (17), chronic lifestyle diseases (15), neurology (15), cardiopulmonary (13) followed by com municable disease (11) (117 of 170 69%) (Frantz et al 2011).Similarly, an overview of papers published between 2003 and 2012 in the South African Journal of Occupational Therapy shows that developmentrelated interventions in childhood is the topic of most papers (17 of 136 papers) with mental health related conditions second (12 of 136 articles).There were two papers on HIV/AIDS during this period.
Tables 3 and 4 outline the conditions seen in Gauteng within all the physio therapy departments.No national figures are available and similar figures are not available for the other professions.
While it is not possible to accurately link the information obtained from the journal articles or the NDoH to the country's burden of disease because these sources do not relate the information to the cause of the conditions, it can be extrapolated that physiotherapists already address some conditions that relate to the burden of disease.Some conditions treated by physiotherapists, such as head injuries can easily be assumed to fall within the category of injuries.With the current data collection methods, other conditions are not as easily classified.For example, ICU conditions, which could be the result of injury, HIV/AIDS related complications, communicable, and noncommunicable diseases.The overview of the publications in the South African Journal of Occupational Therapy (SAJOT) shows that occupational therapists address some conditions related to the burden of disease.However, in the absence of data related to the actual numbers of occupational therapists working in the different fields of practice of the profession, it is not possible to evaluate whether these publications are reflective of the profession.It appears that the statistics kept by hospital departments and other institutions, such as the Health Professions Council of South Africa HPCSA, do not enable researchers to relate such statistics to the country's burden of disease.The way in which statistical data is kept requires reorganisation to determine realistic evaluation of service delivery in the NHI and private contexts.

WHAT IS THE CURRENT RESPONSE TO THE NHI AND WHAT DOES IT MEAN FOR REHABILITATION?
Two major factors are evident from the analysis done using key elements identified in the PHC reengineering efforts, namely discrepancies in reha bilitation service delivery and a poorly structured information system (which appears worse in OT than PT).Despite the dearth of similar statistical information for all three professions, the gaps have been assessed using the response to burden of disease, personnel needs, approaches to service delivery at both a broad level (how the service is structured e.g.CBR vs. institution) and more specifically how patients receive service at the point of contact with health professionals.The type of service will be distinguished based on whether the patient gets his service in one place (supermarket approach) or his has to move from professional to professional (service in silos).Therapists are seeing a wide range of conditions that represent the quadruple burden of disease.Based on the statistics assessed in Gauteng DoH the type of rehabilitation information collected is currently mal aligned with burden of disease data and could be improved.
The availability of therapists remains a challenge to service delivery.In relation to systems and improvement of management as outlined in the NHI document, Bateman (2012) interviewed therapists working in rural areas.Some of the practical difficulties for reha bilitation included: inpatients referred to hospitals and not receiving atten tion, no allocation of transport to rehabilitation, premature discharge with out therapy leading to complica tions and readmissions.An important obser vation is the focus of the health system on curative and mortality issues, whereas a rehabilitationorientated health system would focus on morbidity and quality of life data (Bateman 2012).

EXPENDITURE AND FINANCING OF REHABILITATION SERVICES
Very little information could be found in the literature on actual expenditure distribution of related costs.Occupational and physiotherapy services were 20 and 19% respectively.In hospitals, the onsite services are offered by 3277% of facilities respectively (HST 2013).Furthermore, the current medical aid coverage in the country reveals that expenditure on health is disproportionate in the private and public sector with per person expenditure being four times higher in the private sector (R11150 vs. R2766) (Department of Health 2011a).It is important to align the distribution and the type of services to the burden of disease which would improve the country's health delivery and rehabilitation efforts.

RECOMMENDATIONS Quadruple burden of disease
With regard to the rehabilitation professions response to the burden of disease, further studies and appropriate training should be done into the areas and fields of practice of all members of the professions.The shortage of therapists at appropriate levels needs to be addressed and engagement with fresh strategic approaches to this problem should be examined.

Service delivery
There is need for the reexamination of service delivery models from the level of district hospital to community health centre.A "one size fits all" is not the answer and the perennial shortages of therapists at all levels, calls for radical approaches to service delivery models.The delivery of service at these levels should perhaps respond to the call by the PHC reengineering to provide a service that is not discipline or specific programme based to one that is more holistic.Figure 3 gives a pictorial representation of the two models.
The provision of service in silos of physiotherapy, occupational therapy and speech therapy should be reexamined and shift towards the WHOs supermarket approach where the patient will obtain all rehabilitation services in a trans disciplinary manner (WHO 2012).This calls for a more concerted acceptance of a multidisciplinary health personnel (Davis 2006).Attrition of rehabilitation staff has not been fully studied.George et al (2012) reported a 15% HIV/AIDS prevalence among professional staff and migration to be responsible for attrition (George et al 2012).Urban migration and emigration have been cited as reasons for therapist attrition but no national study could be found to support this.Training of rehabilitation personnel with appropriate skills for a tailor made system is important.The rehabilitation personnel at district level will require good generalist skills and specific skills for the community setting (Maleka and Franzsen 2008).
The NHI aims to promote innovative models of providing specialist care and a parallel to integrated working practices between GPs and hospital based specialists (Department of Health 2011a).Therapists could develop and test models of privatepublic partnerships that could be funded to produce the necessary evidence for larger roll out where the context lends itself to this model.Coupled with the need to examine service delivery models is the need to assess and improve the quality of management within the delivery of rehabilitation services.This includes interventions to improve waiting time, consistency of treatment, quality of treatment; meeting treatment needs and patient satisfaction are some of the issues that need to be examined.

RESEARCH
The time has come for rehabilitation professionals to examine their approach to research.As Mothabeng (2003) points out the need for increased clinical research and alignment with national needs is imperative.However, larger population based studies that can contribute to policy and clinical practice is urgently needed.The NDoH 2011 Research Summit Report outlined some important strengths, weaknesses and opportunities with the current research agenda which rehabilitation professions should strive to build on where appropriate.Some strengths include existing research infrastructure robust surveillance systems and good internationally recognised literature in the areas of chronic disease and injury prevention and violence (Department of Health 2011b).Rehabilitation fraternity could possibly draw data collection systems that will add the dimension of morbidity and rehabilitation specific strengths in improving patient function and quality of life.Existing surveillance systems could include rehabilitation data that contribute to policy changes.Our current research agendas will contribute to appropriate measures and variables but as rehabilitation professionals it is important to engage and map a clear way forward.This could include enhancing the weaknesses that exist in the larger research agenda such as aging and inadequate numbers of researchers, limited funding, lack of national sur veillance systems for morbidity data (e.g.cancer registers, quality of care and poor systems to translate data into policy and practice) (Department of Health 2011b).Opportunities such as the global focus on chronic noncommunicable diseases and social determinants of health, and the WHO call to reduce deaths from noncommunicable diseases by 2% per year should be examined.

CONCLUSION
The NHI calls for an examination of equitable service delivery.To do this, every profession including rehabilitation professions needs to examine their research, service delivery and its distri bution financially and in terms of personnel, response to burden of disease and the quality of service provided.

Figure 1 :
Figure 1: Resources versus population distribution

Figure 2 :
Figure 2: Estimated DALYs per Category for South Africa, 2000, from Econex 2009:2 The most recent figures on the quadruple burden of disease, published by the Medical Research Council's ( MRC) Burden of Disease Research Unit published 2006, as interpreted by Econex 2009, can be seen in Figure 2.

Figure 3 :
Figure 3: Models of service delivery -patient -therapist ) indicated that rapid review of the result in deliberate inclusion.Many of the heath system concerns covered in the NHI policy documents can be applied to rehabilitation service delivery issues.