South Africa

Our work

iDSI identified significant opportunities to engage with the South African government starting in 2011 and is currently focused on institutionalising Health Technology Assessment (HTA) as part of ongoing National Health Insurance (NHI) reforms, as the country moves towards Universal Health Coverage (UHC). iDSI is also scoping out opportunities for capacity-building in HTA in the region and to establish a Southern African regional hub to provide technical assistance to neighbouring countries.

South Africa has a two-tiered (private and public) health system for its 56 million inhabitants, which has led to fragmented funding, risk pools and subsequent huge inequities in healthcare access and quality. The 2018 NHI Bill details the legislative measures needed for the next phase of NHI reforms, which will include establishing an NHI Fund as a mandatory single public purchaser and financier of health services. The Bill also specifies the use of priority-setting and forming an HTA agency to support the efficient and equitable use of the NHI Fund.

iDSI has:

  • Contributed to the decision by the South African government to include establishing a national HTA agency as part of the 2018-2021 government budget of R368m (US$27.3m) towards an interim NHI Fund
  • Provided pivotal input to the NHI process through numerous policy dialogues and capacity-building workshops related to evidence-based decision making and health benefits package design
  • Mapped out various frameworks for health benefits design; clinical guidelines; legislation and policy; and HTA topic selection to inform the move towards NHI

Institutionalising HTA under NHI

iDSI has been advising on the institutionalisation of HTA and evidence-informed priority-setting as part of the ongoing NHI reforms, by participating in the Health Services Benefits advisory working group, under the auspices of the Minister of Health; and is now working with the Council for Medical Schemes to strengthen private sector regulation. Our input has included detailed costed, short and long-term options for the National Department of Health to incubate an HTA unit, with a view to establishing a standalone HTA agency in the long term. Other iDSI analysis included a framework for health benefits design, a review of South African clinical guidelines, a legal and policy framework and a topic selection framework to inform the move towards NHI.

Through PRICELESS SA, an academic unit based at the University of Witwatersrand with technical expertise in health economics and policy influence, iDSI has also undertaken activities to build increased understanding and capacity for priority-setting among policymakers. For example, in March 2017 PRICELESS hosted a three-day training event on Health Benefits Package design and economic evaluation for South African policymakers. This was followed by a policy dialogue specifically for those involved with the NHI benefits package design.

Impact

iDSI input and support for policy dialogue have been pivotal to the NHI planning process with the resultant HTA agency and supporting committees specifically identified in the NHI Bill, and funding committed for an HTA Unit to be incubated within the National Department of Health as part of the 2018 Budget of R368m (US$27.3m) dedicated towards an interim NHI Fund. A national HTA agency could ultimately help to inform the listing, pricing, reimbursement of medicines and health services, and the regulation of public and private providers.

iDSI estimates that for a national HTA agency in South Africa, an annual investment of US$1.5m to finance 20 full-time staff to produce 20 HTA studies and 5 clinical guidelines (for high-burden diseases such as diabetes) could generate approximate savings of US$200m, based on return-on-investment trends of HITAP in Thailand (US$133 per dollar) – or up to an equivalent 91,633 disability-adjusted life years (DALYs) averted based on the York tool for estimating health opportunity costs, through evidence-informed price negotiations and improved clinical care pathways.

Building capacity for HTA and the foundations of an iDSI Southern African regional hub

South Africa’s strong technical and research capacity and policy influence among Sub-Saharan African nations makes it well placed as a spearhead for HTA regionalisation, as well as the generation of funding for policy-relevant research.

iDSI, initially through PRICELESS SA, has been laying the foundation for an Southern African regional hub through scoping, capacity-building and networking activities. Through these efforts iDSI has begun supporting governments across Sub-Saharan Africa to develop the skills and capacity necessary to conduct and review HTAs.

In 2018, iDSI conducted a survey of HTA capacity in sub-Saharan Africa. The information generated from the survey is being used to further understand capacity across the region and to plan future activities in Southern Africa to respond to capacity gaps. The results of the survey were presented at the iDSI/HTA International Setting Priorities Fairly event in September 2018.

Impact

iDSI has formed links with networks such as the Collaborative Africa Budget Reform Initiative and the African Health Economics and Policy Association; and begun engaging with Tanzania and Zambia to introduce evidence-informed principles and methods into Essential Medicines List review and fiscal policy, nurturing the political will for HTA and broadening the impact of iDSI expertise. An important development has been the Master’s level educational programmes at Wits University where a health economics module was included as part of the Masters in Public Health for the first time in 2018. The majority of the 120 applicants were from South Africa and other sub-Saharan African countries, demonstrating demand for formal education in this area.

Key reads

South Africa Policy Dialogue on Designing and Adjusting the Health Services Package for Universal Health Coverage in South Africa

South African clinical practice guidelines: A landscape analysis

South Africa National Health Bill 2018

Consolidated spending plans 2018 from South Africa National Treasury

Government notice/Terms of Reference for the national health insurance work streams 2015

PRICELESS and the IDSI Sub-Saharan African Hub: Together for better decisions and better health

iDSI policy brief: Supporting Tanzania to prioritise its Essential Medicines List 

Effective capacity-building strategies for health technology assessment: A rapid review of international experience

Director General of Health, Precious Matsoso speaks at the first iDSI Africa meeting