South Africa is in the process of preparing for a National Health Insurance (NHI) scheme to reach universal health coverage by 2025. Attaining this goal in a resource-constrained environment will rely in part on understanding which interventions should be prioritised and how resources should be allocated.
Our healthcare budget, similar to healthcare budgets around the world, is not infinite. This means every rand spent on one intervention is a rand not spent on another. Trade-offs are inevitable. How we prioritise our resources in a fair and equitable manner must be based on evidence of what really works and at what cost. This will ensure that the population receives good value for its healthcare rand.
These factors are pertinent today as we mark the first Universal Health Coverage Day, an initiative endorsed by over 500 organisations globally, including the World Bank and the World Health Organisation, and sponsored by The Rockefeller Foundation. This day highlights the need for countries, including SA, to provide access for all their citizens to quality health services without incurring financial hardship.
Priority-setting for health in SA has to date largely been influenced by expert opinion and often by who shouts the loudest. While our combined public and private investment in health ranks relatively high compared to that of emerging economies, our maternal and child health indicators have not met national targets and our rates of obesity and related non-communicable diseases such as high blood pressure and diabetes are skyrocketing.
We propose a more systematic approach for gathering evidence and call for economic evaluations to be conducted as part of the priority-setting process. This will enable us to understand how to scale up the most cost-effective interventions, and will assist policymakers in weighing the costs and benefits of different clinical and public health interventions leading to better health.
At the 2014 World Health Assembly in Geneva, a resolution was adopted for incorporating health intervention and technology assessment to support universal health coverage. This resolution calls on all member states to develop and strengthen priority-setting capacity. A growing number of countries, especially those that have already implemented universal health coverage, or are in the process of doing so, have priority-setting agencies in place.
For SA to reach its goal of universal health coverage, there are several agencies that will be needed. The establishment of the Office of Health Standards Compliance to monitor compliance with norms and standards for quality healthcare delivery is an important first step on the road to universal health coverage, but little attention has been focused on the establishment of a formal priority-setting agency.
One potentially good model for SA is the Thai Health Intervention and Technology Assessment Programme. Its mission is to inform rational health allocation decisions that have an impact on population health. Similarly, in the UK, the National Institute for Health and Care Excellence plays an important role in advising the National Health Service. In SA, an entity of this nature would commission research to identify cost-effective interventions and would be expected to process the evidence in a transparent fashion. In this way, policymakers would be supported to identify where health gaps can be addressed to save the most lives at a reasonable cost.
Cost-effective health interventions would include drugs, devices and treatment guidelines, but would extend beyond this to include health promotion and prevention. A broad range of stakeholders, including policymakers, practitioners, industry and, most important the public, would need to be engaged to understand the process by which these estimates are reached.
The Department of Health is increasingly aware of the need for evidence-based priority-setting and is supportive of work to generate evidence for best buys for health in SA. The National Strategic Plan for the Prevention and Control of Non-Communicable Diseases, for example, lists several cost-effective interventions to achieve its targets.
We do not advocate a “one size fits all” approach to priority-setting, as this would be ineffective in addressing equity gaps. Understanding what is needed in each province and district is essential.
Reaching sustainable health targets is a matter of urgency. A priority-setting agency will be key to ensuring that the public purse is used effectively, efficiently and equitably to get a “good bang for our (health) buck”.