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Getting bang for the buck with the National Health Insurance

- Wits University

The National Health Insurance as a funding mechanism will have to select what it covers and what it does not. A Health Technology Assessment could help decide.

“How do we get bang for our buck to fund NHI?” was the bottom line question Professor Karen Hoffman, director of PRICELESS SA, put to visiting lecturer Professor Andrew Briggs last week.

Briggs is chair in health economics at the University of Glasgow and gave a lunchtime talk at the research unit, which is based at the School of Public Health. His focus was on the imperative of health technology assessment (HTA) in being able to better evaluate costs of products and technologies in priority setting for a country’s health needs. This as South Africa’s National Health Insurance (NHI) bill currently sits before Parliament against deep rumblings,  concerns and uncertainty over the scope of coverage on the bill and exactly how NHI funding will be best utilised.

“As health economists we look at opportunity costs in health terms and health benefits foregone and I think that is the way it should be,” said Briggs, who has been lecturing on modelling methods for cost assessments at Wits this winter.

He looked at universal health coverage through the lens of the United Kingdom’s National Institute for Health and Care Excellence (NICE). NICE is a special health authority that was set up in 1999 to reduce variation in the availability and quality of the UK’s National Health Service (NHS) treatments and care.

Briggs highlighted some of the most positive features of the body as well as some of its shortcomings, with a view for South Africa to dodge similar mistakes or to be able to borrow as good practice in the shaping of the country’s own national health insurance.

He said transparency and decision-making that is explicit have helped give credibility and accountability to a body that must routinely stand up to public scrutiny and corporate and political pressure.
“The process in health assessment technologies is more important than the analysis itself when decisions have to be taken that are not universally popular and where there will be losers and winners,” said Briggs.

He added that NICE includes a feature on its website where people can track the paper trail of most of the deliberations of decisions of what drugs and technologies end up approved for funding on the NHS.

Another tick for NICE, he said, is the broad and inclusive nature of its various committees. Briggs said: “The committees include clinical experts, statistical experts, patient representative bodies and the lay community. People who may be called to testify include specialists and there is also a citizen council and people are provided with rudimentary training to take part effectively.”

His caution of the shortcomings of NICE however, ranged from political interference to blind spots in getting the basics rights and the sometimes shadowy nature of “behind closed doors” price negotiations with private suppliers.

In the example of oncology care in the UK, Briggs said in the last few years political pressure was exerted on NICE to be quicker in its decision making about new technologies and treatments for cancer. Political point scoring meant “thrusting end of life criteria” onto NICE to consider in its decision making. Subsequently government also set up an oncology fund. These politically motivated interventions undermined the processes and autonomy of a body like NICE.

Worse still, Briggs said, that after three years this special oncology fund that was meant to fill in the gaps of coverage not approved by NICE, was found to have grossly overspent and was in that state handed over to NICE “to sort out”, said Briggs.

“There’s also a tendency of NICE to be captured by new technologies and the pressure to look at next new shiny thing instead of using more cost effective, public health interventions that are generally more equitable in terms of population health,” said Briggs.

He also highlighted concerns over the confidential nature of how deals for discounts to the government are struck between big multi-national companies. Briggs said discounts are offered on condition that the deals stay secret and is a well-used corporate tactic to ensure that they can negotiate differently in different countries.

In his talk Briggs also warned of shortcomings in the American public insurance model. Having worked in that country for a period, Briggs said the US model continues to rack up in taxpayers’ dollars and over-usage of the public health service but still has poor outcomes in reaching those who need medical help the most.

Briggs said Americans’ “at any cost” model has resulted in corporate suppliers pushing up prices unsustainably. He added: “It makes health technology assessment and factoring cost in at every point essential.”

Hoffman said trade-offs are inevitable even “if we don’t like to think about opportunity costs” in health. For this reason, she said it makes assessment, and the assessment processes, critical components to consider in shaping South Africa’s NHI.