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South African Family Practice 2019; 61(3):102–108 https://doi.org/10.1080/20786190.2019.1596665 S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 Open Access article distributed under the terms of the © 2019 The Authors Creative Commons License [CC BY-NC 4.0] http://creativecommons.org/licenses/by-nc/4.0 RESEARCH The perceptions of general practitioners on National Health Insurance in Chris Hani district, Eastern Cape, South Africa Mthetheleli Mbongeni Gaqavu and Robert Mash* Division of Family Medicine and Primary Care, Stellenbosch University, South Africa *Corresponding author, email: [email protected] Background: National Health Insurance (NHI) intends to provide universal health coverage to all South Africans, with equity and quality as its tenets. The participation of private general practitioners (GPs) in NHI is essential. The aim was to explore perceptions of GPs on NHI in Chris Hani district, Eastern Cape, South Africa. Methods: A descriptive phenomenological qualitative study using semi-structured individual interviews of 12 GPs from six municipalities was undertaken. Data analysis used the framework method assisted by Atlas.ti software. Results: GPs in Chris Hani district felt that NHI would improve health and benefit society and be of particular benefit to poor and rural people as it will improve access to healthcare. Lack of governmental administrative capacity and a human resource plan were seen as barriers to implementation. They believed that NHI would benefit them through a single purchaser system and support more comprehensive care. GPs were concerned about a lack of information on primary care packages, accreditation, remuneration and patient allocation. They thought that NHI might disadvantage solo GPs. NHI implementation could be improved by actively engaging with GP organisations. Improvement of existing government health facilities and continued medical education were seen as possible ways to better implement NHI. Conclusion GPs in this study were generally positive about NHI and thought it would benefit both patients and providers. However, they had concerns regarding the capacity of government to implement NHI and the implications for solo GPs, and needed more information. Government needs to actively engage GPs. Keywords: general practice, national health insurance, primary care, primary health care, Universal health coverage Introduction The South African health system is struggling and people in great- to fund NHI and membership will be mandatory for all South 4 est need still have the least access to health care.1 The public Africans. healthcare system caters for 84% of the population and spends 4.2% of gross domestic product (GDP), while private health care NHI will purchase services from accredited hospitals, pharma- looks after 16% of the population and spends a further 4.1% of cies, general practitioners (GPs), dentists and other health pro- GDP.1 Expenditure on health care is therefore inequitably distrib- fessionals. The major difference from the current system will uted and, despite spending 8.3% of GDP, South Africa still has a be pricing for the services. The fee for the service model cur- high burden of disease and health outcomes that are not com- rently in use has resulted in high costs; NHI will pay providers mensurate with this expenditure. The public health sector is based on a defined health service package and a capitation- struggling to improve the quality of care and private health based funding model.4 care costs have been spiralling out of control.1 In 2011, the national Minister of Health introduced the National Health Insur- Following accreditation private GPs and hospital groups will ance (NHI) Green Paper to parliament.2 This proposed health voluntarily sign NHI service contracts. The frontline of service system reform was intended to provide universal health cover- delivery will remain the district health system.4 At primary care age, and improve social justice and health equity. level, the focus will be on comprehensive services that include health promotion, disease prevention, treatment, rehabilitative The idea of National Health Insurance began with the 1928 Com- and palliative services.4 mission on Old Age Pensions and National Insurance.3 This was followed by the 1935 Committee of Enquiry into National Health The medical profession is an important stakeholder when deter- Insurance.3 All these initiatives proposed that health insurance mining the structure and anticipating the impact of a reformed be introduced to cover healthcare benefits for low-income health system.4 The participation of private GPs in a health employees, although none of the plans were implemented.3 system funded by NHI is essential to improve access to and The 1942–1944 National Health Services Commission, in contrast quality of primary care. Effective primary care is a prerequisite to the above, recommended the introduction of a national for a cost-effective healthcare system.1 health tax to provide free healthcare services for all South Afri- cans, but this was also never implemented.3 Some sub-Saharan African states have introduced NHI with varying outcomes. Ghana was the first sub-Saharan Africa NHI is not only a funding model for health care. Its goal is to country to introduce NHI in 2003.5 The challenge in Ghana has bring universal healthcare coverage to all South Africans.4 The been operational and financial sustainability in the face of cost current two sectors of public and private health care will be escalation, inadequate technical capacity, inadequate monitor- merged into one healthcare system. There will be a health tax ing mechanisms and broad benefit packages.5 South African Family Practice is co-published by NISC (Pty) Ltd, Medpharm Publications, and Informa UK Limited (trading as the Taylor & Francis Group) Perceptions of general practitioners on National Health Insurance in Chris Hani district 103 Nigeria established its NHI in 2006. Its population coverage is access to radiology, little palliative or rehabilitative care and only 10% as beneficiaries are mostly formal sector employees.6 their service is generally limited to ambulatory care. It has proved to be very difficult to implement NHI in developing economies that have a very large informal sector and poor The researcher was also a GP in private practice in Chris Hani dis- revenue collection mechanisms.6 This has excluded millions of trict and had a postgraduate Diploma in Family Medicine, which citizens from having access to quality health care.6 included training in communication and interviewing. Previous studies exploring the views of GPs in South Africa have Sample size and selection of respondents 7–10 shown mostly negative sentiments towards NHI. The con- Purposive sampling of information-rich participants used the fol- cerns at the time were regarding accreditation, contracting, lowing criteria: remuneration, poorly equipped NHI pilot sites, lack of infor- . mation on the health packages, impact on private practices in Two GPs from each of the six municipalities to ensure prac- terms of workload, quality of care that would be provided, as tices serving different parts of the community were well as costs involved to upgrade practices for more space selected. and staff. Loss of clinical autonomy was also a concern in pre- . GPs with a mixed-practice population including both out- vious research. of-pocket and medical aid patients. Any GPs who had previously worked at an NHI pilot Most of these studies, however, were performed prior to the scheme. release of the White Paper on NHI.11 In December 2015 the NHI White Paper was published and provided more detail and An initial sample of 12 interviewees was therefore intended, with 11 certainty regarding the future direction of NHI. The views of the option of further interviews if saturation of themes was not GPs may have evolved in response to the White Paper and no obtained. Doctors who were personally known to the researcher study has explored the views of GPs in the Eastern Cape, were not selected for interview in order to minimise the effect of which is one of the poorest rural provinces. As NHI becomes a prior relationship on the interviews. more of a possible reality with legislation having been passed, GPs’ views might have evolved. Data collection Individual interviews were conducted by the researcher. Semi- The aim of this study was to explore the perceptions of GPs on structured interviews were performed using an interview NHI in Chris Hani district, Eastern Cape, South Africa. Specific guide. The interview guide explored general views on NHI, objectives included: views on participating in NHI and how implementation of NHI 1. To explore the perceptions of GPs on NHI- how they see, could be improved. The interview guide was reviewed by the understand and interpret NHI. supervisor for content and construct before it was used. To explore the perceptions of GPs on NHI, open-ended questions 2. To explore the factors affecting their willingness to that allowed the interviewees to elaborate and express them- participate. selves fully were used. The researcher was trained by the Div- 3. To explore their suggestions to improving the NHI policy. ision of Family Medicine and Primary Care, Stellenbosch University, on how to conduct qualitative interviews. The pilot interview tape was also reviewed by the supervisor and feed- back was given. Methods Participants were invited in advance to participate in the study Study design with a telephone call or email. An information sheet detailing This was a descriptive phenomenological qualitative study that the research topic, aim and objectives was sent to participants used semi-structured interviews. by fax or email prior to interviews. Interviews were conducted in neutral venues at a time convenient for the interviewees. Setting Interviews were up to 60 minutes long. The researcher recorded The study was conducted at Chris Hani district in Eastern Cape, interviews on a digital audio-recorder. All interviews were con- South Africa.

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