Lobby warns of NHI risk to patients

• Plan’s medicines provisions are inadequate, says Health Justice Initiative

The government’s National Health Insurance (NHI) plan has inadequate provisions for medicines, posing a risk to access to treatments for everyone in SA, the Health Justice Initiative lobby group warned on Monday.

The government’s National Health Insurance (NHI) plan has inadequate provisions for medicines, posing a risk to access to treatments for everyone living in SA, the Health Justice Initiative (HJI) lobby group warned on Monday.

NHI is the government’s blueprint for universal health coverage and is aimed at ensuring everyone can get health services free at the point of delivery. Its enabling legislation, the NHI bill, is before parliament.

The bill entails centralising selection and procurement of medicines for patients under NHI, collapsing the two largely independent systems used in the public and private sector into an entirely new mechanism. In the private sector, most medicines are funded by medical schemes, which pay in full for products listed on their formularies.

Patients can also get nonformulary products, but often have to pay for these products out of their own pockets. People who are not medical scheme members also pay out of pocket for over-the-counter and prescription medicines bought at private sector pharmacies.

Private sector medicine sales are governed by the single exit price (SEP) regulations, which control the ex-factory price of drugs and the markups levied at every step on the supply chain from manufacturer to pharmacy checkout. These prices are publicly available, and the health minister controls annual increases.

In the state sector, the government issues tenders for medicines that are procured at these prices by provincial health departments. Provinces can also procure drugs off-tender.

Section 58 of the bill says the system set out in the SEP regulations will be used under NHI, with manufacturers selling medicines to the NHI fund at prices published by the office of health products procurement.

But the bill is not clear on how patients will access medicines that are not covered by the NHI fund, and how sales of these drugs will be priced and regulated, said the HJI lobby group in a discussion paper released on Monday. The bill also does not deal with weaknesses in the SEP regulations, which do not control the launch price of medicines.

The bill’s proposed exclusion of the NHI scheme from the jurisdiction of competition authorities and competition law is also problematic, as it would prevent the competition commission from investigating anticompetitive behaviour such as collusion and excessive pricing, which pose a barrier to patients’ access to health care, according to the HJI.

The entire shift of SA’s medicine selection, procurement and reimbursement system to “NHI reimbursement” has not been adequately thought through, potentially posing a great risk for the future of medicine selection and access in the country for all people, it said.

This requires immediate attention at the highest levels of the executive and the legislature too, and is likely to need a multidepartment and stakeholder technical group to determine the exact trajectory of this planned process urgently, said the HJI.