The government’s plan for National Health Insurance (NHI) 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 achieving universal health coverage and aims to ensure everyone can obtain health services that are free at the point of delivery. Its first piece of enabling legislation, the NHI bill, is before parliament.
The bill envisages centralising the selection and procurement of medicines provided to 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 obtain nonformulary products, but often have to pay for these products out of their own pocket. People who do not belong to medical schemes also pay out of pocket for over-the-counter and prescription medicines purchased 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 annual increases are controlled by the health minister.
In the state sector, the government issues tenders for medicines which 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 unclear 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 in a discussion paper released on Monday. It 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, said 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 urgently determine the exact trajectory of this planned process.
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