Proposed National Health Insurance Research Articles

‘The National Health Insurance scheme would be good and beneficial but I don’t trust the system …’: a cross-sectional mixed-methods study assessing the awareness and perceptions towards Uganda’s proposed National Health Insurance scheme among informal sector workers in Iganga and Mayuge districts, Uganda

BackgroundMost low-income countries have prioritised implementing national health insurance schemes (NHIs) as a solution to reducing the high out-of-pocket expenditures on health and enhancing access to healthcare, especially among informal...

The Current Healthcare Industry in South Africa

The current South African Healthcare (SAHC) system remains a dual healthcare system, consisting of the public and private healthcare sector. Albeit it unevenly distributed from a gross budget perspective, the gross national spend leans disproportionately towards the private sector coverage of healthcare. This equates to R 243Bn serving approximately 20% of the population as opposed to a similar public budgeted spend of R 247Bn serving approximately 80% of the population. In effect, the private sector serves a minority of the employed population. The SA Government has historically made large government Information and Communication Technology (ICT) investments within the public health sector, regionally based, where the return on capital investments have not been realised. The SAHC sector remains siloed. Health technology is advancing globally, and being propagated by the World Health Organisation (WHO) resulting in a global digital health strategy adopted by many countries. The South African National Department of Health (NDoH) has recently subscribed to its own local version of a ‘Digital Health Strategy’, in accordance with the WHO. The South African Public Healthcare technological infrastructure, in its current state, is deficient with many challenges needing urgent upgrading. The proposed digital or ehealth strategy and the proposed National Health Insurance (NHI) will require the reengineering of a national infrastructural and technological (ICT) environment from the ground upwards. Furthermore, this can only be achieved by reengineering the current state of the public healthcare technological infrastructure including the building infrastructure. This will include a transformation of national legislation. These projects and initiatives must be nationally managed within the ambit of improving the management capacity across all regions and districts that needs to be nationally coordinated. This effort can only be achieved by performing synchronised and well-coordinated implementations of such projects nationally across the SA Public Healthcare sector. This includes the integration of healthcare technologies, or national assets, from district to national level. This study provides further insights into these opportunities and challenges currently facing the South African Public Healthcare sector in preparation for the National Health Insurance (NHI) reform currently in review by the President. It further aims to assist in an approach to a solution addressing this national healthcare crisis.

Mistrust in government and National Health Insurance: A qualitative study of solo private practitioners in Cape Town.

The participation of independent private general practitioners (GPs) is of fundamental importance to the successful implementation of key elements of the proposed National Health Insurance (NHI) reform, notably the contracting units for primary health care (CUPS). This study explored knowledge and perceptions of the NHI reforms of private GPs following the tabling of the NHI Bill in parliament in 2019. An explorative qualitative research methodology was adopted. Using a semi-structured guide, nine solo private GPs, purposefully selected to represent the range of practices in the southern peninsula of Cape Town were interviewed in depth by B.L.P. over the period from January 2021 to March 2022. The GPs indicated support for the values of greater equity outlined in the NHI proposals. However, they had little engagement on or knowledge of their potential future roles in NHI. Concerns over financial viability and design were underpinned by an overall mistrust in the public sector to implement and manage NHI. The study concurs with previous research that private GPs are broadly in support of the principles of, and are potential allies, in advancing NHI. General practitioners need a platform to share their concerns and contribute as co-designers of NHI reforms. In the interim, steps to increase collaboration between private and public sectors at local and provincial level through, for example, referral processes may help to build the trust that is necessary between the sectors.Contribution:This study foregrounds the role of trust relationships in advancing NHI.

Expectations of clients, insurers, and providers: a qualitative responsiveness assessment among private health insurance sector in Kampala-Uganda

BackgroundThere is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda’s proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness.MethodsThis study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes.ResultsClient-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service.ConclusionHealth care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda’s proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

Piercing the veil on the functioning and effectiveness of district health system governance structures: perspectives from a South African province

BackgroundLeadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures.MethodsThis was a mixed-methods, cross-sectional study in GP’s five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members’ perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively.ResultsOnly three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities.ConclusionIn light of South Africa’s move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.

The feasibility analysis of integrating community-based health insurance schemes into the national health insurance scheme in Uganda.

Uganda has a draft National Health Insurance Bill for the establishment of a National Health Insurance Scheme (NHIS). The proposed health insurance scheme is to pool resources, where the rich will subsidize the treatment of the poor, the healthy will subsidize the treatment of the sick, and the young will subsidize the treatment of the elderly. However, there is still a lack of evidence on how the existing community-based health insurance schemes (CBHIS) can fit within the proposed national scheme. Thus, this study aimed at determining the feasibility of integrating the existing community-based health financing schemes into the proposed National Health Insurance Scheme. In this study, we utilized a multiple-case study design involving mixed methods. The cases (i.e., units of analysis) were defined as the operations, functionality, and sustainability of the three typologies of community-based insurance schemes: provider-managed, community-managed, and third party-managed. The study combined various data collection methods, including interviews, survey desk review of documents, observation, and archives. The CBHIS in Uganda are fragmented with limited coverage. Only 28 schemes existed, which covered a total of 155,057 beneficiaries with an average of 5,538 per scheme. The CBHIS existed in 33 out of 146 districts in Uganda. The average contribution per capita was estimated at Uganda Shillings (UGX) 75,215 = equivalent to United States Dollar (USD) 20.3, accounting for 37% of the national total health expenditure per capita UGX 51.00 = at 2016 prices. Membership was open to everyone irrespective of socio-demographic status. The schemes had inadequate capacity for management, strategic planning, and finances and lacked reserves and reinsurance. The CBHIS structures included promoters, the scheme core, and the community grass-root structures. The results demonstrate the possibility and provide a pathway to integrating CBHIS into the proposed NHIS. We however recommend implementation in a phased manner including first providing technical assistance to the existing CBHIS at the district level to address the critical capacity gaps. This would be followed by integrating all three elements of CBHIS structures. The last phase would then involve establishing a single fund for both the formal and informal sectors managed at the national level.

Perceptions of specialists in the public sector, on the role and value of family medicine.

Family medicine (FM) is often perceived to be a 'lesser' speciality compared with other disciplines, despite its importance as a generalist discipline in the healthcare system. Family physicians (FPs) provide comprehensive care at the district level and act as a gatekeeper for patient's upward referral to other specialists. This study aimed to explore the perceptions of healthcare specialists other than FPs involved in registrar training regarding FM at the University of KwaZulu-Natal, South Africa (SA). This was a qualitative study, with seven consultants, other than FPs, who worked at three public sector regional hospitals using purposive sampling. Individual semistructured interviews were conducted, audio-recorded and transcribed verbatim and analysed thematically. Four themes emerged (perception of FM as a medical speciality, role of FPs in the healthcare system and proposed National Health Insurance, FM registrars rotating in units and the scope of their training and how to improve the perceptions of FM by other specialities). Family medicine was regarded as a major and relevant specialist field with a significant contribution to make in advancing patients' care. The country's healthcare system is yet to make the best use of the FM specialist's role in improving quality of care. The perceptions of FM from other specialists were generally positive and reinforced its importance in facilitating improved healthcare in SA. These specialists have high regard for FM and emphasised the large responsibility of practitioners.

Legal reflections on the doctor-patient relationship in preparation for South Africa’s National Health Insurance


 The doctor-patient relationship is the foundation of any medical intervention. Over time, the relationship has changed, from the era of paternalism to the era of self-determination or patient autonomy, following changes resulting from consumerism and lately, in South Africa, socialised medicine as a result of the proposed National Health Insurance (NHI). The premise of this article is that patient autonomy is invariably limited by a determination of who will carry the cost of a medical intervention. In recent years, legislative developments have affected the understanding of a patient and doctor through the introduction of new references, such as ‘user’, ‘data subject’ and ‘consumer’ for a patient, and ‘service provider’ and ‘responsible party’ for a doctor, each giving different meanings to the doctor-patient relationship. Recent statutory additions also include new remedies available to aggrieved patients as parties in the doctor-patient relationship. The article concludes with brief observations on how the NHI will alter the essence and nature of the doctor-patient relationship in future.
 

Primary healthcare seeking behaviour of low-income patients across the public and private health sectors in South Africa

BackgroundThe proposed National Health Insurance (NHI) system aims to re-engineer primary healthcare (PHC) in South Africa, envisioning both private sector providers and public sector clinics as independent contracting units to the NHI Fund. In 2017, 16% of the South African population had private medical insurance and predominately utilised private providers. However, it is estimated that up to 28% of the population access private PHC services, with a meaningful segment of the low-income, uninsured population paying for these services out-of-pocket. The study objective was to characterise the health seeking behaviour of low-income, patients accessing PHC services in both the public and private sectors, patient movement between sectors, and factors influencing their facility choice.MethodsWe conducted once-off patient interviews on a random sample of 153 patients at 7 private PHC providers (primarily providing services to the low-income mostly uninsured patient population) and their matched public PHC clinic (7 facilities).ResultsThe majority of participants were economically active (96/153, 63%), 139/153 (91%) did not have health insurance, and 104/153 (68%) earned up to $621/month. A multiple response question found affordability (67%) and convenience (60%) were ranked as the most important reasons for choosing to usually access care at public clinics (48%); whilst convenience (71%) and quality of care (59%) were key reasons for choosing the private sector (32%). There is movement between sectors: 23/76 (30%) of those interviewed at a private facility and 8/77 (10%) of those interviewed at a public facility indicated usually accessing PHC services at a mix of private and public facilities. Results indicate cycling between the private and public sectors with different factors influencing facility choice.ConclusionsIt is imperative to understand the potential impact on where PHC services are accessed once affordability is mitigated through the NHI as this has implications on planning and contracting of services under the NHI.

Towards a needs-based design of the physical rehabilitation workforce in South Africa: trend analysis [1990\u20132017] and a 5-year forecasting for the most impactful health conditions based on global burden of disease estimates

BackgroundRehabilitation can improve function in many people with chronic health conditions. It is important to consider priority conditions requiring rehabilitation, so it can be realistically positioned and costed in national health financing systems like South Africa (SA)‘s proposed National Health Insurance (NHI). This paper describes temporal trends of top-ranked conditions on years lived with disability (YLDs) rates in SA, for which physical rehabilitation can ameliorate associated disability.MethodsThis study is a systematic synthesis of publicly available Global Burden of Disease (GBD) 2017 estimates. The top 11 conditions contributing most to YLDs and for which evidence-based rehabilitation interventions exist were identified. Age-standardized rates per 100,000 and YLDs counts were extracted from 1990 to 2017. Significance of changes in temporal trends was determined using Mann-Kendall trend tests. Best-fit rates of yearly changes were calculated per condition, using GBD estimates (2012–2017), and extrapolated (by imposing the best-fit regression line onto results for each subsequent predicted year) as forecasts (2018–2022).ResultsTrends for YLDs counts per condition year (1990–2017) and forecasted values (2018–2022) showed an overall steady increase for all conditions, except HIV and respiratory conditions. YLDs counts almost doubled from 1990 to 2017, with a 17% predicted increase from 2017 to 2022. The proportionate contribution to YLDs counts reduced over time for all conditions, except HIV. Although age-standardized YLDs rates appear relatively stable over the analyzed periods for all conditions (except HIV, respiratory conditions and type 2 diabetes), trend changes in YLDs rates over 28 years were significant for all conditions, except neonatal (p = 0.855), hearing loss (p = 0.100) and musculoskeletal conditions (p = 0.300). Significant trend decreases were apparent for 4/9 conditions, implying that another 5/9 conditions showed trend increases over 28 years. Predicted all-age prevalence in 2022 suggests relatively large increases for cardiovascular disease and heart failure, and burns, while relative decreases are predicted for fractures and dislocations, stroke, and musculoskeletal conditions.ConclusionRehabilitation needs in SA are potentially massive and unmet, highlighting the need for innovative and context-specific rehabilitation that considers current local needs and projected changes. These findings should be considered when designing the NHI and other schemes in SA to ensure human and financial resources are deployed efficiently.

Public engagement in the development of the National Health Insurance: a study involving patients from a central hospital in South Africa

BackgroundThe National Health Insurance (NHI) is a proposed health policy in South Africa that aims to change the structure of the current health system. Public involvement in policy making is important and it is a constitutional requirement in the legislation development process in South Africa. Patients are key stakeholders and should be engaged in NHI policy process. Before patients can be engaged, they need to be provided with sufficient information about the NHI. Therefore, the aim of this exploratory study was to examine the levels of patient awareness of the NHI, which is a requisite for meaningful engagement.MethodsThis was a cross sectional study of 244 patients from the follow-up clinics at the Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital in the Gauteng Province, South Africa. The patients were interviewed using a structured interview process and a questionnaire. Descriptive statistics and logistic regression analyses were conducted.ResultsThe majority (79.51%) of the participants were not aware of the proposed National Health Insurance (NHI) in South Africa even though the NHI policy process commenced in 2011. Of the participants who were aware of the NHI, 86% responded that they had not been provided with an opportunity to be involved in the policy making process of the NHI. The odds of awareness were higher for male (OR: 2.08, 95% CI: 1.11–3.9, p value: 0.02) than female participants; White (OR: 2.36, 95% CI: 1.06–5.26, p value: 0.04) and Indian (OR: 2.76, 95% CI: 0.10–7.60, p value: 0.05) participants when compared to Black participants; and retired (OR: 3.13, 95% CI: 1.35–7.25, p value: 0.008) than unemployed participants.ConclusionThe levels of awareness of the NHI were low among the participants from Department of Internal Medicine, CMJAH. Without the awareness and information about the NHI, patients are not equipped to be involved in the NHI policy process in a meaningful way. Public patients are the intended beneficiaries of universal health coverage, therefore they should be prioritized in the NHI community engagement process to ensure that the NHI is community and patient centred.

Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance.

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation.

Primary healthcare delivery models for uninsured low-income earners during the transition to National Health Insurance: Perspectives of private South African providers.

The proposed National Health Insurance (NHI) system aims to re-engineer primary healthcare (PHC) provision in South Africa, with strategic purchasing of services from both private and public sector providers by the NHI Fund. Currently, while access to the private sector is primarily restricted to high-income insured earners, an important proportion of the low-income segment is choosing to utilise private PHC providers over public sector clinics. In recent years, a number of private providers in SA have established innovative models of PHC delivery that aim to expand access beyond the insured population and provide affordable access to good-quality PHC services. To describe the current landscape of private PHC clinic models targeting low-income, uninsured earners and the role they might play during the transition to NHI. Key informant interviews were conducted with representatives of a sample of private PHC provider organisations providing services to low-income, uninsured earners with clinics - beyond the traditional private sector general practitioner model. Organisations were asked to describe their service delivery model, the population it serves, the PHC services offered and the financing model. Written responses were captured in Excel and coded manually, and the results were thematically analysed. Of the eight organisations identified, most have actively engaged strategies to ensure the provision of affordable quality care. Within these strategies, scale is an important pivot in spreading fixed costs across more paying patients as well as task shifting to lower cadres of healthcare workers. Access to government medicines and laboratory tests is an important factor in achieving lower costs per patient. Together, these strategies support the sustainability of these models. We have provided an exploratory analysis of private PHC service delivery models serving the low-income, uninsured patient population, establishing factors that increase the efficiency of such service delivery, and delineating combinations of strategies that could make these models successful both during the transition to NHI and during full-scale NHI implementation. A clear regulatory framework would act as a catalyst for further innovation and facilitate contracting. These existing models can enhance and complement government provision and could be scaled up to meet the needs of expanding PHC under NHI. Understanding these models and the space and parameters in which they operate is important.

Tax as an option to fund the proposed National Health Insurance fund: What do knowledgeable individuals think?

This research paper seeks to answer the question: What tax or combination of taxes knowledgeable individuals think the South African government can use as a potential source of revenue to fund the proposed National Health Insurance?The research methodology adopted is of an exploratory interpretive nature as it deals with the opinions of respondents. This methodology is well suited to the research process as the goal is to obtain and explore knowledgeable individuals’ opinions on what they perceive to be the best tax or combination of taxes which can be used as a potential source of revenue to finance the National Health Insurance fund. The method initially comprised a normative study, focusing on a literature review, the results of which were then used to create a self-developed questionnaire.This research aims to contribute to the body of knowledge which the South African government can consider when making a decision on a tax or combination of taxes as a possible method of financing. A sample of 91 people consisting of 40 tax practitioners (44%), 33 academics (36.2%) and 18 economists (19.8%) were asked to complete the questionnaire. The resultant data were subjected to various statistical analysis methods, including factor analysis, Kruskal-Wallis tests and Cluster analysis.The results reveal that (a) an increase in Value-Added tax is perceived as being justifiable, fair and efficient, while (b) an increase in taxes on individuals or an introduction of payroll taxes is not. The respondents suggest that funds be ring-fenced for National Health Insurance as this will increase accountability and prevent the funds from being expropriated during the budgetary process.

VP33 Pharmacoeconomic Submission Requirements: Africa Compared With England

IntroductionThe South African Pharmacoeconomic Submissions Guideline (SAPG) is currently voluntary for medicines in the private health sector but may become mandatory and more widely used under the proposed National Health Insurance system. To make recommendations on evidence generation and areas where the SAPG could be strengthened, the study compared the SAPG requirements with other African pharmacoeconomic guidelines and the National Institute for Health and Care Excellence Methods Guide (NICE MG).MethodsThe World Health Organisation, International Network of Agencies for Health Technology Assessment (INAHTA), HTA International, and the International Society for Pharmacoeconomics and Outcomes Research websites were consulted, and email requests sent to named individuals from retrieved source material. The European Network for HTA Core Model® (version 3.0) (the Model®) provided the evaluation and comparison framework, using three criteria: completely, partly or not completely requiring the same or similar information as the Model®.ResultsOf the forty-five countries identified, only Egypt had a publicly available pharmacoeconomic guideline (Egyptian Pharmacoeconomic Guideline (EPG)). The guidelines varied considerably in their intended audience, size and content. All three guidelines’ primary focus was the cost and economic evaluation, and health problem and current use domains. Safety, organisational, ethical and legal aspects were poorly covered by the SAPG and EPG guidelines (less than thirty percent of issues in each domain completely / partly covered). The SAPG completely or partly required the same or similar information in the Model® for thirty-nine percent of total issues, the EPG thirty-three percent and the NICE MG sixty-six percentConclusionsThe SAPG was not as comprehensive as the NICE MG and poorly covered some key aspects of HTAs, suggesting that the SAPG could be developed to be more informative for decision-makers. Evidence generation should focus on describing the health problem the technology is targeting and on evidence that can be synthesized into cost-effectiveness analyses.

Knowledge and Perceptions towards the Proposed National Health Insurance Implementation

Public healthcare in Malaysia is largely financed by the governmentsubsidy. With the increased demand and utilisation of healthcare services,the current financing system is seen as no longer accommodating. Tomaintain an agenda of universal coverage and equitable healthcare system,the government is currently proposing the implementation of nationalhealth insurance (NHI) scheme. To determine public disposition towardsNHI implementation, the current study was therefore embarked. A total of471 questionnaire copies were conveniently distributed to selected adultrespondents in Klang Valley, Malaysia. Data analysis performed indicateda strong positive correlation between respondents disposition, measured bysubjective norms, and attitude supporting the implementation. Increase inknowledge was also associated with positive attitude towards NHI. Resultof regression analysis identified both subjective norms and knowledgecontributed to the prediction of the respondents attitude.
 Keywords: national health insurance, health care financing, attitudes,knowledge

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

Exploring the barriers to implementing National Health Insurance in South Africa: The people's perspective.

This article explores the challenges of implementing the proposed National Health Insurance for South Africa (SA), based on the six building blocks of the World Health Organization Health System Framework. In the context of the current SA health system, leadership, finance, workforce, technologies, information and service delivery are explored from the perspective of the people at ground level. Through considerations such as these, the universal health coverage goals of health equity, efficiency, responsiveness and financial risk protection, might be realised.

Training and support to improve ICD coding quality: A controlled before-and-after impact evaluation.

The proposed National Health Insurance policy for South Africa (SA) requires hospitals to maintain high-quality International Statistical Classification of Diseases (ICD) codes for patient records. While considerable strides had been made to improve ICD coding coverage by digitising the discharge process in the Western Cape Province, further intervention was required to improve data quality. The aim of this controlled before-and-after study was to evaluate the impact of a clinician training and support initiative to improve ICD coding quality. To compare ICD coding quality between two central hospitals in the Western Cape before and after the implementation of a training and support initiative for clinicians at one of the sites. The difference in differences in data quality between the intervention site and the control site was calculated. Multiple logistic regression was also used to determine the odds of data quality improvement after the intervention and to adjust for potential differences between the groups. The intervention had a positive impact of 38.0% on ICD coding completeness over and above changes that occurred at the control site. Relative to the baseline, patient records at the intervention site had a 6.6 (95% confidence interval 3.5 - 16.2) adjusted odds ratio of having a complete set of ICD codes for an admission episode after the introduction of the training and support package. The findings on impact on ICD coding accuracy were not significant. There is sufficient pragmatic evidence that a training and support package will have a considerable positive impact on ICD coding completeness in the SA setting.

The World Health Organization's mechanisms for increasing the health sector budget: The South African context.

South Africa (SA) has limited scope for raising income taxes, and the proposed National Health Insurance (NHI) scheme will necessitate growthin the health sector budget. The NHI White Paper suggests five funding scenarios to meet the expected shortfall. These scenarios are a mixtureof a surcharge on taxable income, an increase in value-added tax and a payroll tax. Five alternative options, suggested by the World HealthOrganization, are interrogated as ways to decrease the general taxation proposed in the White Paper. The five mechanisms (corporate tax, financialtransaction levy, and taxes on tobacco, alcohol and unhealthy foods) were chosen based on their fund-raising potential and their mandatoryelement. A literature review provides the information for a discussion of the potential costs of each mechanism. Within specific assumptions,potential budgetary contribution is compared with the requirement. First, raising corporate tax rates could raise enough funds, but the losses dueto capital flight might be too much for the local economy to bear. Second, a levy on currency transactions is unlikely to raise the required resources,even without a probable decrease in the number of transactions. Third, the increase in the tax on tobacco and alcohol would need to be very large,even assuming that consumption patterns would remain unchanged. Lastly, a tax on unhealthy food products is a new idea and could be exploredas an option - especially as the SA Treasury has announced its future implementation. Implementing only one of the mechanisms is unlikely toincrease available funding sufficiently, but if they are implemented together the welfare-maximising tax rate for each mechanism may be highenough to fulfil the NHI scheme's budgetary requirement, moderating the increases in the tax burden of the SA population.