Technical Expert Health Finance: National Health Insurance

2 months ago

Pretoria, South Africa Panagora Group Full time

Background to TSS

The Technical Support Services (TSS) Activity helps USAID/Southern Africa address technical priorities and develop creative, innovative solutions to strategically allocate resources, strengthen connections with partners, and replicate best practices and effective program models. Through the TSS contract, Panagora Group augments capacity by providing technical, operational, and administrative support to USAID/Southern Africa’s portfolio. TSS deploys advisors in response to USAID requests for priority work with government stakeholders, implementing partners, and/or other entities. TSS supports USAID staff and teams to integrate creative solutions into routine work. TSS also provides international and local expertise for surge support, as needed, for USAID Program Cycle requirements, planning, development, outreach, communications, and Health Office human resource functions. 

Background to this SOW

The National Department of Health is seeking a Technical Expert Health Finance (NHI) to support the Deputy Director General within the National Health Insurance Directorate. The technical expert will focus on designing and implementing a capitated payment mechanism for primary healthcare providers in selected proof-of-concept Contracting Units for Primary Health Care (CUP) sites. 

The National Health Insurance (NHI) bill, enacted in May 2024, aims to achieve universal health coverage and improve access to quality healthcare services through the establishment of around 250 CUPs for strategic purchasing of primary health care.

Implementing Contracting Units for Primary Health Care (I-CUPs) Programme

Launched in August 2022, the CUPs program aims to implement the CUP model in designated sub-districts across all nine provinces, each selected as a proof-of-concept area. This initiative involves testing key components of the NHI framework, including digital user registration, provider accreditation, and reimbursement, with the intent of transitioning to a capitation payment model.

Capitation Models

Capitation models involve payments made on a per-person basis, serving as both a funding formula for CUPs and a reimbursement mechanism for healthcare providers. During the proof-of-concept phase, most services will be delivered by Provincial Departments of Health and funded through Provincial Equitable Shares, while the NHI Indirect Grant will support additional services, particularly from private providers.

Capitation Payment Mechanisms

Under a capitation model, providers receive a fixed payment for each registered user over a specified period, regardless of whether care is provided. Payments are based on the average healthcare needs of users and can include risk adjustment for populations needing more care. While capitation models enhance provider autonomy and efficiency and mitigate financial risk, they also carry the risk of cost-cutting that may compromise care quality. Therefore, it is essential to combine capitation with performance-based payment components to ensure quality care and patient outcomes.

Position Responsibilities 

The I-CUPs program provides a unique opportunity to apply existing international and local research on capitation design, including insights from the 2018 GTAC capitation project, to develop a tailored approach for South Africa. The framework for designing an outcomes-based capitation model for primary care reimbursement in proof-of-concept CUP areas is outlined below.

Key Tasks and Deliverables:

Literature Review: Examine existing research on capitation and risk adjustment.

Progress Report: Provide oversight, guidance, and support for the I-CUPs program.

Internal Consultation Report: Assist the Deputy Director General (DDG) in consultations regarding the primary care capitation contract.

External Stakeholder Presentation: Support the NDOH team in consultations with external stakeholders on the primary care capitation contract.

Methodology Development: Create a detailed methodology for calculating the risk-adjusted capitated fee and facilitate decision-making processes.

Scenario Planning Document: Aid in discussions with providers and stakeholders regarding the proposed risk-adjusted capitated fee.

Facilitation of Consultations: Lead discussions on outcomes-based payment design, including HIV/TB-related outcome measures.

Data Collection Specifications: Develop detailed requirements for data collection and reporting.

Capitation Manual Refinement: Update and refine the capitation manual.

Pilot Report: Prepare a report on the NHI and CUPs pilot.

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