The National Department of Health (NDOH) has been busy since August 2022 exploring the implementation of National Health Insurance (NHI) in South Africa. The focus is on Primary Health Care (PHC). Each province has been asked to decide on a sub-district as a Proof-of-Concept (POC) for the Contracting Unit for PHC (CUP). The proposal from Johannesburg Health District (JHD) for Soweto (Sub-District D) as CUP POC was adopted by Gauteng Department of Health. A Johannesburg Joint Task Team has been working through elements of the NHI to develop a project plan. Prof Shabir Moosa is the CUP Project Manager.
Soweto has been divided into five Contracting Units for PHC (CUPs), around the major Community Health Centres (CHCs) of Soweto [Lillian Ngoyi, Mofolo, Zola, Iterileng and Chiawelo]. We focused on Chiawelo CUP to begin with, with Chiawelo CHC as hub and the clinics around its catchment area as spokes in the wheel.
The Task Team explored the way forward by ensuring an understanding of NHI and PHC Contracting, the role of the CUP and then preparing both public and private providers for potential contracting within the CUP. There was initial confusion with the NHI Bill putting forward an extensive role for the CUP. This was changed with the NHI Act limiting the CUP to just being an administrative sub-unit of the NHI Fund. The NHI Act (2023) states that the objectives of the CUP are to assist the NHI fund to identify needs, profile disease, improve access, identify public/private providers, manage contracts, monitor disbursements, ensure functional referral, facilitate integration of public/private, and resolve user complaints, amongst other things.
The Task Team tried gathering information on population and needs but this was very limited with regards to the population of Chiawelo. We got mostly qualitative descriptions in sub-district operational documents, extrapolated data from StatsSA (and outdated) as well as very limited updated data from Community Healthcare Workers in the area. Most of our time was spent focusing on readying the public service for NHI contracting. Thus was principally exploring/supporting the challenged use of the Health Patient Registry System (HPRS), including access to computers and internet at clinics across Soweto. There were also attempts to understand costs and develop cost-centres for public facilities. A referral paths was created for doctors in clinics (and potential private GPs) in the Chiawelo area and NHI education conducted at the Soweto Referral Forum, facilitated by Bheki Mlangeni District Hospital in support of Soweto.
There was an exploration of private provider contracting done in Gauteng, and then support for the renewed contracting, principally for the Mother and Child Programme. This involves the Department of Health providing consumables free to private providers and limiting the private providers to specified maximum fees for the services related, audits of consumable use and expectations of regular reports. As we proceeded we eventually developed a database of private providers in the Chiawelo area and engaged with them three monthly from July 2023 to explore potential contracting. Models, service packages and costs were explored and presented to develop the collaboration. However these were predicated on firmer details coming from the NHI Branch of the NDOH. This has been limited with the political contestation around NHI. In a workshop in July 2024 there was an expectation that the CUP would develop NHI Champions in each facility to educate both internally and externally. A database of both private providers and community stakeholders was collated in plans for regular workshops in anticipation of contracting. The next quarterly Chiawelo CUPs meeting is 29th November 2024 at Chiawelo CHC.
With the NHI Act being signed in April JHD has set up a monthly NHI Task Team meeting across Johannesburg since then to strengthen CUP implementation across all Sub-Districts of Johannesburg. The agenda has been developed from the Chiawelo CUP, with progress reports on Chiawelo CUP, then exploring Communications / NHI Champions, HPRS use (and IT challenges), OHSC Certification, Sub-District Referral Forums, Sub-District Governance and Cost- Centre/Functional Business Unit Development, MCWH Contracting, and Engagement with contracted Private Service Providers across all the Sub-Districts of Johannesburg Health District.
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In order to simulate the CUP idea of ensuring funding is based on population-based need there has been work on developing the boundaries of CUPs across Johannesburg Health District. This has been premised on DHIS Data providing catchment populations by facilities (Jhb CUP Pop Data), and then grouping clinics/wards around a large node (either a CHC or large clinic).
See draft maps of various CUPs across Sub-Districts of Johannesburg Health District below:
- Sub-District A
- Sub-District B
- Sub-District C
- Sub-District D
- Sub-District E
- Sub-District F
- Sub-District G
Sub-District managers are busy finalising these CUP boundaries. As we proceed we hope to collate available data (DHIS, GCRO, StatsSA, CHWs App etc) by ward into CUP level data to assess a range of profiles of the population. Sub-District managers are also expected to search by suburb in each CUP using a site developed by the NDOH here and assimilate all local private providers into a single list per CUP.
Regular and robust engagement is planned to strengthen the collaboration and contracting with private providers across JHD. Please fill the form below to build the JHD database https://forms.gle/3e5pTN78GbMRPZMKA
Please also join the WhatsApp groups for Private Providers to get communicating locally.
- Sub-District A (Fourways/Midrand/Ivory Park etc.)
- Sub-District BC (Roodepoort/Randburg etc)
- Sub-District E (Alexandra / Sandton etc.)
- Sub-District F (Hillbrow/Rosettenville etc.)
- Sub-District D (Soweto)
- Sub-District G (Orange Farm, Lens etc)
See below a useful example of the COPC model to make NHI contracting efficient and high quality.
