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National Health Act, 2003 (Act No. 61 of 2003)


National Health Insurance Policy towards Universal Health Coverage

Chapter 5 : National Health Insurance Coverage

5.3 Service coverage

5.3.1 Expanding access to Hospital Services


120. NHI will contract with accredited public and private providers at specialist and hospital levels based on need. Services to be rendered at the hospital level will be based on comprehensive healthcare services that are appropriate to the various levels of care. These services will include diagnostic, curative, allied, palliative and rehabilitative services.


121. Patients who need to be treated by specialists or in hospitals will have to be referred by PHC providers to certified and accredited hospitals and specialists. This means, except in acute emergency medical contexts, patients cannot self-refer to a specialist or a hospital without being seen at the PHC level either at a clinic or by a general practitioner.


122. Hospital services will be provided based on the existing classification of hospitals in the public sector and taking into account the level of care to be provided. Using this classification, level 1 (district) services will be provided by generalist medical (and dental) practitioners including surgical interventions under anaesthesia. The scope of services to be rendered at level 2 facilities (regional) will include services that can be provided by general specialists in anaesthesiology, general surgery, internal medicine, obstetrics and gynaecology, orthopaedics, paediatrics, psychiatry, diagnostic radiology, pathology and allied health services.


123. Tertiary services will be rendered through level 3 facilities. The comprehensive health care services at this level will include sophisticated diagnostic and treatment services. The services will be provided by general specialists in anaesthesiology, general surgery, internal medicine, obstetrics and gynaecology, orthopaedics, paediatrics, psychiatry, radiology and diagnostic services such as pathology.


124. Quaternary and other tertiary services will be rendered through national and central referral centres. The services rendered will include sub-specialist and super-specialist services such as advanced trauma care, organ transplantation and have technologically complex equipment and clinical support services.


125. Hospital and medical specialist healthcare services will be specified by the NHI Benefits Advisory Committee based on evidence of efficacy, quality, safety and cost-effectiveness. Accredited hospitals and specialists will deliver healthcare services in accordance with clinical protocols and referral guidelinesg. This will provide guidance on the referral system and on what services should be rendered or performed at designated levels. Ambulatory specialist healthcare services will be delivered through duly accredited public and private providers. Specialists will be required to comply with guidelines, treatment protocols, prescribed quality and other standards and the prescribed referral system.


126. Identified providers of health care services for priority areas such as Obstetrics and Gynaecology, Paediatrics and Trauma Services in the private sector will be contracted based on need. As NHI matures, these high priority services will be more widely available to the population from a wider network of accredited providers.



g The channelling of a patient to another level of care, either at a higher or lower level for continuity of care