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


National Health Insurance Policy towards Universal Health Coverage

Glossary of Terms




1. Acute Emergency Care: Defined as medical care that includes health system components, or care delivery platforms, used to treat sudden, often unexpected, urgent or emergent episodes of injury and illness that can lead to death or disability without rapid intervention1. It encompasses a range of clinical health-care functions, including emergency medicine, trauma care, pre-hospital emergency care, acute care surgery, critical care, urgent care and short-term inpatient stabilisation. It is a care that is provided to respond to immediate life-threatening conditions and requires resource redistributions to minimise impending death or disability.


2. Allocative Efficiency: Refers to when resources are allocated so as to maximise the welfare of the community by achieving the right mixture of healthcare programmes to maximise the health of society. It is used to inform resource allocation decisions in this broader context as a global measure of efficiency. It takes into account not only productive efficiency with which healthcare resources are used to produce health outcomes but also the efficiency with which these outcomes are distributed among the community. Such a societal perspective is rooted in welfare economics. In theory, the efficient pattern of resource use is such that any alternative pattern makes at least one person worse off2.


3. Asylum seeker: Refers to a person who seeks safety from persecution or serious harm in a country other than his or her own and awaits a decision on the application for refugee status3.


4. Catastrophic health care expenditure: Health care expenditure resulting from severe illness/injury that usually requires prolonged hospitalisation and involves high costs for hospitals, doctors and medicines leading to impoverishment or total financial collapse of the household.


5. Child mortality: It includes peri-natal and neonatal mortality. Peri-natal mortality–is the death of a baby who was born live after 20 weeks of pregnancy or dies within seven completed days after birth measured per 1000 births. It includes stillbirths. Neonatal mortality– refers to the death of a live born baby within 28 days of birth and is measured per 1,000 live births.


6. Clinical Governance: Is described as a system through which healthcare teams are accountable for the quality, safety and experience of patients in the care they delivered. It means specifying the clinical standards delivered by health care staff and showing everyone the measurements made to demonstrate what has been done as initially set out.


7. Contracting Unit for Primary Health Care (CUP): Adapted from Thailand's CUPs where it is described as a unit that can be contracted to provide primary healthcare services such as prevention, promotion, curative, rehabilitative ambulatory, home-based acre and community care. Each CUP has its own catchment area and population. It must fulfil certain criteria to be recognised as a CUP, especially in relation to human resources where there must be a doctor, pharmacist, dentist and nurses. The patient has to register with a health facility that is in a CUP catchment area and access services within that area. In rural areas where staff are only available in hospitals, the health centre must associate with the District hospital to constitute a CUP.


8. Contracting-out of Providers: It is based on the theory of combining public finance with private provision and has been used in activities ranging from 'internal market' arrangements in which providers compete for funding from a government payer to purchases of medical and non-medical inputs by service providers4. While contracting-out arrangements for non-medical services have been widely adopted with apparent success, 'market failures' of contracting-out of medical services often arise from inefficient and potential disruption to healthcare delivery. Prerequisites of more extensive contracting models include the development of information systems and human resources5.


9. Diagnosis Related Groupers (DRGs): It is a system of patient classification developed to classify patients into groups economically and medically similar, and expected to have comparable hospital resource use and costs. Providers are reimbursed at a fixed rate per discharge based on this classification and has a strong incentive for cost-containment. In a DRG system, quality and monitoring measures are essential to avoid negative effects of premature discharges from hospital, selection of low-cost patients and increase of admissions.


10. Emergency Medical Services: Are defined as any private or state organisation dedicated, staffed and equipped to offer pre-hospital medical treatment and transport of the ill or injured and where appropriate the inter-health establishment referral of patients requiring medical treatment en-route, pre-hospital emergency medical services for events and the medical rescue of patients from medical rescue situations6.


11. Financial Risk Pooling: A program created by law where financial resources risks are placed into a pool to provide a safety net for a broad cross section of society with differing medical risks with the purpose of benefiting from cross-subsidisation within the Fund.


12. Health Outcomes: Defined as changes in health status that are usually due to an intervention and can be applied for individuals as well as populations. It requires data about the state of health.


13. Health Technology Assessment (HTA): Defined by the WHO as a systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making.


14. International Classification of Diseases (ICD): Developed by the World Health Organisations as a standard diagnostic tool for epidemiology, health management and clinical purposes. It is used for reimbursement and resource allocation decision making. It is also used to monitor the incidence and prevalence of diseases and other health problems, providing a picture of the general health situation of countries and populations.


15. Irregular migrants (or undocumented / illegal migrants): People who enter a country, usually in search of income-generating activities, without the necessary documents and permits7.


16. Long-term residency: Refers to a new visa regime that replaces permanent residency that provides for immigrants to be admitted and sojourn in the Republic for longer periods in respect of prescribed categories, with validity periods and renewals or review in accordance with the purpose of residence. It will not be linked to citizenship8.


17. Mandatory prepayment: Refers to paying for health before the person is sick and this is compulsory according to income levels and the funds are pooled for the entire population. This includes general tax revenue.


18. Maternal mortality: Refers to the number of women who die due to pregnancy related causes. Maternal mortality is measured per 100,000 live births in a given population. It includes any pregnancy related death and is measured from the beginning of pregnancy to six weeks after birth or termination of pregnancy.


19. Monopsony: Refers to a large buyer that controls a large proportion of the market and strategically uses this to drive the prices down.


20. Multi-disciplinary Teams: The concept dates as far back as the 1944 when the Henry Gluckman9 recommended that private providers such as GPs, dentists pharmacists, physiotherapists, and others should provide comprehensive primary care services in a team on a ‘one-stop shop’ basis (i.e. patients should be able to get the full range of primary care services required in one facility or comparable arrangement which does not require the inconvenience or travel costs for the patient).


21. Out-of-pocket payment: Refers to paying cash to a health care provider at the point of care each time a person is sick.


22. Passive purchasing: Refers to a systems that follows a predetermined budget or simply paying bills when presented.


23. Prescribed Minimum Benefits(PMB’s): Refer to a set of defined medical benefits that all medical schemes are mandated to cover to ensure that all their members have access to certain minimum health services, irrespective of the particular benefit option that they belong to.


24. Primary health care (PHC): Addresses the main health problems in the community of providing promotive, preventative, curative and rehabilitative services. According to the WHO’s 1978 Alma Ata Declaration, “primary health care is essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part of both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing healthcare as close as possible to where people live and work, and constitutes the first element of a continuing healthcare process”.


25. Priority-setting in health care: Defined by the WHO as the task of determining the priority to be assigned to a service, a service development or an individual patient at a given point in time in healthcare where health needs are greater than the resources available. Priority-setting also involves allocation of resources to effective healthcare interventions such as high-cost medicines, prevention, or primary care; or even about complex policy interventions such as introducing pay-for-performance schemes for remunerating providers.


26. Productive efficiency: Refers to the maximisation of health outcome through optimal combination of inputs for a given cost. In health care, productive efficiency enables assessment of the relative value for money of interventions with directly comparable outcomes. It cannot address the impact of reallocating resources at a broader level - for example, from geriatric care to mental illness - because the health outcomes are incommensurate10.


27. Public Administration: Refers to the aggregate machinery used through managerial, political and legal instruments and processes to fulfil legislative, executive and judicial mandates for the provision of government regulatory and service functions funded through state budgets that uses interaction with other stakeholders in the state, society and external environment in the provision of public services11.


28. Quality of Care: It is the safe, effective, patient-centred, timely, efficient and equitable provision of healthcare services to achieve desired health outcomes. It takes into account patient safety, meaning the prevention of harm to patients and it employs clinical governance processes to assure quality.


29. Rationing: Refers to limiting of service entitlements in one way or another and it is done in all countries, whether rich or poor. Decisions about how to ration benefits influences health system performance in terms of universal health coverage (UHC) goals. All public and private healthcare systems ration patient access to healthcare. The private sector rations access by charging market prices to patients, with demand driven by a person's ability and willingness to pay. Public systems generally ration care on the basis of a patient’s need, for example by covering priority cost-effective treatments, and through the use of waiting lists. Patients may also be asked to make a co-payment.


30. Refugee: Refers to a person who, "owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country12.


31. Risk Adjusted Capitation: Refers to a fixed payment made to a provider in a defined catchment area per person covered and registered, usually on a monthly basis, regardless of whether they seek care or not.


32. Sustainable Development Goals (SDGs): In 2015 the United Nations adopted Agenda 2030 which is aimed at realising the human rights of all and to achieve gender equality and the empowerment of all women and girls. The Agenda will be achieved through the adoption and implementation of 17 Sustainable Development Goals (SDG's) with 169 targets on each goal to be achieved over the next 15 years. Goal 3 of the SDGs is aimed at ensuring healthy lives and promoting wellbeing for all at all ages.


33. Strategic Purchasing: The WHO describes strategic purchasing as active, evidence-based engagement in defining the service-mix and volume, and selecting the provider-mix in order to maximise societal objectives. Strategic purchasing requires information on a range of issues such as prioritisation, cost-effectiveness, staff and facilities, price, quality and projections on available resources. It is aimed at improving the performance of the health system and make it progress towards universal health coverage. It is undertaken by an active purchaser that pools funds on behalf of a population and purchases health services from accredited and contracted providers.


34. Structural imbalances: Refers to the misalignment between resources and need, which undermines access to health services. In South Africa, this can be equated to costly private health services for the privileged few and schemes for financing care that excludes the poor. It also includes grossly inadequate numbers of staff or the wrong mix of staff, infrastructure or organisation.


35. Technical Efficiency: Refers to the physical relation between resources (capital and labour) and health outcome. It addresses the issue of using given resources to maximum advantage. A technically efficient position is achieved when the maximum possible improvement in outcome is obtained from a set of resource inputs. An intervention is technically inefficient if the same (or greater) outcome could be produced with less of one type of input13.


36. Temporary residence visa: Refers to any of the visas issued to a foreign national to enter and temporarily reside in the country. These include transit, visitors, work and business visa14.


37. Treatment Guidelines: Refers to statements that include recommendations intended to optimize patient care. Such guidelines are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.


38. Universal Health Coverage (UHC): The World Health Organisation (WHO) defines UHC as ensuring that all people can use promotive, preventative, curative, rehabilitative and palliative services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition of UHC embodies three related objectives: (1) equity in access to health services –  those who need the services should get them, not only those who can pay for them; (2) that the quality of health services is good enough to improve the health of those receiving health services; and (3) financial risk protection-ensuring that the cost of using care does not put the people at risk of financial hardship. UHC brings the hope of better health and protection from poverty for hundreds of millions of peopleespecially those in the most vulnerable situations.


39. Voluntary prepayment: Refers to paying for health before the person is sick but this is not compulsory and the funds are pooled for only those who contribute. Medical Aids in South Africa is an example of voluntary prepayment.


40. Vulnerable groups: Refers to population groups that include women, children, older persons and people with disabilities as described in Chapter 1, Section 4 (2) (d) of the National Health Act, 61  2003) and the various subsequent sections of the NHA.