Abstract
Background: The first phase of the National Health Insurance (NHI) pilot programme focusing on primary healthcare has been implemented in Tshwane and 10 other districts of South Africa since 2012. This was envisaged to improve the quality of healthcare at primary healthcare level, and offset the burden of non-emergency healthcare at hospital outpatient level. However, there are no population-level studies that have been done to determine the relationship and interdependence of primary healthcare and hospital outpatient-level indicators that are needed to forecast utilisation of health services. This information is key to plan for roll-out of NHI, in setting benchmarks to guide health policy and allocation of resources.
Objectives: To determine the interdependence and relationships between primary healthcare and hospital outpatient-level indicators in a NHI pilot district, and forecast the utilisation of services to 2030.
Methods: This was a quasi-experimental ecological study design, making use of selected primary healthcare and outpatient department indicators in the District Health Information System monthly reports between January 2010 and December 2019 for Tshwane district. We used the vector error correction model to determine the interdependence and relationships between these indicators, and used these to forecast utilisation of services to 2030.
Results: The study found that most non-emergency care is provided at primary healthcare level by professional nurses. It confirmed the influence of selected primary healthcare and outpatient department headcounts on each other by finding the existence of four co-integration relationships between the variables. Both long-run and short-run causality exists between them. Based on these relationships, we forecasted that by the end of 2030, the outpatient department follow-up headcounts would have doubled, but both primary healthcare total and clients seen by a professional nurse will marginally decline.
Conclusion: Our findings confirm that there is a relationship between primary healthcare and outpatient department indicators, which can be used to plan for provision of services in the future. Based on this relationship and current trends, we found that implementation of the NHI pilot programme will not attain the envisaged goal by 2030.