chronic

Alarmingly high HIV/AIDS prevalence rates in Ugandan fishing communities are threatening the lucrative fishing industry, which brought some US 105 million into the country in 2004, a new government survey has found.

In scaling up antiretroviral treatment (ART), financing is fast becoming less of a constraint than the human resources to ensure the implementation of the programmes. In the countries hardest affected by the acquired immunodeficiency syndrome (AIDS) pandemic, AIDS increases workloads, professional frustration and burn-out. It affects health workers also directly, contributing to rising sick leave and attrition rates. This burden is shouldered by a health workforce weakened already by chronic deficiencies in training, distribution and retention. In these countries, health workforce issues can no longer be analysed from the traditional perspective of human resource development, but should start from the position that entire societies are in a process of social involution of a scale unprecedented in human history. Strategies that proved to be effective and correct in past conditions need be reviewed, particularly in the domains of human resource management and policy-making, education and international aid. True paradigm shifts are thus required, without which the fundamental changes required to effectively strengthen the health workforce are unlikely to be initiated.

KZN MEC Peggy Nkonyeni has increased the budget of the province's emergency services by almost 30%, but says it is still not enough to meet demand.

It gives me great pleasure to present the budget of the national Department of Health for your consideration, debate and acceptance.

Womens Rights in the Fight against HIV/AIDS

The speech of the Deputy Health Minister Nozizwe Madlala-Routledge.

The brain drain of nurses and doctors in African countries is jeopardising the global fight against HIV/AIDS.

Furious doctors are planning to march on parliament, and may even go on strike, over what they say is a crisis in South African medicine. They have: hit out at chronic under-funding by the government and the halving of budgets; claimed that the department of health is spending more on bureaucracy than patients; complained of appalling pay and working conditions; and, threatened to emigrate in their hundreds. The doctors' dissatisfaction has grown to such a degree that the SA Medical Association has become an affiliate of Cosatu. A weekend conference in Johannesburg to discuss strategies for doctors' survival was peppered with war talk. Dr Kgosi Letlape, head of the Medical Association, said although doctors were essential personnel and may not strike, this drastic action was still a possibility. But first we need to raise public awareness about our plight. Letlape said it was time for doctors to join forces and stand up and fight. We have been at the bottom of the food chain for too long. We are not going back. We will negotiate with the government. But if deafness ensues, we will resort to sign language, he warned. The doctors' anger was fuelled by the last-minute pull-out from the conference by the minister of public service and administration, Geraldine Fraser-Moleketi. She said she wasn't able to address the pay and working conditions of public sector doctors. Letlape said the association had tried desperately to create dialogue with the government but doors had been slammed in its face. If there is anyone out there with other remedies, herbal or otherwise, please try to help us, he said. Dr Mark Sonderup, chairman of the SA Registrars' Association, who works at Groote Schuur Hospital, said a sore point was the chasm between administrators and clinicians, as well as expensive top-heavy administrations. Groote Schuur, for example, had appointed a new chief executive officer and seven or eight medical superintendents since 1996, along with healthcare and nursing managers. There is a huge bureaucracy running a hospital that has lost half its beds in the past seven years. They seem to be spending less money on care and more money on administration systems, he said. The joint budget for Groote Schuur and Red Cross Children's hospitals was R1,1 billion in 1996. That had been halved to R525 million this year, but hospitals in the area were seeing one million more patients a year. Money is falling down the pyramid, allegedly to primary healthcare, but it's definitely not reaching those people who really need it. Is it going into administration and bloating the bureaucracy? Sonderup asked. Dr Timothy Berlyn, of the Junior Doctors' Association, said: As many as 60% to 70% of my friends in the medical sector plan to emigrate. Another 20% will stay to specialise and then they will leave. The majority of the rest of them will migrate internally - to the private sector. He said the migration was having an avalanche effect. As doctors left, those left behind picked up a bigger burden and became stressed. Then they left. It's a never-ending cycle. Professor Denise White, chair of the Medical Association's committee on public sector doctors, said she wasn't working in the public health sector for the money. We just want a fair deal to serve the people of this nation. White said the association had made many submissions to the department, but was stonewalled - something it would no longer tolerate. White said problems with working conditions included: understaffing, lack of essential medicine and equipment; inadequate support and supervision of junior doctors in rural areas; declining capacity for supervision and training of registrars; poor living conditions for community service doctors; lack of security at work; burgeoning patient loads; and the burden of diseases like HIV/AIDS and TB. (Di Caelers: The Cape Argus, 22 September 2003)

It is clear that large-scale treatment for HIV will depend on re-thinking the use of human resources if it is to have public health benefits. Health care staff working in multi-disciplinary teams providing long-term HIV care may find their roles changing over time in ways that will need careful management. The role of nurses is of particular importance in many settings, and there is clearly scope for expanding that role with appropriate training and support. Nurse practitioners trained to prescribe a range of medicines and nurse-led clinics are among the options that need to be explored. Specialised pharmacists can also take on a major role in supporting people with HIV on treatment. A system that chooses first-line regimens that can be managed with limited direct involvement from doctors will be able to make more use of other health care staff in managing them. Human resource issues are therefore directly connected with the development of national treatment guidelines. Lay involvement, starting with peer support, may also be needed for a successful large-scale treatment programme. A variety of models for peer support and treatment education are available for use. Social stigma doesn't automatically disappear when services are established (though treatment certainly helps to overcome it). As well as training, resources are needed to prevent occupational exposure to HIV. Continuing professional support and development are needed by all staff involved in delivering HIV treatment, and not only in relation to ARVs.

Low-income earners are a vast largely untapped market for the medical schemes industry. At the recent Discovery Health / Personal Finance Health Wise seminars, Penny Tlhabi, the managing director of the Board of Healthcare Funders, discussed the challenges schemes will have to overcome if they want to attract low-income members. The Department of Public Service and Administration's initiative to start a single medical scheme for all public servants is expected to be a catalyst for extending private healthcare to low-income groups. The proposed government scheme will be able to contract with a number of administrators, and is expected to use its large membership to negotiate a viable low-cost option. There is talk that this low-cost option could later be opened to all low-income earners - not just those in the public sector. The key issues driving the need to develop low-cost options for low-income earners are: the government's desire to redress past imbalances and ensure that all South Africans have access to quality healthcare; the move towards employment equity in the workplace; trade unions' demands for equal treatment for all employees; and, the deterioration of public health facilities, which is stimulating the demand for private healthcare. In addition, low-income options present the only real opportunity for growth in the medical schemes industry, as the higher-income market is already saturated. Despite the need for access to medical schemes, there has been little growth in new membership. The number of people who belong to medical schemes has remained more or less the same: there were about seven million members during 2001 - an increase of only 0.23 percent on 2000. These seven million members represent only 16 percent of the South African population. The medical schemes industry is highly competitive, with a substantial number of members moving between schemes. Research conducted by the Board of Healthcare Funders (BHF) last year showed that only three out of the 10 largest schemes surveyed increased their membership base. Despite medical scheme industry estimates that another seven million people could join low-cost medical scheme options, the uptake has been very slow, with only about 150 000 people currently in such options. Also, a significant portion of these new members consisted of people moving from one scheme to another, cheaper scheme, or from a high- to a low-cost option within their scheme. Reasons why people are not joining schemes include: shrinking employment in the formal sector of the economy; the unaffordability of membership; and, falling disposable incomes. Obstacles facing schemes The main objective of the Medical Schemes Act is to ensure that vulnerable groups, such as the elderly and people with chronic conditions, have healthcare cover. The Act made open enrolment and community rating compulsory for medical schemes. Open enrolment means you cannot be turned away by an open medical scheme that you want to join. Community rating means that schemes cannot make you pay a higher contribution because of your health or age. A scheme may only differentiate its contribution rates on the basis of your income and number of dependants. The Act also introduced a basket of essential benefits that all schemes have to provide, known as prescribed minimum benefits. However, while the medical schemes industry supports the objectives of the Act, the implementation of the legislation has had some unintended consequences, because membership of medical schemes is voluntary. One of these unintended consequences is that prescribed minimum benefits have made low-cost schemes unaffordable for low-income earners. In terms of the latest regulations under the Medical Schemes Act, the prescribed minimum benefits will be extended from January 2004 to included 25 common chronic conditions. In the past schemes have structured their benefits in such a way that many members who are in poor health are forced to join the more expensive options if, for example, they want to access chronic medicine benefits. This has forced members who cannot afford to pay the higher rates to buy down into the lower-cost options. As a result, the low-cost options have a lot less healthy members and their claims soar. The ultimate consequence of this is that the contributions on these options increase, making them less affordable. The Act requires that, by the end of 2004, schemes keep 25 percent of their gross contributions in reserve. Schemes have had to increase contributions to meet the reserve requirements, and these requirements do not take into account the real level of financial risk that schemes face. This is a highly significant driver of costs and it does not encourage growth in scheme membership. Other challenges facing medical schemes include: a growing burden of diseases such as tuberculosis, HIV/AIDS and malaria; a shortage of medical specialists in South Africa; and, a lack of competition among healthcare providers. The growing concentration of power among providers has made it difficult for schemes to enter into contracts with specialists and private hospitals. There is also a lack of hospital networks that are willing and able to manage the risks faced by medical schemes and, ultimately, members. This prevents low-cost options from lowering their costs by, for example, entering into a contract with a hospital in terms of which the hospital will treat its members for a fixed fee per day or per operation, and in this way share the risk between the scheme and the service provider. Costs in the private aging healthcare sector are increasing dramatically - between 1982 and 1997, the increase in real terms was 517 percent. These increases are being driven by the cost of new technology and drugs, the population and the fee-for-service system. (In the fee-for-service system, members pay a fee, set by the healthcare provider, for services they receive. Schemes and members have little control over the fee and there is a tendency by the service providers to overservice.) There are no real incentives, such as tax breaks, for low-income earners to belong to a medical scheme rather than rely on public healthcare.What is needed for low-cost schemes to succeed? A new business model must be developed for low-cost medical schemes so they can become viable. The model will require schemes to forge strategic partnerships with carefully selected healthcare providers on the basis of a shared vision, the ability to practise cost-effective medicine and integrity. The most important issue is the quality of the providers in the network. Another critical issue is information systems and how information is used to develop incentives for providers to practise cost-effective care.Measuring the quality of healthcare is also very important because, if used inappropriately, risk-sharing models may affect the quality of care of members. For example, if a doctor is paid a fixed fee per month to service all the members of a particular medical scheme, he or she may be incentivised to underservice his patients in an effort to maximise his profits. Incentives for administrators, consumers, schemes, and providers should be aligned through risk-sharing so that each one assumes a portion of the risk. It was also necessary for low-cost schemes to provide innovative, pro-active and well-managed HIV/AIDS benefits, and innovative benefits based on clinical best practice rather than crude financial limits, and for there to be incentives, including tax subsidies, for employers and employees to obtain and retain medical scheme cover. The use of co-payments and deductibles (where members pay a portion of the account) - where appropriate - for elective procedures, is important to expose consumers to the costs of healthcare and encourage them to act prudently. Furthermore, education programmes for members that enable them to make informed choices are critical to the success of these products, In conclusion there is definitely is a business opportunity for low-cost schemes, but it requires innovation and a can-do attitude. (Source: Personal Finance, 16 August 2003).