Private healthcare

HEALTH Minister Aaron Motsoaledi yesterday revealed a proposal to introduce three levels of healthcare in SA, with a focus on underserved areas such as rural regions and schools.

The proposal came at the Board of Healthcare Funders’ annual conference, where Dr Motsoaledi called for the regulation of healthcare fees .

He said manufacturers of antiretrovirals (ARVs) originally told the government it was not possible to reduce the cost of the life-saving HIV/AIDS medication because it was expensive. "We said: ‘ Give us the costs .’ And when the costs were given, we found that ... it was not as expensive as that," Dr Motsoaledi said. "And you remember we reduced ARV ( prices ) by 50%, didn’t we?"

Dr Motsoaledi elicited a swift response from the private healthcare industry last week after he broke down the cost of a circumcision in a private hospital.

According to a presentation by Dr Motsoaledi , hospital fees alone ranged between R4184 and R13900, excluding urologist and anaesthetist fees. These hospital fees did not include an overnight stay. In contrast, one of the urologists could do the procedure for R1500 in his rooms, and general practitioners in townships charged R600-R1200.

After a similar presentation last week, private healthcare providers said state hospitals charged less as they were subsided by taxpayers.

Whether medical schemes have to pay in full the minimum prescribed benefits or not to their clients is the subject of a court appeal.

During his presentation yesterday, Dr Mostoaledi hit out at the "deadly divide" in SA’s healthcare system . He announced a plan to introduce three streams of care, which would have an increased effect in rural areas.

The first is the provision of specialists in each of the rural district municipalities. These positions would be announced by the end of this month, and if the posts were not filled, the minister had received an undertaking from all the medical schools in the country to fill the posts from among their own staff on a year-long rotational basis.

The second part of the plan was the establishment of a school health programme. "We have 12-million learners and no one taking care of their eyesight and hearing. Drugs and teen pregnancies are running rampant, while we wait for them at the hospital. I want to see nurses in every school, and we will call on the help of retired nurses if necessary."

The third facet of the proposal was the provision of primary healthcare workers in every municipality. The success of a pilot project in KwaZulu- Natal has led to plans to roll out the system in every municipality in the country. With Sapa

Private healthcare prices in South Africa have to be regulated, Health Minister Aaron Motsoaledi said.

Speaking at the Board of Healthcare Funders conference at Sun City, Motsoaledi called for a pricing negotiation forum, saying healthcare in South Africa was "predatory".

He said the health structure was worse now than during apartheid.

"There is a tendency to believe that a long and healthy life is the right of those that can afford it and that is totally wrong," he said.

"The reality is that our people are dying in large numbers. We are running a healthcare system in this country that is not working."

The solution lay in re-engineering the primary healthcare system.

Motsoaledi announced a plan to introduce three streams of care, which would have a particular impact in rural areas.

Board spokesman Heidi Kruger welcomed Motsoaledi's comments, saying: "I think it's brilliant. The sooner it comes through the better. We can't have a situation where there is no containment on costs."

Kruger said private healthcare providers charged whatever they wanted, "pushing up" medical aid premiums.

The current system was an "open-ended liability for funders" so medical schemes could not budget properly.

Regulating healthcare costs would be "very constructive" and "provide certainty", Kruger said.

Motsoaledi is hoping to begin setting up the pricing forum by the end of the year.

However, he told delegates at the conference that hospitals were creating a stumbling block in the process because that sector did not want to have its prices regulated.

Motsoaledi accused the public and private health sectors of "engaging in destructive, unsustainable practices". He was particularly outspoken about the high cost of private hospital treatment and called for a stronger emphasis on primary care, rather than the present curative system with its "rapidly escalating" costs.

"The public health system is in a crisis of quality and I am going to deal with it head on, but it is not an excuse for profiteering," he said.

"Our country is going in the wrong direction . all of us, public and private," he said. "We have a predatory healthcare system where the sick and the vulnerable are the ones who get attacked."

Rarely in South Africa can a minister have come to power carrying such a weight of expectation as Barbara Hogan. Her first major public speech at the Aids Vaccine Conference in Cape Town in October was greeted with enthusiasm, and even international delegates speculated about the bright future that seems to lie ahead at last for South African healthcare. Her speech was reminiscent of one of those games where one has to bash crocodiles on the head as they pop up apparently randomly through holes in the floor. Politely, and without naming names, Hogan took a baseball bat and bashed all the major crocodiles on the head: Matthias Rath and his vitamins, for instance. Most of all she asserted the fact that HIV causes Aids.

Doctors in private practice will flee the country in droves if Health Minister Manto Tshabalala- Msimang caps the rates they may charge patients. That is according to a survey of doctors, commissioned by the SA Medical Association. It found that most doctors and specialists in private practice would emigrate if the National Health Amendment Bill were enacted. Of the 2568 general practitioners and specialists who responded to the survey, 60percent said they would consider leaving the country if the bill became law . The association has 4941 specialist members countrywide in private and public practice.

The private hospital sector was keen to enter into public-private partnerships with the health department but faced reluctance and red tape in some provinces, Ramesh Bhoola, the chairman of the Hospital Association of SA (Hasa), said this week.

The team to draw up the long-awaited health charter was revealed by minister Manto Tshabalala-Msimang yesterday.The team of 20 includes equal representation from the private and public sectors. First draft is expected early next year.

Inequality and a lack of transformation are glaring in the healthcare sector. Though First World facilities and care are available at a price, children in disadvantaged communities continue to die of preventable diseases because of a lack of basic public healthcare facilities.

The president has signed the new law which requires all healthworkers to apply for a certificate of need. This will be implemented after promulgating the relevant regulation.

Siyabulela Qoza of Sowetan Business spoke to Dr Penny Tlhabi, managing director of the Board of Healthcare Funders of Southern Africa, 25 August 2003. How has the industry transformed over the years? The healthcare industry generates about R40 billion a year with about half of that going to the private side of the business. In terms of consumption, this constitutes about 8,5% of gross domestic product. Most of the transformation has happened at the level of people served. People who earn more than R5 000 a month are well served and there are opportunities in the market of people who earn less money than that. Only about 10% of people in the market belong to medical aid schemes. White men still mainly control the schemes but there is movement taking place. Whether this movement is enough, or fast enough, is another question. Women are opting out of the industry because the working hours are not flexible. The training programme for specialists is not friendly to women. What are the opportunities for black economic empowerment within the industry? There are limited opportunities at the medical aid schemes level except for the administrators. At the moment 10% of total healthcare spend goes to administrators. Private hospitals and pharmaceutical companies attract 33% each. Neither of these industries is within our jurisdiction. But we are interested in their transformation and are aware of what is happening. The Government is planning to put all its employees into one scheme. There is huge interest in the transformation of the administrators because the Government will enter into contracts with administrators to serve its 800 000-strong workforce. Is there a need for government intervention? The private healthcare industry can emulate the financial services charter. The initiative is driven by the private sector. Besides, people are likely to commit to it more if they feel they were championing the cause. Is there room for growth in the industry? There is a perception that the quality of care in public facilities is deteriorating. The result has been that people who would not think of buying private healthcare are joining medical aid schemes because of the higher standard of healthcare. There is a lot going for the private healthcare industry. We need to make sure people who can afford private care are on medical aid. What is the effect of HIV/AIDS on healthcare provision and what do you expect going forward? There is pressure on public facilities. They will struggle because there are estimates that 30% of bed occupancy will be taken up by AIDS-related illnesses. The effect is expected to peak between 20 10 and 2015. This pressure may burst schemes because people would be claiming more than they put in. Schemes have been coming up with innovative ways of dealing with this. Are industry regulations moving in the right direction? We can understand that the government had to transform the industry primarily because access to healthcare was skewed. But we differ with the government on the social health insurance route it has taken because of huge income disparities in our country. The government needs to ensure that there is enough space for the private healthcare to operate profitably. Based on earlier proposals, the Government seems to want to play a bigger role in the provision and financing of healthcare. If you look at the unemployed, there is a need for the Government's role but there should be room for the private sector to cater for everybody else. How solvent are the medical aid schemes? We will know that at the end of the month when we get a report on the industry report on solvency. Is healthcare affordable in South Africa? About 16% of the population has medical aid cover, meaning 84% of South Africans cannot afford healthcare cover.

This week, the National Health Bill has been the focus of public hearings by the Parliamentary Portfolio Committee on Health. Individual sections of the law were placed under the microscope to establish precisely what they mean. Of course, this is a valuable process. But as we took the bill apart, bit-by-bit, I invited participants to consider the measure as a whole. Why do we have a National Health Bill? We believe the fundamental purpose of the bill is to design a health system suited to the enormous task of ensuring all people in our country have access to healthcare. For government, this is not just a noble ideal. It is a real responsibility in terms of the bill of rights in the constitution. Moreover, we have a duty, over time, to increase the scope of services within the bounds of available resources. The National Health Bill tackles this challenge from a number of different angles. Very importantly, it assembles the pieces of the public health system in a coherent way and clearly defines what health functions each sphere of government perform. Our experience over the last nine years has informed this aspect of the legislation. It also makes sure the links between the various spheres of government are firmly in place, so that there is no excuse for poor co-ordination at policy level. The informal structures of consultation that we developed as a way of expressing co-operative governance are now cast firmly in legal language. Central to any rights culture - especially when it comes to socio-economic rights - is the consumer. And the bill deals with the rights of patients as individuals - focusing on patients' rights to information, to confidentiality, and to choices in terms of the health interventions they will undergo. It also deals with their collective rights to participate in policy making. Perhaps the most striking feature of the bill is that it defines private and public healthcare providers as part of a single national health system. When it talks about the rights of service users, the ethics of medical research and compliance with basic standards of care, this legislation draws no distinction between the public and private sectors. The degree to which government exercises control over the private healthcare sector is always a sensitive issue. In discussions on the National Health Bill, debate tends to focus on the provision that all health establishments will be licensed on the basis of need for their service. In the past, some of the loudest critics of this provision were precisely those who cry foul when medical aid rates shoot up, leaving pensioners and those with low incomes out in the cold. Or who decry the inability of the public health services to ventilate all low-weight babies, to provide kidney dialysis for all in need and to offer expensive drug treatments. You can't have it both ways. The market alone is not a fair or effective mechanism to distribute healthcare. Resources simply do not follow demand. If they did, we would not have 75% of our people depending on public facilities, while this sector consumes about 47% of national health spending. We would also not have the vast majority of doctors and medical specialists devoting themselves to the private sector. As government, therefore, we examined the existing relationship between the private and public health sectors - and how this impedes universal access to good healthcare. It is clear that inefficiencies and inflated costs in the private health sector not only hurt private consumers, they also turn the screws on the public sector. All health facilities draw their professional personnel from a limited common pool. If private hospitals proliferate in a situation where half their beds stand empty, they absorb professionals without providing value-for-money care. In this context, inflated prices and unethical practices, such as over-servicing, are likely to arise. Faced with unreasonable costs, many patients resort to the over-stretched public sector. And so the vicious cycle will continue ... unless someone stops it. Through the National Health Bill, and specifically through needs-based certification of health establishments, government seeks to establish a more rational and fair allocation of health resources. This is the key to good healthcare for all. Perhaps I am an optimist, but I believe debate on the certificate of need did not question its legitimacy but sought to improve the process. I believe that South Africans realise that we have to rise above our narrow interests to build a united nation. I also believe that we appreciate that effective healthcare reduces the inequalities and tensions in our society and enables us to look each other in the eye. ( Source: The Cape Times, 20 August 2003).