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2018/09/24
2018/09/03 12:00 PM
FIN24
All South Africans will be covered by the National Health Insurance (NHI) by 2025, which will begin in a phased approach from 2019, President Cyril Ramaphosa told healthcare sector representatives on Friday.

He urged health professionals and the industry meeting at the Council for Scientific and Industrial Research (CSIR) in Pretoria to see universal health coverage as an investment and not a consumptive expense.

Ramaphosa’s consultations with the healthcare industry come as the public and interested parties have until various dates in September to comment on three key pieces of legislation set to shake up the healthcare sector - the NHI Bill and the Medical Schemes Amendment Bill both released in June; and the Health Market Inquiry preliminary report, published in July.

Ramaphosa said he would like to emerge from the meeting on Friday having gained consensus on a number of issues, ahead of a health summit to be held at an unspecified date.

There have been concerns about the affordability of the NHI, with the Davis Tax Committee in March 2017 finding that according to its scenario planning a 4% increase in payroll tax and a 3% increase to the value added tax (VAT) rate would be needed to fund universal health coverage.

Ramaphosa said that an NHI will bring down costs as there will be economies of scale on medicine and equipment.

He praised the public health system which he said had done a lot to improve life expectancy and reduce HIV infections since democracy.

But the president said he is concerned about staff and medical equipment shortages in public facilities and the uneven access to healthcare by higher income and lower income households.

“We must accept the reality that the quality of service cannot be improved by a fatigued and demoralised workforce,” Ramaphosa said.

He pointed to Scandinavian countries such as Norway and Sweden which introduced universal healthcare saying they saw this as an investment in the health of their workforce and population.

“I am determined that this matter should be addressed so that we should be defined as a country that cares for the people who are most vulnerable when they are sick,” Ramaphosa promised.

The meeting was closed to the media shortly after Ramaphosa’s address to allow the industry to hold a frank conversation with the president.
  
2018/09/06
2018/09/10 10:17 AM
 
The EFF has tabled a private member’s bill in parliament, aiming to make it mandatory for public sector clinics to remain open 24 hours a day.

An attached explanatory memorandum highlighted that health service challenges are not limited to specific time periods and can afflict a person at any time of day or night.

“Millions of South Africans are denied their right to have access to health services as enshrined in the Bill of Rights because an insufficient number of health facilities are open after hours, thus denying these South Africans access to health facilities should they fall sick or become injured after hours,” it said.

“People do not only get sick or suffer injury during the day when healthcare facilities, especially clinics, are open. Many South Africans live too far from hospitals and are therefore unable to access healthcare establishments all the time. Clinics are in most instances the most effective health establishment to access.”

It added that these mandatory changes should be implemented at any clinic funded by the state.

The proposed legislation follows a recent push by the ANC-led government to make healthcare more affordable in South Africa.

Notably, this will include the introduction of a National Health Insurance (NHI) scheme, which will effectively subsidise a large part of healthcare in the country in an effort to make it more accessible.

National Health Amendment Bill (Private Member’s Bill) by BusinessTech on Scribd
  
2018/09/06
2018/09/10 10:18 AM
Opinion:
The Health Market Inquiry report has been published at a rare moment of opportunity for a new dawn in health reform in South Africa. In the context of a crisis in the public and private health systems, it is the time for active citizenship – or forever hold your peace.

Every month I pay R9,568 for myself and my three dependants for medical aid coverage – insurance, for want of a better word – to cover the costs of access to private healthcare services should we need them. That amount is almost three times the government’s annual per capita expenditure on public health, currently R4,300. It’s my personal contribution to an ever-widening inequality in health, an issue that our Constitution has defined as a human right: everyone’s right of “access to health care services”.

When I use this insurance the medical scheme often only covers a portion of by medical bills. In fact this year, despite being a healthy person in a healthy family, of claims totalling R17,000 just over 60% have been covered by my medical aid.

I’m relatively lucky. Touch wood, my family don’t suffer much ill health – we know this could change within a second which is why we pay for the insurance. Medical aid scheme members who get cancer or a mental illness, will tell you a much worse story. In some instances the costs of medical care for catastrophic illness like cancer can bankrupt a family. The Heart of Private Healthcare, a report compiled by SECTION27 in 2014, told the stories of patients who experienced exactly this.

In 2014 as a result of widespread complaints about rising prices and declining benefits the Competition Commission set up an inquiry into the private health care market, called the Health Market Inquiry (HMI). A panel of independent experts was appointed, chaired by former Chief Justice Sandile Ngcobo, and it began a slow, patient process of compiling and studying the evidence about the private health market.

The inquiry has been a mammoth task, involving the study of over 43-million individual patient records, 11-million admissions, numerous written submissions and specially commissioned studies.

At the beginning of July 2018 it published its Provisional Findings and Recommendations in a 479 page report, backed up by lots of mini-reports and annexures. It’s a complex, dense and evidence-heavy report. The recommendations made by the HMI may be a once-in-a lifetime possibility to make private health well again.

Over the period 2010 – 2014, the average expenditure per private medical scheme member increased by 9.2% per annum. After adjusting for factors such as inflation, age, members’ plan type, gender, disease profile and membership movement, the unexplained (or residual) increase in spending per member was still greater than 2% per annum in real terms. To put this in context, 2% of spending amounts to around R3-billion in 2014 terms, that is R330 per beneficiary per annum that could not be explained by factors rationally expected to drive expenditure. – Finding of Competition Commission Health Market Inquiry

According to the Competition Commission nearly nine million people in South Africa (16.9% of the population) are members of medical schemes. Many of them feel resentful. They feel they pay a lot to medical schemes yet have to pay still more out of pocket when they need care.

We “choose” to use private health care in the shadow of Africa’s largest public health system, a system that is staffed by some of the best specialists in the world, providing some of the best health programmes in the world. But we do so because the public health system is mismanaged, characterised by long waiting times, drug-stock outs, poor infection control and is stretched beyond the limit.

So the truth is that we use private health primarily out of fear and convenience. When you have a health need it needs to be met.

The HMI report confirms that premiums are rising and benefits are falling. As we see the grandiose and ostentatious new buildings of medical schemes administrators going up in Sandton, many wonder aloud whether our premiums pay for our more than just our health. Similarly, as a new private hospital seems to spring up on every well-heeled corner, suspicions grow that our health insecurities are feeding a highly profitable business that is adding to inequality. Judging by who are the top income earners it’s also making some people very rich.

The HMI report suggests that this is possible because most medical scheme members don’t know what they are paying for. Neither are they able to judge the quality of care they receive. In fact, they often don’t know whether the healthcare they receive really helps them or even if they need it.

Economists call this an ‘information asymmetry’ – put simply, the inequality of knowledge between me, the user, and my health care provider (be it a broker, the scheme itself or a specialist) leaves me vulnerable to exploitation.

But it’s not just my personal health or pocket that suffers. The way the private system is run impacts negatively on public health – and vice versa.

Expenditure on private health, where R235-billion is spent on nine million people, overshadows the R201-billion the government spends on the other 44-million. Yet the two systems are tied at the hip: they have overlapping staff, overlapping regulatory institutions, and of course an overlapping population for whom healthcare is a right.

So as we talk about giving real meaning to the Constitutional right of access to health care services, it’s important that we address the strengths and weaknesses of both systems and not just the easier-to-target public health system.

But before I go there, let me make several points to blow some clouds away from this issue.

For the time being, the private sector is an indispensable part of our health system and economy. It has world class facilities and specialists, as well as a dedicated and a mostly ethical workforce of general practitioners, nurses, specialists, hospital staff and administrators.

Private doctors are feeling picked on and many are fleeing the country so it’s also important to stress that the HMI’s findings are not against the health professionals; they are against the systems that have developed in the absence of adequate regulation and oversight of private health care. The HMI provides evidence of an over concentration in ownership of private hospitals; they point to the power of for-profit medical scheme administrators vis a vis the not-for profit schemes they manage; the absence of accountability of trustees, consumer ignorance and the collapse of price controls (as one way to keep prices low). All these factors have combined to create a perfect storm that drives up costs. The words the HMI uses are polite: “Supplier-induced demand”, “unexplained expenditure” and “over-servicing”.

Finally, it’s not only the rich that benefit from the private health market. If we count the elite as being the top 5% of earners (and their dependants) in South Africa, they number around two million people. That means that the other seven million of us who use private health are middle class or on low incomes; this includes most members of trade unions, whose leaders negotiated medical aid as an employee benefit many years ago. We spend over R200-billion a year on our health and then another R4-billion on the services medical aids refuse to cover.

So, given that it covers so many lives and given the corresponding incapacity of the public system to take us into its arms, it is clear that we need the private for-profit health sector if we are to realise “everyone’s right of access to health care services”.

However, that should not make us hostage to (mis)fortune or overlook the duty on the government to intervene in private markets to protect and advance human rights. And this is where the HMI report becomes very important.

Its overall finding is that private health care is characterised by “market failure”. In response, its recommendations are not a “private health grab”, but reasonable, well rationalised, well researched recommendations that will benefit the whole health system.

In this respect a vital finding of the HMI concerns the lack of co-operation, planning and sharing of resources between the public and private system. A cold war between these two systems is in nobody’s interests. It means that while hospitals are full to bursting one side of the road (public), they are half empty on the other (private). The public health system turns its demand away, often to die at home; the private system has to specially manufacture demand by ensuring that its much smaller population over-utilises its most expensive services.

“While there is excess capacity in most provinces in the private sector, there are widespread shortages in the public sector throughout the country. The national bed population of the private sector exceeds that of the public sector, despite servicing approximately 16% of the overall population … [Thus] the capacity needed in the public sector to increase accessibility to public health care is actually available as excess capacity in the private sector”.

What is to be done?

The HMI report has been published at a rare moment of opportunity for a new dawn in health reform in South Africa. In the context of National Health Insurance (NHI), health systems are getting closer and more honest scrutiny. President Cyril Ramaphosa admits there’s a crisis in the public health system and, in the face of the evidence compiled by the HMI, there’s little point denying the crisis of private health.

However, now is not the time for blame or political point scoring – too many people are paying the price. Activists need to force a new consensus on health reform, not further divisions.

The HMI contains a raft of important recommendations for regulations, systems for effective and fair price control and institutions to oversee the market. But unfortunately the Competition Commission and the Department of Economic Development have done next to nothing to publicise and simplify its findings or to generate debate.

Consequently there is a danger that if we do not pay the recommendations proper attention they will get subverted by those parts of the private sector that do benefit from the status quo, the three very profitable hospital groups, or that they are just overlooked by a faction in government fixated on NHI and ideologically wedded to a different path of achieving universal health coverage.

The best way to prevent this from happening is to ensure that citizens have their say and are heard by the Competition Commission. Regrettably the date for public submissions closes on 7 September 2018. Contact the HMI Inquiry Director Clint Oellerman at ClintO@compcom.co.za and ask that the period for public consultation be extended.

But in addition scheme members can contact their administrators or scheme Trustees about the findings of the report or challenge the Minister of Health to accept and implement the recommendations.

The HMI has done its work. Now is the time for your active citizenship – or forever hold your peace.
  
2018/09/06
2018/09/10 10:19 AM
Medical Aid Members commonly believe they have cover which they don't, while often spending far more on a plan than necessary, according to the 2018 GTC Medical Aid survey of benefit and cost comparisons.

A recurring theme in the research was a failure to establish the optimum combination of medical aid and appropriate gap cover. As were misdirected premiums and poorly thought through benefit selection. Moreover, salary increases have, on average, not kept pace with medical inflation which high lights the complexity of an industry facing two major Bills and seismic changes.

As Gary Mockler GTC Group Chief Executive Officer comments, "The pending NHI National Health Insurance and amendments to the Medical Schemes Bill are inevitable. The dis parity between the have's some eight million members and the have not's some 45 million is real and needs addressing.
Government intervention is urgently required. It is however equally important to not break that which is already working. As with some many other pressing South African socio political issues, cool heads, calm nerves and commercial logic need to prevail."

While Minister of Health Aaron Motsoaledi has mooted the scrapping of Medical Aid brokers, Medihelp's Principal Officer Heyn van Rooyen, among others, has been quick to emphasise the importance of accredited advisers.

Brokers, he adds, are subject to stringent compliance rules, such as accreditation with the Council for Medical Schemes, and industry related examinations. They also undergo considerable training.

Mockler says GTC research confirmed the benefit of wellness programmes to members, employers and schemes alike, far outweighing their cost.

"The continued deterioration of our country's 'Burden of Disease' must be of increasing concern to Risk Management Committees of all employers. Businesses and organisations now have the opportunity to engage with the well ness programme suppliers in an effort to curb future increases and monitor deteriorating staff health issues.

Now in its sixth year, Consulta's South African Customer Satisfaction Gary Mockler GTC Group Chief Executive Officer Index (SAcsi) is an independent national benchmark of customer satisfaction of the quality of products and services available to household consumers in South Africa. The 2018 survey reveals that, on average, customer satisfaction fell from 74.2 last year to 72.7 this year. Only two schemes performed above average. Medihelp's satisfaction level was 75.1, up from 72.6 last year a 2.5 improvement, while Discovery's satisfaction level was 73.1 (down by 1.7 from its 74.8 score last year).

Medihelp also performed well in SAcsi's Perceived Value Index, with a rating of 73.6 compared to the industry average of 69.4. It showed strong improvement in terms of the Treating Customers Fairly measure, with a rating of 78.3.

Consulta CEO Prof Adre Schreuder reports, "There has been a general decline in the customer satisfaction of members of medical schemes on an industry level in the past 12 months. This was primarily the result of members of Discovery and Bonitas, two of the biggest players in the industry, rating their schemes slightly lower on aspects relating to satisfaction and value for money.

Only two schemes managed to improve their position on ratings of customer satisfaction from last year, namely Medihelp and GEMS." Satisfaction levels for medical schemes are substantially lower than those measured in other financial services industries and the claims process is where most frustration is felt.

"Members," he elaborates, "often feel that they do not receive the cover and benefits they expect from their medical scheme and this is most strongly expressed when claims are not honoured or paid in full." The multitude of medical insurance products is confusing so, while the market's dominant heavyweights remain strong, Schreuder suggests that pack leader Discovery has shifted focus to other business offerings thus allowing its competitors "to even out the playing field in the medical product suite by delivering simpler, traditional medical insurance that is seen to be less expensive and easier to understand,"

He cites Medihelp as a good example three years ago the scheme was in a below par position. Efforts to focus on delivering a simplified product, coupled with improved service levels, has resulted in strong improvements in the perception of value for money and overall customer satisfaction. The 2018 sample included 1675 respondents randomly selected from five medical schemes.


Twin bills
The proposed National Health Insurance NHI Bill is the first piece of enabling legislation for realising the government's commitment to universal healthcare.

The Medical Schemes Amendment Bill, proposes sweeping changes to the running of medical schemes. The changes are touted to benefit a wider range of members and pave the way for a NHI financing system serving all South African citizens, not just those who can afford medical aid products.

To remain relevant private medical schemes need to assess the value they provide to customers, such as quality, affordability, transparency and ease of use, which should be integrated into their daily operations. "As the Government takes steps to roll out healthcare financing for the entire population, the central issue it will have to address is ensuring that it operates to the same level currently delivered by the private health care industry, and customer experience will be the driving force behind this," Prof Schreuder cautions.
  
2018/09/05
2018/09/10 10:19 AM
BIZCOMMUNITY
An alternative reimbursement model has been launched that will benefit patients and encourage best practice among clinicians in the private healthcare sector.

With the event-based contract (EBC) model, a medical aid can make a single, fixed payment to the individual healthcare team members who are treating a patient for an episode of care.

EBC was spearheaded by the South African Society of Anaesthesiologists (Sasa) and rolled out to Discovery Health's arthroplasty network. For example, a hip or knee replacement requires a team of professionals comprising a minimum of an anaesthetist, an orthopaedic surgeon, an appropriate hospital facility and a physiotherapist. The contract will cover the period for eligible patients from surgery into the recovery and rehabilitation period.

The model is the result of four years of extensive research and consultation with the healthcare sector, and is aligned with the Health Professions Council of South Africa’s (HPCSA’s) ethical rules and South African legislation.

“Sasa is committed to enhancing the delivery of healthcare services, ensuring that patient care is secured above all else. This led us to explore models that incentivise greater accountability and more collaborative work among clinicians, and offer both the funder and patient cost certainty, without compromising the patient’s care. The new contracting model achieves all of these goals,” says Natalie Zimmelman, Sasa chief executive.

Protects the patient without adding cost

It should not increase medical costs for patients and will, in fact, probably result in lower fees for private healthcare services over time, as all players in the healthcare system seek better efficiencies with good health outcomes, she adds.

Zimmelman says that the EBC is appropriate for the South African market – “which does not have the kind of sophisticated regulatory processes and active oversight seen in many other markets” – in that it promotes a greater level of transparency, and makes clinicians and facilities (clinics and hospitals) more accountable to each other and to their professional peers.

“This new patient-driven care model protects the patient without adding cost. Because the clinician contracts directly with the funder, they will share the risk, and it will drive collaborative care and information sharing, while keeping the patient at the centre. Ultimately, it’s always about putting patient safety first while ensuring the sustainability of the South African healthcare sector.”

Sasa also notes that this model can be used as an example of a mechanism for the procurement of private healthcare services under the National Health Insurance.

"The Sasa EBC is an example of a positive move towards enhancing and placing value on the integration of anaesthetic services in holistic patient care, supported by an innovative fixed-fee reimbursement model. The approach provides regulatory certainty and societal peer review, and entrenches quality-of-care principles through the monitoring of team processes and care outcomes," says Darren Sweidan, Discovery Health’s head health professional unit.
  
2018/09/05
2018/09/10 10:21 AM
MEDICAL BRIEF
Whatever the current failures of the proposed National Health Insurance scheme, it has the potential “to move the country towards socio-economic equality by prioritising a vision where the health system itself is a re-distributive mechanism”, Leanne Brady, public sector doctor turned health systems researcher at the University of Cape Town, Injairu Kulundu, social practitioner researching transgressive learning for social change at Rhodes University and Eleanor Whyle, health systems researcher at the University of Cape Town in a Daily Maverick report.

In February 2018 President Cyril Ramaphosa announced that the country’s land redistribution programme would be accelerated. This included the proposed introduction of land expropriation without compensation. It sparked an intense public debate and brought to the fore questions of what is just and fair in a country built on oppression and social exclusion.

They write that on Friday 24 August, the president’s address to the National Health Insurance (NHI) stakeholder consultative meeting in Gauteng generated very little public debate, and hardly even made the news, yet the introduction of NHI is – like land reform – an attempt to fundamentally shift public policy and create a more just, cohesive South Africa.

Brady, Kulundu and Whyle write: “The proposed NHI Bill (which is up for public comment until 21 September) would change the way the health system is financed by bringing all health funds into one pool, allowing the government to make more strategic purchasing decisions. One of the benefits of the consolidation of health funds into a single pool is that it allows for cross subsidisation of finances from rich to poor, healthy to sick, and young to old.

“Currently, health system financing mechanisms direct most of the country’s health resources towards the rich. Of the total 8.7% of GDP being spent on health, more than half is being spent in the private sector providing care to 16% of the population. Only 4.2% finances the public sector, providing care to the remaining 84% of the population. NHI is an important part of the journey towards building a universal health system. The NHI conversation is not new – reforms aimed at addressing the inequitable distribution of resources have been on the table in South Africa for more than 80 years. Such reforms have largely been driven by the recognition of a few basic principles.

“These include the understanding that health is a fundamental human right, not a commodity; that health and access to health care should be distributed equitably on the basis of need (and not ability to pay), and that this can only be achieved through cross subsidisation.

“For those who may not have engaged with the NHI debate so far, here are five things the planned health financing system has in common with the government’s push for land reform.”

They write that five things that NHI and land expropriation have in common are that they:
Build social solidarity – they write that both land reform and NHI have the potential to build social solidarity across race, gender and class. Structural mechanisms of redistribution are vital to ensure we move beyond the ideals of transformation, towards a society that really does benefit everyone who lives in it.

They say that beyond the obvious point that a public health system is a public good, and that access to health is a fundamental human right, there is also a strong argument to be made that when people sit in the same queue to get their babies vaccinated, or share a hospital room while recuperating from an illness, they form human connections that bridge socio-economic divides. This creates an opportunity to build solidarity in our fragmented society.

Address historical and current injustice – Brady, Kulundu and Whyle write that both land reform and NHI seek to redress inequalities that are borne out of historical and current social injustice. These policies ask South Africans to recognise that the current distribution of social goods – such as health care and education – is unjust and is rooted in the idea that some lives matter more than others.

Highlight uncomfortable tensions between the “individual” good and the “public” good – they say these policies also highlight what Julius Nyerere terms the “inevitable and inescapable conflict” between what is good for “the individual” and what is good for “the public”. Land and health are simultaneously hugely political and deeply personal, and put many individuals in the uncomfortable position of asking whether their access to health, and land, are the products of injustice – and if so, what should be done.

Allow for the redistribution of wealth – Brady, Kulundu and Whyle say that crucially, both land expropriation and the NHI are fundamentally about the redistribution of wealth in a society with one of the highest rates of inequality in the world.

Run the risk of widening inequalities further – they say neither land reform nor NHI will come without risks. There is a chance they could widen inequalities even further – if, for example, there aren’t mechanisms in place to make sure land is redistributed equitably and fairly. In the case of the NHI, there is both the potential for widespread misappropriation of funds, and private capture (where private sector interests are over-represented in public decision-making forums).

They say it is also important to acknowledge that the Bill, in its current form, fails to address a number of key issues such as tackling the social determinants of health, strengthening leadership and human resource management and creating avenues for public participation and civil society engagement.

Brady, Kulundu and Whyle write: “There have been lively public debate and public hearings around land reform during 2018. It is important that the same level of engagement and discussion starts happening around the NHI and health care more broadly.

“This needs to go beyond the media rhetoric of a health system in crisis, to include examples of people and systems that are working, despite significant challenges. It is critical to include both front line providers and the broader public in the NHI conversation, as it is these examples from which we need to learn.

“The absence of platforms for meaningful public participation in health reforms is worrying. South Africans need to be more informed and more involved in shaping their health system.

“The NHI brings us to a crossroads; if well designed and carefully implemented it moves the country towards socio-economic equality by prioritising a vision where the health system itself is a re-distributive mechanism, offering more than just health care. As with land expropriation, what hangs in the balance is the possibility for a more just and equitable South Africa.”

  
2018/09/05
2018/09/11 02:01 PM
MEDICAL BRIEF
While it is not surprising that the SA Federation of Trade Unions has an issue with a private system of healthcare, it is incorrect to call it a “racialised” system, writes Marius Roodt, a campaign manager at the Institute of Race Relations (IRR).

Roodt was responding to the South African Federation of Trade Unions (Saftu) spokesperson Patrick Craven’s complaints about South Africa’s current “racialised” healthcare system in Politicsweb.

Roodt writes: “Saftu has come in support of the government’s proposed National Health Insurance (NHI) scheme, saying part of the reason was that the new system would end ‘racialised’ healthcare (‘NHI only way to end present racialised health regime – Saftu’, Politicsweb, 28 August). Saftu claimed that one of the problems with the current two-tier system is that it is ‘racist’.

“Ideologically, it is no surprise that Saftu and its spokesperson, Patrick Craven, have an issue with a private system of healthcare, but it is incorrect to call it a ‘racialised’ system, an indication of how the left in South Africa views issues through a racial, rather than class lens.

“According to the latest data from Statistics South Africa, nearly half of all people covered by medical aid are black. Overall, whites account for only about a third of all people covered by medical aid schemes. Coloured people account for about 10%, and Indian South Africans 7%. One can criticise the current system, but to call it a racialised system, is simply incorrect. One must ask why Mr Craven wants to deprive black people of choice in how they receive their medical care?

“Mr Craven lists a number of problems in the public healthcare system – from the Life Esidimeni catastrophe and the shortages of nurses in various hospitals to the fact that only 15% of public hospitals meet the current norms and standards for participation in NHI – but seems to think that more government control will somehow solve these problems. The fact is that it won’t.

“Forcing more people into the public sector (which NHI will do, as the private sector will eventually cease to exist under the state system) will only cause more problems. The truth is, NHI will not reduce the burden on the public sector, but only increase it.

“The NHI is going to be a huge government bureaucracy – perhaps the biggest in South Africa’s history. And it is clear that the government is bad at running most things – the disasters at Eskom, South African Airways, and a number of other state-owned enterprises (SOEs) is evidence of this. In addition, even well-resourced countries – with more capable governments than ours – which have a single-payer system, such as Canada and UK, struggle to provide timeous and quality healthcare for all.

“There is no reason to think that South Africa will be able to.

“Furthermore, the private sector covers far more people than the less than 20% that Mr Craven claims. It is estimated that through out-of-pocket expenses, at least 28% of South Africans, and perhaps as many as four-in-ten, make use of the private sector. In addition, more than a quarter of South Africans go to a private doctor as their first of port of call if they or a family member become ill or was injured. The fact that people are prepared to fund medical expenses in the private sector out of their own pocket shows that many people are wary of the public system.

“Levels of dissatisfaction are also much higher among those who use the public healthcare system, compared to the private sector.

“Furthermore, Mr Craven dismisses out of hand the concerns that health professionals have about NHI, and the risk of this leading to large-scale emigration. Although figures are hard to determine, between 2004 and 2009, nearly 20% of people who had completed their medical training did not report for community service. As one cannot practice in South Africa without completing this, it is likely that these potential doctors left the country to practice elsewhere.

“Others sources estimate that between 20% and 30% of South African-trained doctors work abroad. South Africa already has a shortage of doctors (even the ratio in the private sector is lower than that found in comparable countries such as Brazil) so any policy which could accelerate the emigration of doctors must be implemented with much care and restraint. We must take the warnings of organisations such as the South African Society of Anaesthesiologists and South African Private Practitioners’ Forum seriously.

“Many doctors prefer to work in the private sector, but this is not because of a lack of resources. A survey of doctors by Colleges of Medicine of South Africa found that the two primary reasons why doctors left the public sector was because of the poor working environment and poor workplace security. This is unlikely to change under NHI. Had these professionals not had the option of leaving the public sector for private practice, they may well have left South Africa altogether.

“The same survey also found large differences between what doctors reported as pressing issues in the public and private sector. A telling statistic is that 39% of those surveyed felt that management and hygiene standards were poor in the public sector, compared to only five percent in the private sector.

“What could lighten this burden is to allow private universities to train doctors – this is partly why India and Brazil have better doctor:patient ratios than South Africa.

“NHI will also see an increase in taxes.  Mr Craven’s organisation, Saftu, recently took to the streets to protest the recent increase in the rate of value-added tax (VAT). Unfortunately, without very high rates of economic growth, the only way to fund NHI will be through additional taxes, and it is very possible that VAT will increase.

“Instead of bringing all healthcare under the control of the government (which will be the result of NHI) we should increase access to the private sector. This can be done through tax-funded vouchers, or by allowing low-cost health insurance schemes (which are basically outlawed). What can also be done is to require all employed people to be a member of a medical aid scheme – for those on lower incomes their contributions could be covered or subsidised by their employers, who would then be able to claim tax credits. Public-private partnerships to further strengthen the public sector must be considered.

“This is not to say that there are no issues in the private sector, but these can, to a large degree, be solved by sensible regulation.

“Most important, however, is to fix the public sector. Mr Craven is correct in identifying problems in the public sector. Forcing more people to use the system – by pushing out private providers – will not result in better outcomes. There is no doubt that the already overburdened system will struggle to meet the healthcare needs of all South Africans – it already struggles to meet the needs of those who use it today. Improving the public sector will require merit-based appointments, strict accountability for poor performance, and effective action against corruption and wasteful spending.

“These interventions could enable South Africa to provide decent levels of healthcare for all its citizens. NHI will not.”

  
2018/09/04
2018/09/11 02:01 PM
BUSINESS DAY
Discovery saw all of its emerging businesses turn profitable for the full year to June as the group positions itself as a global financial services player.

The emerging businesses, which comprise Discovery Insure, the global Vitality business and Chinese-based insurance provider Ping An, contributed operating earnings of R158m. The group’s total operating earnings increased 17% to R8.2bn.

Discovery was launched 25 years ago by Adrian Gore as a new entrant in SA’s medical scheme industry and has since mushroomed into a significant financial services business in SA, adding Discovery Life, Invest and Vitality to become a company with a market capitalisation of R110bn.

“The progression of the group across the board was good. Every business was positive and every business performed in line with expectations or beat them. All of our emerging businesses are profitable and present a much bigger opportunity than what we thought,” said Gore, Discovery’s CEO. He described one of the highlights being the performance of Ping An, which is delivering exponential growth.

Discovery owns 25% in Ping An, which increased new business 95% to $443m, while its written premiums increased 87% to $753m.

Gore said during the results presentation that Ping An’s revenue for the first seven months of 2017 had already exceeded the revenue generated during the whole of 2017.

Discovery’s normalised headline earnings per share of R8.36 and a dividend per share of R1.14 both rose 16% year on year.

The established local businesses will soon be bolstered by the entry of Discovery Bank.

Gore said Discovery would be purchasing the 25% that FirstRand owns in DiscoveryCard for R1.8bn, subject to regulatory approval. Discovery will issue new shares to fund the acquisition in due course.

What can clients and investors expect from the bank? Much of the same, encapsulated in Discovery’s “shared value” model in insurance.

“In health insurance, when you shift behaviour to healthier options, you realise economic value. We [Discovery] catch some of that directly in our claims when healthier people claim less often. People often don’t make rational decisions. So we use some of the value created to incentivise change and that creates a virtuous cycle,” Gore said.

“Banking is no different,” he explained. “Bad behaviour is behind much of the risk. So certain choices, like corrosive spending, creates default, which is loss-making for a bank. These poor choices can be altered through a system of incentives which can produce better economic outcomes for the clients and the institution.”
  
2018/09/04
2018/09/11 02:02 PM
BHEKISISA
The famous African proverb, “It takes a village to raise a child”, is absolutely true. There is nowhere that this sense of community - of common responsibility - is stronger than in Africa.

As Africans, we draw our strength from each other.

The story of human progress is one of collectives. Realising our greatest achievements, overcoming our most challenging obstacles and telling humanity’s shared story has always relied on one common denominator: collaboration. We are at our strongest when our neighbours can rely on us just as we rely on them.

Yet, despite the collective power of our communities, some challenges are still incredibly daunting. When faced with a widespread public health issue such as pneumonia, for instance, it is easy to feel overwhelmed.

The statistics speak for themselves: according to Unicef, pneumonia is responsible for 17% of deaths in children under the age of five in sub Saharan Africa — making it the leading cause of childhood mortality.

Globally, the illness kills about 1.3-million young children each year, according to 2011 estimates published in The Lancet medical journal. It sometimes feels like one person cannot make a difference when faced with such an enormous problem.

But there is strength in numbers.

Especially with vaccines.

When a significant number of people in a population are vaccinated, they help to protect the unvaccinated people around them from diseases such as pneumonia. This is called  “herd protection” and it works by breaking the cycle by which pneumonia is passed from one person to another.

Because, when most of a community is vaccinated, even the odd case of pneumonia is unlikely to spread to more people. In this way, the community itself becomes a tool to fight infectious disease and especially protects those among us who are the most vulnerable to getting sick, such as newborn babies, the elderly, or those with health conditions.

Herd protection is no substitute for getting vaccinated, and the key to unlocking the power of herd protection against pneumonia is the pneumococcal conjugate vaccine (PCV).

In 2009, South Africa - alongside Gambia and Rwanda - became the first African nation to introduce the PCV. Fast-forward to today and data from the public-private partnership for vaccines Gavi show that 35 countries across Africa are ensuring that vulnerable populations are protected against pneumonia by the PCV, which is fantastic progress.

By the end of 2017, PCV had been introduced in 140 countries but global coverage was estimated at just 44%, World Health Organisation (WHO) and Unicef data from 2018 show.

Those numbers are good, but we can achieve better coverage if we work together. WHO estimates from 2017 show that more than two-thirds of South Africans have been vaccinated against pneumonia in the 10 years since the PCV was introduced.

Although this is cause for celebration in some respects, more than 30% of the country remains unprotected against the disease. Here is a statistic that should inspire hope.

According to a 2017 study in the International Journal of Infectious Diseases, we can achieve herd protection in South Africa if just two out of every three children under five are immunised against pneumonia.

This is an ambitious but achievable vaccine coverage rate and would help tens of thousands of South African children every year to grow up healthy and strong, fulfilling their potential.

Of course, to create continent-wide protection, we must aim for each and every child to receive the PCV. When we each do our part, not just for ourselves but for our neighbour, our village, our country and our continent, we can defeat pneumonia. Closing the immunisation gap is the final piece of the puzzle.

Because it takes a village not only to raise a child but also to protect them.

Keith Klugman is the director for pneumonia at the Bill & Melinda Gates Foundation. You can follow him on Twitter @findingpneumo. [Full disclosure: The Bill & Melinda Gates Foundation funds the Bhekisisa Centre for Health Journalism]
  
2018/09/04
2018/09/11 02:04 PM
BUSINESS DAY
Board of Healthcare Funders calls for better planning and regulations to enforce efficient allocation of human resources

The government should consider regulating where private sector doctors and specialists work, in order to distribute their services more evenly across the country, the Board of Healthcare Funders (BHF) says.

"The disproportionate distribution of health-care professionals is a concern. Better planning and regulations are required to enforce efficient allocation of human resources … It is therefore imperative that the certificate of need be revisited," said the BHF, a key player for medical schemes in the country, in a report released on Friday.

It is a controversial suggestion unlikely to sit well with doctors, who previously persuaded the Constitutional Court to set aside regulations requiring them to obtain a certificate of need, or ministerial approval, prior to practising.

While the National Health Act contains provisions that enable the minister to regulate this arena, he has not done so since the Constitutional Court case.

However, the issue is very much still alive, as the Competition Commission’s health market inquiry recently recommended in its draft report that the health department develop a new framework for licensing all health-care facilities, based on a national plan that considers public and private sector capacity and the needs of the population to be served.

While its emphasis is on private hospitals, it said licensing could be extended beyond acute facilities over time.

The BHF’s head of research, Charlton Munrove, said other approaches to licensing should also be considered. "The best way to do it would be to try to create incentives to get [healthcare] professionals where they are needed, or let them see public sector patients too. It needs to be a collaborative approach or you end up in court." he said.

The BHF released research on Friday showing that almost half (22,802) the health-care professionals working in private practice in 2017 were in Gauteng, which is home to about a quarter of SA’s population. Its analysis was based on the Practice Code Numbering System (PCNS) database it manages on behalf of the Council for Medical Schemes. Health-care professionals working in the private sector need a PCNS number in order for their patients to claim from their medical schemes.

The analysis found a 52% increase in active health-care professionals registered on the PCNS over a 17-year period, rising from about 36,000 in 2000 to 54,800 in 2017. Over this period, the average age of health professionals registered with the PCNS increased, suggesting older professionals are migrating from the state sector to the private sector, said the BHF.

The number of medical scheme members rose from 7-million beneficiaries in 2000 to 8.9-million beneficiaries in 2017, a growth rate of just 27%.

It suggests an oversupply of private sector health-care professionals, creating an incentive to over service patients, said Munrove.

However, Alex van den Heever, from the Wits School of Governance, said the PCNS data overstate the number of private health-care professionals as it includes people who are registered but not billing and did not exclude people who are employed by the state but also do a limited amount of private sector work.

"The absence of any evaluation of the public sector data provides a distorted picture. There were 14,454 GPs in the public sector in 2016, up 7.4% from 2006 [and] there was a 49.2% increase in professional nurses. The more limited increase in specialists has been largely due to the strategic prioritisation of district health services over provincial and tertiary hospitals and [is] not due to any activity of the private sector," he said.
  
2018/09/03
2018/09/11 02:04 PM
BIZCOMMUNITY
The "startling costs" of South African private healthcare is at the heart of the Competition Commission's Health Market Inquiry (HMI) draft report released in July. While cost is a key theme, the report also describes a sector lacking the vital force of authentic, robust competition.

Currently, the South African private healthcare sector is an opaque system dominated by a small handful of players. Members pay for medical scheme cover, and accept that they will also have to pay costs out of their own pockets.

The common refrain of the medical aid will pay is one that is inherently false. It is not the medical aid that pays, but the member. “The fact that so many people cling to this erroneous statement reveals two important facts about our business,” says Carl Grillenberger, CEO of Advanced Health.

“First, few consumers understand medical aid schemes, or are able to navigate them effectively. Second, the private healthcare economy routinely ignores the vital concept of value-based purchasing.”

He explains that the draft HMI report describes a fee-for-service model that reliably stimulates oversupply through wasteful expenditure and the provision of more services than are actually needed.

Competition is cosmetic

“Our private healthcare market is driven by supply induced demand, where competition mostly occurs mostly at a cosmetic level, and is based on a supposed choice between available products rather than value for money. The choice, of course, is often illusory. Consumers end up trying desperately to compare glossy medical aid scheme brochures and failing, despite their best efforts, to compare like with like,” Grillenberger says.

“The Competition Commission also tells us that lack of competition runs right through the market. Simply put, trustees and principal officers experience little pressure to hold scheme administrators to account for their actions - especially when it comes to procuring services based on value.

Runaway medical inflation

“Another key theme of the draft report is that there is very little incentive for change, because the South African private healthcare market is a de facto oligopoly where three hospital groups have a combined market share of 83% of the national private facilities market in terms of the number of beds. The same groups control 90% of all private healthcare admissions.

“All these are factors contributing to the most urgent issue facing our industry: runaway medical inflation,” he says.

There has been an average difference between medical inflation and CPI inflation of 4.2% over the last 10 years.

“In our calculations, we have projected an average differential of 4% for the coming decade. If today’s trajectory holds, by 2028 medical aid costs will be two and a half times their current value.

“In other words, the net income of an average income earner’s gross income increases at the CPI rate, but their medical aid contribution escalates at 9.6% per annum. If this trajectory continues, medical aid inflation will see private healthcare members experience a deteriorating net income in the coming years.

“The reality is that within 10 years a substantial number of medical scheme members will not be able to pay scheme contributions and will fall out of the market.

As the membership fall off accelerates, our industry is likely to shrink at a compounding rate. As this happens, more strain will be placed on a national health system that is clearly buckling in some places and broken in others. I think we all understand that our country cannot afford to further stress such a fragile system,” Grillenberger says.

NHI

“Many medical scheme administrators are much more concerned about the proposed implementation of National Health Insurance (NHI). The reality is that the NHI remains unlikely to achieve lift off any time soon. Not only is funding a major, unresolved issue, but the Department of Health still needs to dramatically improve services to resolve the fundamental distrust that still exists between state patients and provincial service providers. Without this key change, NHI won’t find the traction it needs to become operational.”

To resolve supply induced demand, the draft HMI report suggests serious consideration be given to alternative remuneration models (Arms).

Value-centric transformation

“I think it’s clear that value-centric transformation of private healthcare is the only thing that will fully secure the long-term viability of our industry. By choosing to change we will make the private healthcare sector better for all players however it will also drive other crucial social contributions.

“Change will ensure our activities don’t destroy the South African public healthcare system, it will give patients better choice and value, lay the foundation for the long-term sustainability of the sector, the economy and the country.

“As an industry, we know what we need to do. We need to take the first step towards a value-centric structure, to change the market for the better, before it’s is too late,” Grillenberger says.
  
2018/09/03
2018/09/11 02:05 PM
RANDFONTEIN HERALD
Government’s proposals will allegedly have dire consequences for all citizens, regardless of whether they rely on private or public health services.

Even though South Africans are entitled to decent levels of healthcare, the new proposals by the government will allegedly have dire consequences for all citizens, regardless of whether they rely on private or public health services.

Therefore, the Institute of Race Relations (IRR) is inviting South Africans to endorse their submission opposing National Healthcare Insurance (NHI).

The media statement issued by the IRR, states that the public has until 21 September to comment on two bills released by the Minister of Health, Dr Aaron Motsoaledi.

“As in the case of Expropriation without Compensation (EWC), the poor and the vulnerable will be at greatest risk should the proposed radical change in the way in which South Africans receive healthcare be introduced. The two primary consequences are that the country’s excellent private healthcare system would be steadily undermined, and the already deficient public health system impossibly burdened, at vast cost to taxpayers. NHI is likely to cost at least R500 billion at its start, and could go as high as R1 trillion,” the IRR said in a statement.

In its submission, the IRR argued that not only will private healthcare choices be drastically reduced, but South Africans will be compelled to pay increased taxes to help fund the NHI, which Dr Motsoaledi said will be like a giant state-run medical aid.

When it becomes fully operative, all health revenues will be paid into a single NHI Fund, which in turn will pay for all the health services provided to patients both by public and private practitioners and health facilities. South Africa’s public healthcare system is riven with problems and it often fails those who use it, not because of a lack of resources, but rather because of poor management and poor use of resources. Making people pay into a central fund will not fix these problems.

The IRR said a staggering 85 per cent of public clinics and hospitals cannot comply with basic norms and standards, even on such essentials as hygiene and the availability of medicines.

“Cases of medical negligence, often involving botched operations or brain damage to newborn infants have increased to the point where claims for compensation total R56 billion. This is more than a quarter (27 per cent) of the entire R201 billion budget for public healthcare in 2018/19,” the IRR said.

The IRR argued that providing all South Africans with quality healthcare is achievable without completely destroying the current system.

It said universal health coverage is already available at the country’s public hospitals. What must be done to achieve higher healthcare standards is to ensure merit-based appointments, strict accountability for poor performance, and effective action against corruption and wasteful spending. Public-private partnerships would also help improve their operation – something the NHI would undermine.

It said further that the burden on the public system should also be reduced by increasing access to private healthcare. Low-cost medical schemes and primary health insurance policies should be allowed, while poor households should be helped to join these schemes or buy these policies through tax-funded health vouchers.

“To further spread the risk, health insurance could be mandatory for all employed people, with the contributions of those with lower incomes subsidised by employers, for which businesses could earn tax credits,” the IRR added.
  
2018/09/02
2018/09/11 02:20 PM
INDEPENDENT ONLINE
At a time when South Africa's hospitals are faced with critical staff shortages which impact on the health-care system, some intern and community service doctors remain unemployed.

In KwaZulu-Natal, the South African Medical Association (Sama) has confirmed that it is trying to assist more than 40 doctors who have yet to be placed at local hospitals. Sama vice-chairperson Dr Mark Sonderup confirmed that there was still a “substantial” number of doctors who remained unemployed.

“It doesn't make sense that government invests in educating doctors and then they cannot help them to progress. This is unacceptable. Senior leadership in the country needs to step in now and address this as a matter of urgency,” said Sonderup.

He said the national Department of Health was of the view that South African doctors who trained in the country should be given first preference.


“We understand this, but it is our view that there should be no problems with regards to placing other folks, such as those who have been naturalised,” said Sonderup.
  
2018/09/02
2018/09/11 02:22 PM
MEDICAL PLAN ADVICE
The Free Market Foundation is an independent public benefit organisation. It started in 1975 and fosters the rule of law, liberty for all and an open society.

It seems as though the NHI isn’t about liberty for all. The Free Market Foundation director, Temba A Nolutshungu has attacked the instigator of the the National Health Insurance. He says the NHI is going to have disastrous consequences.

The entire South African healthcare system is to be overhauled with the introduction of 2 new bills – the National Health Insurance (NHI) Bill and the Medical Schemes Amendment Bill. These bills are open for public comment for a few months.

Can anything from Motsoaledi really work?
Free Market Foundation on Healthcare in South Africa and NHI. The director of FMF has said he can’t understand how the minister of health can come up with such a disastrous healthcare policy, especially when events such as the Esidimeni tragedy have happened under the watch of the health minister, Aaron Motsoaledi.

Does he think that anything good can come out of it? Nolutshungu said that ideally private healthcare providers in the private sector should remain as they are. He said that the government should be purchasing healthcare for those people who can’t afford it. Nolutshungu also reminded government of the failures in socialist countries where healthcare was nationalised.

There’s a Question Mark over the NHI
The proposed legislation of the National Health Insurance is going to lead to the nationalisation of health services. That would happen if doctors had to contract to the NHI. We spoke to a consultant in the health market industry, Michael Settas. He acknowledges that universal health cover is a high ideal. But there is a question mark over the NHI as South Africa’s spending on healthcare is already high.

The Free Market Foundation held a media briefing in Sandton regarding key documents set to shake up the healthcare industry – the NHI Bill, the Medical Schemes Amendment Bill and the Health Market Inquiry preliminary report.

Settas said the government should reassess the NHI and the Medical Schemes Amendment Bill for their financial impacts. He said that the final legislation could differ quite drastically from the proposals in the documents.

A Huge Exodus of Doctors Anticipated
Settas also warned that making medical experts contract to the NHI could see them leaving to settle in other countries. At a media briefing held on 15 August at the Free Market Foundation, Settas said that the NHI is unaffordable.

The NHI can’t work and it will destroy the private healthcare sector. Settas questioned the timing of the NHI Bill ahead of the 2019 elections as well as the absence of information on the funding of the NHI. In fact other important details of the NHI were also missing such as how the public sector will improve quality of care and what the NHI benefit package will contain.

Further Warning from the Free Market Foundation
Member of the FMF, Dr Johann Serfontein, also warned that the recommendation that market share for private hospital groups be capped at 20% could face legal challenges. He said that a mistaken idea was out there justifying the need for NHI is that the public sector subsidises the private health sector.

Of course there are parts of the NHI Bill that are good – allowing people to access health care benefits from accredited providers at no cost. This at least will make it that no one needs to go without treatment because of lack of funds.
  
2018/08/31
2018/09/11 03:25 PM
BUSINESS DAY
Advanced Health puts expansion on ice and will revisit empowerment when it posts no loss

Advanced Health has shelved plans to bring in an empowerment partner -at least until it breaks even, the day surgery group’s CEO, Carl Grillenberger, said on Thursday.

Advanced Health owns day hospitals in Australia and SA, and listed on the JSE’s Alt-X in 2014. It has expanded rapidly in SA but has battled to attract patients to its 10 facilities in the country, resulting in sustained losses since its listing.

Unlike the US, where about 70% of all surgical procedures are done in day clinics, only 12%-15% of operations in SA’s private health-care sector take place in these facilities.

Day hospitals have generally received a cool reception from doctors, and have struggled to get medical schemes to direct patients to their facilities because they do not have a national footprint.

Only 54 day hospitals in SA are not held by the "big three" hospital groups — Netcare, Mediclinic and Life Healthcare — and they are clustered in the Western Cape and Gauteng.

On Thursday Advance Health reported a loss of R36.3m for the year to June. While an improvement on the R48.2m loss the year before, this was largely due to an improved performance in its Australian business. The group earns 71% of its revenue from its five day hospitals in Australia, two of which were acquired during this period.

Revenue from Australia grew 33% to R292m and from SA 30% to R117m, taking Advanced Health’s overall revenue for the year to end-June to R409m, a 32% increase on 2017’s R309m.

Headline losses per share improved to 14.12c, from 21.74c in the previous year, in line with expectations.

Advanced Health had "a couple of discussions" with potential empowerment partners, but there was no prospective deal in play at the moment, Grillenberger said. "The moment we are closer to break even or profitable, we will look at investors."

The target for break-even is October 2019, which is when he plans to hand over the reins of the company, he said. "I have agreed with the board of directors that I want to step down by October 2019 [and] leave a profitable business to the person who is going to take over."

The focus for the future was on improving patient volumes in SA, and it was holding talks with medical schemes and administrators to try to encourage them to direct more patients to its facilities, said Grillenberger.

"Funders should inform patients about the cost difference [between day hospitals and acute hospitals]. If it is cheaper, why not use the day hospital?"
  
2018/08/31
2018/09/11 03:29 PM
BUSINESS MEDIA MAG
While the NHI remains a work in progress in terms of policy and planning, medical aid members and schemes worry about the future. For now, at least not any time soon, nothing will change. As a 2017 NHI White Paper stipulates: until the new system is fully implemented and operational, things will stay business as usual.

The question is: What will happen to medical aid schemes once the NHI kicks in? According to Gerhard van Emmenis, principal officer of Bonitas Medical Fund, South Africa’s second largest open medical scheme, one of the first changes will be a decline in the number of medical schemes.

“From what I understand, once the NHI is a fact, there will be three or four medical aids left. These will serve as complementary health product providers and will fill the gaps left by the NHI,” he says.

While comprehensive in terms of healthcare coverage, the NHI won’t cover everything. “Dentistry and optical care aren’t necessarily high priorities because there are bigger burdens in other areas, particularly lifestyle diseases such as diabetes (blood sugar), high blood pressure and cholesterol,” says Van Emmenis.

In terms of its own post-NHI future, Bonitas seeks to be one of those complementary healthcare providers. “We also hope to play a role in preventive and managed healthcare coverage, something which has been neglected. There are risks involved when people are only diagnosed once they suffer from a certain preventable condition.”

Diabetes is a good example, he continues. “Many people are pre-diabetic. We try to change their lifestyle and make sure they go to the doctor regularly to prevent them from becoming diabetic. The government has made a pledge to tackle the epidemic of lifestyle conditions and we want to work hand in hand with them on this.”

Besides plugging the gap left by the NHI, Bonitas hopes to play a role in helping government make the new system’s structures as cost-efficient as possible. “Our knowledge and experience enable us to assist the government with the funding aspect, ensuring there is value for money, for instance, by avoiding duplications,” Van Emmenis says, noting that the company has been an active participant in the different NHI discussions between the government and private healthcare providers. “We have quite a lot of experience in making and keeping healthcare systems cost-efficient.”

A greater focus on preventive and primary healthcare at community level is overdue, says physician and industry expert Brian Ruff, the founder of integrated care management company PPO Serve. “South Africa has a very high hospital-centred system as most medical aid benefits apply to hospitalisation,” he says.

He says high hospitalisation rates for procedures that could be performed at community level, for instance at the GP, are one of the key culprits that have been driving up the prices of medical care. This has resulted in above-inflation premium hikes, benefit cuts and ultimately gaps in care, especially for complex medical problems, he says.

“We need to make healthcare benefits available at a community level,” he says, noting that the NHI intends to do just that. This is good for patients’ well-being and the affordability of care. “Delivering primary preventive healthcare at community level costs much less than in hospital.”
  
2018/08/30
2018/09/10 10:17 AM
The latest report from the Institute of Race Relations (IRR) is a detailed critique of the government's proposed National Health Insurance (NHI) system. It argues that while South Africa's deeply deficient public health service is in desperate need of reform, the "main purpose of the NHI is not to improve health services but rather to drive the private sector out of the healthcare sphere". The NHI "will help achieve this by putting an end to the medical schemes that primarily fund private medicine and are essential to its survival", writes author of the report, IRR Head of Policy Research Dr Anthea Jeffery.

At risk along with the healthcare of the country's 58 million citizens is South Africa's "world class system of private healthcare, to which some 30% of its population on average, or roughly 17 million people, have access through their medical schemes, health insurance policies or out of pocket payments". The report notes that South Africa's 82 medical schemes "are vital in providing access to private healthcare" to 9.5 million people up from 6.9 million in 1997 , of whom 48% are now black, while 11% are so called 'coloureds', seven percent are Indian and the remaining 34% are white.

"Despite this major shift, the government plans to use the NHI to put an end to almost all medical schemes, primarily because of its ideological hostility to the 'profit' motive in private healthcare," the report states.

"The government's determination to press ahead with a new, vast bureaucracy likely to cost an unsustainable R500bn at its start and possibly going as high as R1tn makes no attempt to remedy profound defects in the public health system."

Jeffery adds that South Africa currently spends 4% of gross domestic product on public healthcare, which is more than many other emerging economies can manage. "But, despite the best efforts of many dedicated professionals working in the sector, the country gets little bang for its substantial buck. Instead, public healthcare is plagued by poor management, gross inefficiency, persistent wastefulness and often corrupt spending.

"The upshot is that 85% of public clinics and hospitals cannot comply with basic norms and standards, even on such essentials as hygiene and the availability of medicines. Cases of medical negligence often involving botched operations or brain damage to new born infants have increased to the point where claims for compensation total R56bn. This is more than a quarter 27% of the entire R201bn budget for public healthcare in 2018 19."

Instead, according to the report, the NHI "assumes that throwing more resources at the public sector will provide a cure all, whereas poor skills, cadre deployment, and a crippling lack of accountability lie at the heart of the malaise and will have to be overcome."

By contrast, it’s suggested that the NHI will likely undermine the potential for improvements.

"South Africa is already short of nurses, doctors, specialists and other health providers, but the NHI offers no credible means of increasing their supply. On the contrary, the pool of available health providers and facilities is likely to shrink once the NHI takes effect."

This, Jeffery says, is firstly because only 15% of public clinics and public hospitals currently do well enough on basic norms and standards to qualify for NHI participation.

"The remaining 85% fail to maintain proper standards of hygiene and the like and will be barred from taking part. In addition, many private specialists, doctors and other health providers with scarce skills might decide to emigrate, rather than subject themselves to NHI controls over their fees and treatment decisions."

The report advances proposals for a successful healthcare system available to all.

"Universal health coverage is already available, mostly for no charge, through the country's public clinics and hospitals. To function better, these need merit based appointments, strict accountability for poor performance, and effective action against corruption and wasteful spending. Public private partnerships would also help improve their operation."

Jeffery says the burden on the public system should also be reduced by increasing access to private healthcare. "Low cost medical schemes and primary health insurance policies should be allowed, while poor households should be helped to join these schemes or buy these policies through tax funded health vouchers.

"To help spread risks, medical scheme membership and or health insurance cover should be mandatory for all employees, with premiums for lower paid employees buttressed by employer contributions for which businesses would garner tax credits. Medical schemes and health insurers would then have to compete for the custom of South Africans, which would encourage innovation and help to hold down costs."

But none of these solutions will emerge through NHI, Jeffery adds. The report warns that "by the time people realise that the NHI cannot deliver on its golden promises, the private healthcare system will effectively have been destroyed".

Dr Anthea Jeffery, IRR Head of Policy Research
  
2018/08/24
2018/09/03 12:01 PM
CITY PRESS
If South Africa is to successfully pull off the National Health Insurance (NHI) initiative it’s going to take a collective, concerted effort from all stakeholders.

This was said by President Cyril Ramaphosa, who has thrown his weight behind the country’s proposed attempt at turning around its healthcare sector

“The NHI is fundamentally about social justice. Providing universal and quality health care for all is not only a matter of moral principle,” he told the high-level officials who attended the national health insurance consultative meeting in Tshwane on Friday.

The meeting was attended by Justice Minister Michael Masutha, Health Minister Aaron Motsoaledi, Gauteng Premier David Makhura, politicians, stakeholders and health professionals.

“This meeting is providing us with an opportunity to broaden consensus around the core principles that will define the NHI,” Ramaphosa said.

“More importantly, we wish to emerge out of this meeting having collectively considered and exchanged ideas about the proposed reforms in the legislative and regulatory framework of our healthcare system.”

The positives

Ramaphosa said the country had achieved a lot in terms of ensuring access to healthcare since 1994.

“We abolished the apartheid structures of the health care system, rolled out primary health care facilities to areas where they were needed most, and waged an effective battle against HIV and Aids,” he said.

“We also did a lot to dramatically improve the social and political determinants of healthcare – including the near universal provision of clean water to millions of the poor, decent education and the provision of social grants to poor households.”

Nuts and bolts

The Sustainable Development Goals, adopted in 2015, spell out South Africa’s responsibility to achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

“It is inconceivable that anyone could argue against the need for every South African to have access to health services on the basis of need and not on their ability to pay,” said Ramaphosa.

He described South Africa’s health system as a “racialised two-tier” system sustained on the basis of uneven distribution of resources.

“The National Health Insurance is meant to ensure that all our people, black and white, rich and poor, receive the quality health services they need without the imposition on them of financial hardship. Our people should be able to access a comprehensive range of health services, including prevention, treatment, rehabilitation and others. These services – no matter who is providing them – should be of good quality,” he said.

The problems

The Office of Health Standards Compliance recently tabled a report to Parliament’s Portfolio Committee on Health that indicated that, on average, health facilities inspected met less than 50% of the required quality health standards.

“This is totally unacceptable,” said Ramaphosa.

He wanted those attending the meeting to come up with ways to address the severe shortage of and challenges faced by both essential employees, such as doctors and nurses, and support staff such as radiographers and porters.

“We must be clear that the resources needed to provide quality health care services represent investment rather than consumption, particularly if you consider the benefits of a healthy population and a productive workforce.”

Ramaphosa believes that the NHI could be affordable if it was properly designed and managed.

Foundations already in place

Achieving universal health coverage was not just about spending more money, said Ramaphosa.

The country already had many healthcare resources. These needed to be used efficiently and fairly to scale up the supply of quality health services for everyone, with enough trained and motivated health workers, and to transform the health system to address the needs of all South Africans.

“We need to build on the strengths of the public health system which, notwithstanding its persistent challenges, has helped improve the life expectancy of our people, successfully turned the tide in our battle against HIV and Aids and rolled out the massive health infrastructure we now have across the country. The NHI can and will be a success,” he said.

The numbers

South Africa currently spends R420 billion – 8.5% of domestic funding – on healthcare.

“This is more than any other middle-income country, and it is very close to advanced economies such as the United Kingdom and Canada,” said Ramaphosa.

From 2019, once the bill is passed, the NHI will be implemented incrementally until the entire country is covered by 2025.

“We envisage a transformed health system that will not just have better health outcomes, but one that will also save money for individuals, households and the country as a whole,” said Ramaphosa.
  
2018/08/23
2018/09/03 12:02 PM
MED BRIEF AFRICA 
The Department of Health’s Dr Anban Pillay has slammed the Free Market Foundation (FMF) for criticising the National Health Insurance (NHI) Bill and has requested that we submit reasons why we believe the government’s proposed NHI scheme will not work and a list of proposed alternatives.

Specifically, Dr Pillay states, “It can’t be on an ideological basis, it has to be on a technical basis as to why any system that they [the FMF] propose would be better than the system we [government] are proposing.”

It’s ironic that Dr Pillay states that the proposed alternatives must be of a technical nature and without an ideological bias because, although the government has been working on its proposed NHI scheme for over a decade, we are no closer to understanding any of the material details, such as how much its proposed scheme will cost, where the money to finance its grandiose plan will come from, and what exactly will be included in the so-called “comprehensive service benefits package”. Despite the lack of these critical technical details, government is pushing ahead with its “free healthcare for all” which, in the absence of any economic data, can only be described as a politically motivated proposal ahead of the 2019 general elections.

We estimate that the government’s NHI scheme will cost R471bn in 2018 terms. Government has suggested that the money will come from an increase in VAT; a dedicated payroll tax (split evenly between employers and employees); and a surcharge on taxable income – or a combination of these three sources. Given that VAT has already been raised by a percentage point, it’s highly unlikely that it will be raised again to finance NHI. The obvious recourse then is more taxes on workers. The consequences of increasing taxes on workers will be lower take home pay and even job losses. Leaving people and companies with less money for savings and investment, the NHI will usher in even slower economic growth and less job creation, again hurting the poor. SA’s 9.6 million unemployed cannot afford the costs NHI will impose. Moreover, when one considers that total revenue from personal income tax collections – South Africa’s main source of tax revenue – amounted to only R453bn in 2017, we get some idea of the futility of this ambitious proposal.

The country not only lacks the financial resources to fund NHI but the quality of care in the public sector is so abysmal that few facilities would qualify to provide services under NHI. According to inspection records published by the Office of Health Standards Compliance (a government agency), hospitals and clinics in the government’s flagship NHI pilot programme are failing to improve any faster than those in the rest of the country. Among the 696 hospitals and clinics it inspected in 2016-17 only five complied with the Department of Health’s norms and standards to achieve an 80% “pass mark”. Facilities fell short on matters ranging from the availability of medicines to infection control.

There is a critical shortage of skilled healthcare professionals in South Africa – not only in the government-controlled sector but also in the private sector. There are many reasons for this critical shortage – including but not limited to the high rate of violent crime that has caused skilled professionals to seek refuge elsewhere. The sub-standard working conditions in South Africa’s government-controlled healthcare sector also drive away qualified staff. But the main reason is that government has a monopoly on the training of doctors. Since the 1970s, South Africa’s eight government controlled medical training facilities have not adjusted their quota and continued to produce approximately 1,500 doctors per annum, regardless that, over this period, the South African population has more than doubled, the country suffers from an extraordinarily high burden of disease mainly driven by the HIV/AIDS crisis, has a high rate of violent crime and road accidents. Moreover, government adopted an ill-conceived policy of restricting the number of skilled healthcare professionals who may practice in South Africa.

Our proposal to alleviate the chronic shortage is to increase the number of positions available at government-controlled facilities and to allow more skilled healthcare professionals to practice medicine in South Africa. We also propose that government abolishes its monopoly on the training of doctors and allows the private sector to train doctors.

Laws should be judged not by their intentions, but by their outcomes. We all want good things for the poor and to see better healthcare for all. Aside from healthcare, South Africans have other constitutional rights, such as for housing and education. We at the Free Market Foundation have proposed for many years that healthcare be treated the same way as these other rights. The government should look after the poor and leave the private market alone.

More specifically, we think the state should simply finance healthcare for the poor and leave the rest of the population to decide for themselves how to spend their money. However, the NHI proposals seem to be more concerned with removing the so-called “two-tier system” than trying to design an affordable mechanism to provide high-quality healthcare for the poor. We have a multi-tier system for both food and housing, and most of us recognise that driving private restaurants out of existence and implementing state-controlled food delivery will not deliver food to the poor. If you doubt that, take a look at what is going on in Venezuela.

The only question government should ask is: what is the best way for the poor to get high-quality healthcare? It is neither necessary nor appropriate for the government to provide “free healthcare for all” because doing so would waste scarce taxpayer resources. Taxpayers could fund healthcare for those who cannot afford it, but where is the sense in interfering in the arrangements of those who can?

The proposed mandatory payments into the central NHI fund will crowd out private insurance as cash-strapped individuals will not be able to afford to pay their voluntary private-insurance premiums as well as the mandatory NHI payments. Those unable to pay the two premiums will be forced to use the already overstretched public health service.

While the rich can hop on a plane and seek medical care anywhere they please, it will be the poor and middle-class that will be unable to escape the vagaries of the government-controlled system. NHI would perversely increase the inequalities in healthcare while concentrating power in the hands of state officials, leaving no room for private medical schemes.

Whether directly or indirectly, the government would control the availability, financing and delivery of all healthcare — the choice will no longer be for the individual to make. Compulsory NHI funding would serve the government’s interests, not individual South Africans.

This is not scaremongering. These are the economic realities. South Africans need to exercise real personal choice in choosing medical insurance that best meets their individual needs. Increased competition would force medical schemes and providers to compete directly for members by providing value and choice. Personal ownership of healthcare would help control costs and guarantee better quality, eliminating the need to depend on the government.

South Africans fought hard for their freedoms from an overbearing state. Allowing the government to take over that most personal aspect of our lives, our healthcare, would undo these hard-won gains.

Would it not be better to adopt a universal healthcare model, where the government funds healthcare for the poor, and allows the private healthcare sector to grow, innovate and expand? Such a healthcare model would not only be good for South Africa’s financial health, but would lead to better health outcomes for the poor, which is surely what we all want.

Jasson Urbach is an economist and a director at the Free Market Foundation.
  
2018/08/22
2018/09/03 12:03 PM
IOL
Suggested amendments to competition policy could, if adopted and implemented, revitalise black economic empowerment and the small business sector and set the country on a remarkable growth trajectory.

Minister Ebrahim Patel’s Economic Development Department (EDD), under which competition institutions and policy fall, has recommended far reaching amendments and which, more importantly, address what the law calls public interest.

Public interest specifically refers to employment creation and the development of the small business sector, and is a radical departure in competition law from the conventionalism in other jurisdictions. This public interest is an urgent necessity as, in terms of the latest figures from Statistics SA, the unemployment rate has shot up to 27.2percent.

The broad unemployment rate for black Africans is 41percent and for whites 8percent; while for coloureds it is at 29percent and for Indians at 15percent. Inequality is stark as the World Bank (2018) reports that household wealth held by the top 10percent was 71percent, while the bottom 60percent held 7percent of net wealth.

It is these frightening figures that have prompted the government to boost the tempo of interventions to remedy the situation. It is using the three levers in its control, and they include competition policy, the basis of this article; and the other two are procurement and black economic empowerment policies.

To contextualise the approach by Patel’s EDD and delve into the public interest imperative much more deeply; the World Bank, IMF and the Organisation for Economic Co-operation and Development have at different times decried the levels of concentration in our economy. High concentration levels mean sectors have dominant players, sometimes two or three, and these make entry impossible because of vertical and horizontal linkages.

The Competition Commission has released numerous reports on collusion and uncompetitive behaviour which, arguably, is a direct consequence of these levels of concentration. Apart from the impact these have on the poor, and as indicated earlier, this collusion and uncompetitive behaviour also crowds out new entrants and other small businesses, mostly black owned.

Private healthcare

In its latest report the commission revealed that three hospital groups, Netcare, Mediclinic and Life have a combined market share of 83percent of the national private healthcare market in terms of number of beds, and 90percent in terms of total number of admissions.

The litmus test for our post-democracy economy is not necessarily only the presence of black shareholders in major companies, including those listed on the JSE. It is also the extent to which black-owned small to medium companies are a formidable force in the economy in general. After all, this is where skills development and job creation take place and, more potently, entrepreneurship and innovation are unleashed.

Unsurprisingly, the latest report by Zodwa Ntuli’s BEE Commission confirms the above in terms of companies being committed to black economic empowerment. The report reveals that 60percent of major companies were between being outrightly non-compliant (level 8) or compliant to mostly level five. Only 5percent of large companies were level one, which is the highest.

Those who are 100percent non-compliant are a little above 27percent. It must also be considered that, as less than 30percent of major companies submitted reports, the situation could even be worse. More depressing levels are reflected in the medium-sized companies, the so-called Qualifying Small Enterprises, but this analysis is for another day.

Patel’s suggested amendments will be a massive shot in the arm and, to say the least, very, very welcome. Furthermore, and if truth be told, and as Ben Turok argues in his book ANC Economic Policy; when the ruling party took power in 1994 it, rightly or wrongly, enacted policies that avoided a backlash from domestic and international capital.

Thus, so-called internationally accepted economic fundamentals, in other words neoliberalism, became the narrative. Yesteryear’s Growth, Employment, and Redistribution policy is testimony.

There is nothing wrong with neoliberalism, as we are in a global environment which will have norms and practices, but, as any other approach, it also has its downsides. The most important downside is that market driven policies strengthen the incumbents.

Hence, policies must always be based on the realities on the ground, rather than some airy fairy “trickle down” assumption. Deviations must also be factored in, so that policies are tailored to suit the voter, and not internationalism.

This dogmatic adherence to neoliberalism accounts, but not exhaustively, for the low levels of economic transformation and the dire poverty, unemployment and inequality that runs rampant, more so in black areas. While some may argue that investors may become wary of a turbulent environment with daily protests, because economic marginalisation definitely stops investors from coming in. Finish and klaar.

To get into the discussion on the amendments to competition policy, they are what the doctor ordered in terms of the realities on the ground. Firstly, they will eliminate unfair price discrimination or excessive pricing by dominant firms. This dominance makes it hard for small and medium businesses to compete.

When this dominance is linked to the Preferential Procurement Policy Framework Act, black aspirants are knocked for a six.

Routed out

Other abuses by large firms like predatory pricing (when dominant firms lower their prices below reasonable economic levels to force competitors out of the market), margin squeezes (when dominant firms who operate across the value chain use their position to manipulate prices in the different markets in which they compete to force competition out), and refusing to supply scarce resources are also routed out by the amendments.

The bill also has provisions which make it easier for the authorities to exempt collaboration between small and medium businesses to enable industrial expansion and better aggregate employment.

The Competition Commission has been given teeth to deal with errant companies and fines could be at 10percent of turnover even for a first offender, and as much as 25percent of turnover for repeat offenders.

Finally, it is hoped the EDD will take another look at horizontal linkages, in other words, the control of value chains by major entities. For instance, small black publishers have to compete with publications owned by their printers and distributors. This is patently unfair, given the fact that these small publishers indirectly subsidise the publications owned by the major company.

For black entrepreneurs the amendments are like manna, and this could then be the start of effective economic restructure that could see more blacks in the economy. South Africa needs more such fire power.

Dr Thami Mazwai is a member of the Black Economic Empowerment Advisory Council, but writes in his personal capacity.

The views expressed here are not necessarily those of Independent Media.
  
2018/08/22
2018/09/03 12:03 PM
PRETORIA NEWS
The National Health Insurance (NHI) was not designed to work; instead, it was an aspirational proposal nobody really had to deliver on, but just keep promising endlessly into the future.
And if implemented, both the private and public health systems would deteriorate further, Professor Alex van den Heever, a former senior adviser on the Council for Medical Schemes, warned.

Van den Heever yesterday did not mince his words in his criticism of the NHI during a crisis summit hosted by Solidarity Research Institute in Centurion.

The institute presented its report on research, conducted among 3983 health practitioners.

According to the draft NHI bill, the fund will be the single public purchaser and financier of health services. The fund will also be a “mandatory prepayment health services system”.

But Van den Heever said: “My central concern with the way in which the public and private and health systems are operating is that there are vested interests driving those and the patronage model of governance of the health and private systems is going to continue.”

He said the private sector was also failing and there were people who benefited immensely from this.

“Our problem going forward is that the public and private systems will continue to deteriorate and nothing will change because there is actually no proposal on the table to address what is failing in either of the system and no political world to address those failures.”

Dr Chris Archer, a health care practitioner, specialising in gynaecology and obstetrics, also thought the NHI implementation was a bad idea and needed to be debated.

“I encourage other organisations, particularly the business community to seriously start debating this issue because we have not. Health Minister Dr Aaron Motsoaledi has gone around the country talking, but there is never any opportunity to debate the issue.”

Archer, addressing the impact on specialists and specialist services, said there was not much on the NHI document about specialists.

He said opportunities for corruption would be vast, should it be a success. “NHI proposal is not in the best interest of the people of this country,” he said.

Research psychologist from Solidarity Research Institute Nicolien Welthagen said: “During our research we came to understand our people are not knowledgeable on the NHI. I sent out an electric questionnaire and we did an opinion study. The results were that people don't have the knowledge; 93% of people were concerned they would (not) be able to implement the NHI, how it will be managed and how it will be rolled out.”

The report presents significant findings regarding health care professionals’ knowledge on the NHI, how informed they were, and their opinions regarding the state's ability to implement it successfully.

  
2018/08/22
2018/09/03 12:04 PM
SOLIDARITEIT
Die konsepwetgewing vir die Nasionale Gesondheidsversekering (NGV) het sedert dit in Julie bekend gestel is groot kommer oor die toekoms van gesondheidsorg in Suid-Afrika onder praktisyns, ekonome en gewone burgers gewek.

Die kommer in verband met gesondheidsorg in Suid-Afrika moet nie ligtelik opgeneem word nie en die Solidariteit Beroepsgilde vir Gesondheidspraktisyns het voorts besluit om ʼn krisisberaad te hou waarby topkenners vanuit die gesondheidsorgomgewing betrek is, wat beide publieke en private gesondheidsorg onder die loep geneem het, ekonome en gesondheidspraktisyns hul insette aangaande die voorgestelde implementering van die NGV gegee het, en voorts hul kommer oor die moontlike korrupsie en swak dienslewering wat met die sisteem gepaard sal gaan, uitgespreek het.

Volgens Dirk Hermann, bestuurshoof van Solidariteit, het gesondheidspraktisyns nou bystand nodig. “Een van die eerste beroepsgildes in die Solidariteit-stal is die Gilde vir Gesondheidspraktisyns wat nou gestig is weens die kommer wat in die beroep heers weens die verwagte implementering van die NGV. Die Gilde doen vandag wat ʼn gilde moet doen en dit is om die beroep te beskerm wat moontlik gemaak word deur ʼn beroepsgilde wat sterk staan,” het Hermann gesê.

Hermann het voorts gesê dat die openbare gesondheidstelsel op die oomblik misluk. “Die toetslopies van die NGV het misluk, maar ons staat hou nie van klein mislukkings nie, hulle hou van groot mislukkings. “Hierdie beraad dien as inset van die Solidariteit Beroepsgilde vir Gesondheidspraktisyns se kommentaar op die voorgestelde wetgewing. Ons regspan, onder leiding van een van Suid-Afrika se voorste regslui, advokaat Albert Lamey, gaan elke inset vandag oorweeg vir ons kommentaar,” het Hermann bevestig

Flip Buys, voorsitter van die Solidariteit Beweging, het by die beraad gesê dat staatsinmenging tot verhoogde mediese koste, swakker diens en sieker mense in Suid-Afrika gelei het. “Hierdie ongesonde toedrag van sake is veroorsaak deur onder andere: Oorregulering wat kostes opjaag, prysvasstelling wat byvoorbeeld die mark vir medisyne verwring, apteke wat sluit en vrye mededinging verhoed, plafonne op die ontwikkeling van meer hospitale wat kunsmatige tekorte skep wat pryse opstoot, regulasies wat die opleiding van meer dokters en spesialiste verhoed en wat só tekorte skep wat pryse opjaag,” het Buys gesê.

“Die NGV hou wel ʼn groot bedreiging vir almal se gesondheid in, maar weens die staat se onvermoë is dit eerder soos ʼn skilpad as ʼn kwaai renoster wat op ons afpyl. Daarom is dit lewensbelangrik dat ons die tyd nou gebruik om die beleid te beïnvloed,” het Buys afgesluit.

Volgens Hermann gaan die Solidariteit Beroepsgilde vir Gesondheidspraktisyns nou die vaandel opneem en as netwerk optree waar die lede van die Gilde mekaar kan versterk. “Ons wil deur die Gilde aan jongmense die geleentheid gee om die beroep te betree. Ons het reeds ʼn studiefonds vir jonges wat medies wil studeer en gaan dit versterk. Uit die gilde wil ons mentorskappe en internskappe aan jongmense bied. Voorheen is baie hiervan uit die staatsomgewing gedoen. Vir die Afrikaanse wêreld gaan die gemeenskap baie van hierdie verantwoordelikheid self moet neem,” het Hermann verduidelik.

“Ons verwag ook dat tienduisende mense ons kommentaar sal steun. Elke stem is nou nodig. Groot regeringsprojekte kan nog misluk, maar my en my gesin se gesondheid kan nie,” het Hermann afgesluit.
  
2018/08/21
2018/09/03 12:22 PM
IOL
The proposed National Health Insurance aims to provide health care for all South Africans.

The latest report from the Institute of Race Relations (IRR) argues that while South Africa’s deeply deficient public health service is in desperate need of reform, the ‘main purpose of the National Health Insurance is not to improve health services but rather to drive the private sector out of the healthcare sphere’.

The report, ‘What’s Wrong with the Golden Promise of the NHI?’ is a detailed critique of the government’s proposed National Health Insurance system.

The report goes on to explain that the NHI will drive the private sector out of the healthcare sphere and  ‘achieve this by putting an end to the medical schemes that primarily fund private medicine and are essential to its survival’, writes the author of the report, IRR Head of Policy Research Dr Anthea Jeffery.

At risk - along with the health care of the country’s 58 million citizens - is South Africa’s ‘world-class system of private healthcare, to which some 30% of its population on average, or roughly 17 million people, have access through their medical schemes, health insurance policies, or out-of-pocket payments’.

The report notes that South Africa’s 82 medical schemes ‘are vital in providing access to private healthcare’ to 9.5 million people (up from 6.9 million in 1997), of whom 48% are now black, while 11% are so-called ‘coloureds’, seven percent are Indian and the remaining 34% are white.

"Despite this major shift, the government plans to use the NHI to put an end to almost all medical schemes", primarily because of its ideological hostility to the ‘profit’ motive in private healthcare.

The government’s determination to press ahead with a new, vast bureaucracy - likely to cost an unsustainable R500bn at its start and possibly going as high as R1 trillion - ‘makes no attempt’ to remedy profound defects in the public health system.

Jeffery w rites that: "South Africa currently spends four percent of gross domestic product (GDP) on public healthcare, which is more than many other emerging economies can manage. But, despite the best efforts of many dedicated professionals working in the sector, the country gets little “bang” for its substantial “buck”.

Instead, public health care is plagued by poor management, gross inefficiency, persistent wastefulness, and often corrupt spending.

"The upshot is that 85% of public clinics and hospitals cannot comply with basic norms and standards, even on such essentials as hygiene and the availability of medicines. Cases of medical negligence - often involving botched operations or brain damage to newborn infants - have increased to the point where claims for compensation total R56bn. This is more than a quarter (27%) of the entire R201bn budget for public healthcare in 2018/19."

Instead, the NHI ‘assumes that throwing more resources at the public sector will provide a cure-all, whereas poor skills, cadre deployment, and a crippling lack of accountability lie at the heart of the malaise and will have to be overcome’.

By contrast, the NHI will likely undermine the potential for improvements.

"South Africa is already short of nurses, doctors, specialists, and other health providers, but the NHI offers no credible means of increasing their supply. On the contrary, the pool of available health providers and facilities is likely to shrink once the NHI takes effect.

"This is firstly because only 15% of public clinics and public hospitals currently do well enough on basic norms and standards to qualify for NHI participation. The remaining 85% … fail to maintain proper standards of hygiene and the like and will be barred from taking part. In addition, many private specialists, doctors, and other health providers with scarce skills might decide to emigrate, rather than subject themselves to NHI controls over their fees and treatment decisions."

The report advances proposals for a successful healthcare system available to all.

"Universal health coverage is already available, mostly for no charge, through the country’s public clinics and hospitals. To function better, these need merit-based appointments, strict accountability for poor performance, and effective action against corruption and wasteful spending. Public-private partnerships would also help improve their operation.

"The burden on the public system should also be reduced by increasing access to private healthcare. Low-cost medical schemes and primary health insurance policies should be allowed, while poor households should be helped to join these schemes or buy these policies through tax-funded health vouchers.

"To help spread risks, medical scheme membership and/or health insurance cover should be mandatory for all employees, with premiums for lower-paid employees buttressed by employer contributions for which businesses would garner tax credits. Medical schemes and health insurers would then have to compete for the custom of South Africans, which would encourage innovation and help to hold down costs."

But none of these solutions will emerge through NHI.

The report warns that by the time people realise that the NHI cannot deliver on its golden promises, the private health care system will effectively have been destroyed.

"South Africans will then be left with nothing but a failing state monopoly on which to rely".
  
2018/07/27
2018/07/31 01:14 PM
THE CITIZEN
If a service is provided by a company rather than government, this does not automatically mean a market is at work. The point is obvious but has passed by many in South Africa.

Private provision of services is moving into the spotlight as the government looks to make the health system more accessible to the poor. One aspect is the Health Market Inquiry HMI, established by the Competition Commission and chaired by former Chief Justice Sandile Ngcobo.

It recently released a provisional report recommending more regulation of private health care. It has invited comment on its ideas. It is inevitable that whatever proposals it comes up with will be attacked as an assault on the free market.

This will ignore the reality that there is no market in health care in South Africa, at least not one which works the way markets should work. Markets work only for people who have enough money to take part.

So the local healthcare market would exclude many people who cannot afford private care. But that is not the only problem even those able to join medical schemes do not get the benefits markets are meant to offer.

For markets to work, consumers must be able to make informed choices: they must have both a real right to choose and enough information to make that choice. But information and choice operate weakly in private healthcare and not at all in the private health insurance offered by medical aids.

The Competition Commission and the department of health are not trying to abolish the market, they are trying to make it work. The accurate debate is about whether they are doing it in the best possible way.

It might be true that people who can afford private medical care can choose then general practitioner. But that is where it ends. If patients need specialised care to hospital treatment, they don't choose the specialist or the place they will be treated.

Given all this, the HMI's proposal that healthcare providers and funders should be regulated is a pro-market move it seeks to make informed choice more of factor than it is now.

Similarly, an amendment to the Medical Aid Schemes Bill, which would abolish brokers, is currently up for discussion.

It, too, is not an attack on the market. Its likely effect would be to force brokers into the customer relations departments of the medical schemes, improving market information by ensuring that consumers know that they are dealing with people who work for the schemes, not for them.

Again, to oppose this measure is not to defend the market it is the opposite. For years, it was assumed the market was delivering satellite television where there was only one supplier.

Concentration in the formal economy means most good: are produced by subsidiaries of a handful of companies and sold in stores owned by only two or three.

While competition between a couple of firms is technically market, it is hardly one which offers benefits to consumers. The claim that markets must be left alone very often means there is a need to leave existing private providers alone.

This hides the reality that, in current circumstances, the challenge is not to protect private providers but to ensure they really are subjected to the rules by which markets are meant to force them to play.
  
2018/07/26
2018/07/31 01:14 PM
FIN24.COM
The national department of health recently took a swipe at medical schemes’ use of brokers to realise membership growth in a stagnant industry. Medical brokers were paid R2.2bn in 2017, according to the department.

“Almost two-thirds of principal members of medical aid schemes pay monthly to a broker as part of their premium,” said health minister Dr Aaron Motsoaledi at the presentation of the Medical Schemes Amendment Bill. “Many of these members do not even know that they are paying this money, which in 2018 is R90 per month.”

The department wants this money to be made available to pay for direct health expenses of members, rather than serving brokers “who are actually not needed in the healthcare system”, he said.

“The draft Medical Schemes Act Amendment Bill does not contemplate the termination of the role of brokers,” says Dr Jonathan Broomberg, CEO of Discovery Health. “It simply requires that members give explicit consent for the appointment of their broker, after which medical schemes may continue to pay broker commission.”

Discovery Health Medical Scheme, with its 2.77m beneficiaries at the end of 2017, owns 57% of the market for open medical schemes. The scheme paid broker service fees worth R1.2bn in 2017, according to its annual report.

Broker fees are capped at 3% of a member’s medical aid contribution per month, or R90, whichever is the largest. Medihelp, another open medical scheme counted among the 10 largest schemes in the country, paid brokers R60.5m in 2017, up from 2016’s R54.8m.

“Medihelp believes that brokers will continue to add significant value to medical schemes in the future,” says Heyn van Rooyen, the fund’s principal officer. “Since the bulk of the scheme’s new business is enrolled via its distribution channel, it is obvious that this resource simply cannot be done away with.”

The number of beneficiaries at Medihelp grew by 2.3% during 2017, or 4 563 net new beneficiaries. The amount spent on brokers to service this growth, by dividing the amount spent on them by the number of new beneficiaries, equates to R13 268 per net new beneficiary.

Discovery Health Medical Scheme spent R28 399 per net new beneficiary as the scheme’s number of insured lives grew by 42 755 in 2017. BestMed, also one of the 10 largest medical schemes in SA, lost 236 members during 2017 while paying brokers R70.45m, according to its annual report.

Bonitas, the second-largest open medical scheme, lost 24 571 beneficiaries during 2017, and paid brokers R281.2m over the same period, according to its annual report. Suffice it to say the fund did turn a R16.9m deficit for 2016 into a R730m surplus last year.

At the release of the amendment bill, Motsoaledi had this to say of medical aid brokers: “We are aware that most of the work supposedly done by brokers is actually done by the Council for Medical Schemes – the statutory body.”

But the minister’s criticism of the use of brokers is not shared by medical schemes.

Medihelp’s Van Rooyen points out that healthcare brokers are subject to stringent compliance rules, such as accreditation with the Council for Medical Schemes, and industry-related examinations. They also have to spend considerable time and effort on undergoing training, he says.

“We believe that well-reasoned feedback will be fed through to the legislator during the time allowed for comment on the proposed bill,” says Van Rooyen.

Broomberg is also optimistic about the continued existence of medical aid brokers.

“We envisage that brokers will obtain the relevant consent from members, as many already do at present, and that brokers will continue to play a vital role in advising members on the appropriate choice of medical scheme options, as well as in assisting members to access their benefits,” he says.

Some of the listed companies providing medical aid brokerage services as part of their offerings include Sanlam, PSG Konsult and Liberty.
  
2018/07/26
2018/07/31 01:15 PM
Today, the DA conducted an oversight inspection at the Elim District Hospital in Limpopo. The health facility was administered under the failed National Health Insurance (NHI) pilot project in the Vhembe District.

The challenges at the Elim District Hospital are proof that the NHI will not address the serious issues at the root of the collapsing public health sector. Simply put, the NHI is not a feasible plan to fix the public health care system. If the pilot projects are failing, how can the ANC government expect it to succeed on a national level?

In the 2016/17 financial year, the Vhembe District scored a lowly 42% in the Office of Health Standards Compliance’s (OHSC) Annual Inspection Report and the DA’s findings at the hospital were indicative of why the district performed so poorly.

The DA spoke to the hospital’s CEO, Pfuluwani Matodzi, who stated that the 108-year-old hospital is currently faced with challenges such as staff shortages, despite the fact that 95% of the hospital’s budget is allocated towards personnel costs. Other challenges raised by the CEO include infrastructure issues and continuous water shortages.

Due to the facility’s budgetary constraints, the hospital is unable to pay for goods and services, lab costs, blood services and infrastructure repairs.

A visit to the maternity ward highlighted the plight of the hospital. It was seriously overcrowded, linen was old and many of the baby bassinettes were in disgraceful condition. Most disturbing was the fact that at the time of the visit there we no Bacillus Calmette–Guérin (BCG) vaccines for newborns.

Just down the road at the Waterval Clinic, there were no diabetic medicines, which is one of the biggest killers of people in Limpopo. There were also no antibiotics, cough syrups or medicines to treat minor ailments.

The DA is the only party that has a tried and tested alternative to the NHI. The DA’s Our Health Plan is the most credible and workable offer, as it will ensure that no South African is denied quality health care because they are poor.

In the DA-governed, Western Cape, patients have access to the best public health system in the country and we will continue to fight to ensure that all South Africans have access to dignified health services.

Issued by Lindy Wilson, DA Shadow Deputy Minister of Health, 26 July 2018
  
2018/07/26
2018/07/31 01:17 PM
THE SOUTH AFRICAN
The Solidarity Research Institute has released a report detailing the enormous amount of funding necessary to effectively implement the National Health Insurance (NHI) scheme.

The numbers far exceed those previously calculated by the Health Minister, Aaron Motsoaledi. What’s more worrying is the heavy impact this will have on South African taxpayers.

According to Solidarity researcher, Morné Malan, funding required by the NHI is closer to R357 billion with a deficit of approximately R210 billion.




NHI: How does it affect the taxpayer?

Malan outlined the exorbitant fees which would need to be carried by the South African taxpayer. According to his research, value-added tax (VAT) would effectively double in order to carry the weight of NHI.

Commenting on the burden taxpayers will be forced to carry, Malan said:

“It is very difficult to determine from where the additional money to fund the NHI will come. It will take as much as 70% of personal income tax, or even as much as 99% of the income through value-added tax (VAT) to provide for the deficit. VAT will effectively have to be doubled.”

Motsoaledi admits that he has no idea how much the NHI program will cost. Initially, the health minister threw out a thumb-suck figure of R259 billion. He blamed this irregularity on poor estimations calculated by an external accounting firm.

Both the World Bank and the World Health Organisation have agreed that the exact cost of a nationalised health system cannot accurately be quantified.

How much is a nationalised health system going to cost?

Motsoaledi firmly believes that introducing the national healthcare reform is a step in the right direction in the fight against South Africa’s social and economic inequality. The minister has remarked:

“You cannot balance books against service delivery on human life.”

Malan argues that the proposed system will almost certainly cost much more than what the government’s initial estimates indicate. Commenting on the speculative costs of NHI, the researcher said:

“What is even more worrying, is that the number for NHI funding is rather closer to R357 billion with a deficit of approximately R210 billion. It is simply madness to assume that this deficit can be eradicated by taxes.”

Malan added that while in theory, a free healthcare system has its merits, there is simply not enough money in the country to implement the scheme effectively.
  
2018/07/26
2018/07/31 01:54 PM
THE CONVERSATION
If a service is provided by a company rather than government, this does not automatically mean a market is at work. The point is fairly obvious but has passed many in South Africa by.

Private provision of services is moving into the spotlight in South Africa as the government looks to make the health system more accessible to the poor. One aspect is the Health Market Inquiry, established by the Competition Commission and chaired by former Chief Justice Sandile Ngcobo. It recently released a provisional report recommending more regulation of private healthcare. It has invited comment on its ideas.

It is absolutely inevitable that whatever proposals it comes up with will be attacked as an assault on the free market in health care. This will ignore the reality – that there is no market in healthcare in South Africa, at least not one which works in the way in which markets are meant to work.

To get an obvious point out of the way first, markets work only for people who have enough money to take part. So it is true that a healthcare market in South Africa would exclude many people who cannot afford private care. But that is not the only problem with the private healthcare system – another is that even those who are able to join medical schemes do not get the benefits markets are meant to offer.

For markets to work as they are meant to, consumers must be able to make informed choices: they must have both a real right to choose and enough information to make that choice. But information and choice operate weakly in private healthcare and not at all in the private health insurance offered by medical aids.

This places the South African debate about healthcare in perspective. The Competition Commission and the health ministry are not trying to abolish the market, they are trying to make it work. The accurate debate is about whether they are doing it in the best possible way.


No real choice

It might be true that people who can afford private medical care can choose their general practitioner. But that is where it ends. If patients need specialised care or hospital treatment, they don’t choose the specialist or the place where they will be treated.

And so they have no way of ensuring that they get the best possible care. While popular wisdom in the suburbs often assumes that all private doctors and hospitals are good, inevitably some are a great deal better than others and some are no good at all. But consumers do not make an informed choice on where to go and who to go to, although this is a far more important decision than buying a kettle.

Informed choice of a medical aid scheme is just about non-existent. Most people belong to the scheme their employer chooses. If they are “lucky” enough to have a choice in theory, they do not have one in practice. Medical aids do not publicise what they do and the language they often use most people can’t understand and so there is no way to “shop around” in ways which would make an informed choice possible.

The situation is quite the same when people have joined schemes. Information on what is allowed and what is not may be understandable to doctors and pharmacists, but not to scheme members.

The supposed solution is the medical aid broker, who is meant to help consumers to choose and to deal with the scheme after they join. But the brokers are paid by the schemes and so it is no surprise that they are there to look after the scheme, not the consumer.

Brokers direct people to the schemes they are working for, not those which will best meet the needs of the consumer. Anyone who has a problem with a medical aid’s decision will soon find that the broker is a public relations officer, not a consumer representative. Their job is to justify the scheme’s decision, not to question it.

Pro-market moves

Given all this, the Health Market Inquiry’s proposal that healthcare providers and funders should be regulated is a pro-market move – it seeks to make informed choice more of a factor than it is now. There is room for debate on whether it is going about it in the best way. But to claim that it is an attack on markets ignores the way in which private healthcare operates.

Similarly, an amendment to the Medical Aid Schemes Bill which would abolish brokers is currently up for discussion. It, too, is not an attack on the market. Its likely effect would be to force brokers into the customer relations departments of the medical schemes, improving market information by ensuring that consumers know that they are dealing with people who work for the schemes, not for them.

Again, to oppose this measure is not to defend the market – it is the opposite. To argue against it is to say that a market in which people know who they are dealing with and can make informed choices is not a good idea.

The tendency to assume that private provision means that there is a market even when there is not is not restricted to health care. For years, it was assumed in the mainstream that the market was delivering satellite television when there was only one supplier. Moving from services to goods, many beer drinkers no doubt toast the market as they choose between a range of labels produced by one company.

More generally, concentration in the formal economy means that most goods are produced by subsidiaries of a handful of companies – and sold in stores owned by only two or three firms. While competition between a couple of firms is technically a market, it is hardly one which offers strong benefits to consumers.

Making markets work

This has two implications for South Africa’s economic debate. The first is that not all proposals for regulating private economic activity are an attack on the market. A key feature of the country’s economy is that it is dominated by very few players and so markets often do not work as they should. A stronger government role could mean stronger, not weaker, markets.

The second is that, in these circumstances, the claim that markets must be left alone very often means that there is a need to leave existing private providers alone. This hides the reality that, in current circumstances, the challenge is not to protect private providers but to ensure that they really are subjected to the rules by which markets are meant to force them to play.

This article was originally published on The Conversation.
  
2018/07/26
2018/07/31 02:06 PM
POLITY
The trade union Solidarity is seriously concerned about the tremendous negative impact the proposed National Health Insurance (NHI) will have on tax payers.

According to Morné Malan, a researcher at the Solidarity Research Institute, the government’s total tax income is currently just more than R1 Trillion of which more than a third would have to go to the NHI. Malan further said that it is improbable that the government will cut on expenditure elsewhere and therefore, it is very difficult to determine from where the additional money to fund the NHI will come. It will take as much as 70% of personal income tax, or even as much as 99% of the income through value added tax (VAT) to provide for the deficit. Therefore, to continue with the same services which are currently funded by VAT, as well as provide for the shortfall regarding the NHI, VAT will effectively have to be doubled, which presumes that people’s spending patterns will stay the same, which will definitely not be the case.

Malan explained that according to the government’s own, very optimistic numbers, government spending on health care will have to increase with approximately 10,6% annually from 2019 until 2024/25. Given the current deficit in our budget, it is nearly impossible to determine where the additional funds will come from.

Solidarity is also concerned about the government’s naïve estimate on the scope and cost of the proposed project. According to Malan, the government base their numbers on the presumption that the economy will continuously grow at a rate of 3,5%, while South Africa is currently not even close to that growth rate. They further assume that the demand for health care in South Africa will experience the same increase experienced in other countries, such as Thailand, for example. The latter ignores the fact that we have an extraordinary high burden of disease in South Africa according to the World Health Organisation’s (WHO) Disability Adjusted Life Years method.

Malan argues that the proposed system will almost certainly cost much more than what the government’s initial estimates indicate. According to the government’s calculations in the white paper, the NHI will need approximately R256 billion by 2025, of which R72 billion will be a deficit on current government expenditure on healthcare. Malan explained further it is already difficult to imagine how the insurance would be funded and that the already over-taxed population will not be able to handle further increases. “What is even more worrying, is that the number for NHI funding is rather closer to R357 billion with a deficit of approximately R210 billion. It is simply madness to assume that this deficit can be eradicated by taxes,” Malan said.

According to Malan, the potential size of the NHI can be summarised as 1.2 times the size of total revenue presently generated from personal income tax, or even 1,5 times the income received by VAT. This means more than double these income sources of the government. Malan concluded by saying that it is simply not possible to fund the NHI within the current state of our economy, regardless of ideological wishful thinking.
  
2018/07/26
2018/07/31 02:49 PM
SOLIDARITY
Die vakbond Solidariteit het vandag sy kommer uitgespreek oor die geweldige negatiewe impak wat die voorgestelde Nasionale Gesondheidsversekering (NGV) op belastingbetalers sal hê.

Volgens Morné Malan, ʼn navorser verbonde aan die Solidariteit Navorsingsinstituut, is die regering se totale belastingopbrengs tans net meer as R1 000 miljard, waarvan meer as ʼn derde van hierdie opbrengs na die NGV sal moet gaan. Malan sê voorts dat dit onwaarskynlik is dat die regering elders op besteding gaan sny, daarom is dit bitter moeilik om te bepaal waar die bykomende geld om die NGV te befonds vandaan gaan kom. “Slegs om die tekort op te maak, kan soveel as 70% van persoonlike inkomstebelasting verg, of selfs soveel as 99% van die opbrengs wat deur belasting op toegevoegde waarde (BTW) verkry word. Derhalwe, om voort te gaan met dieselfde dienste wat tans deur BTW befonds word, asook om die tekort op die NGV te betaal, sal BTW effektief moet verdubbel wat veronderstel dat mense se bestedingspatrone dieselfde gaan bly, terwyl dit vir seker nie die geval sal wees nie,” het Malan gesê.

“Volgens die regering se eie, baie optimistiese syfers gaan staatsbesteding op gesondheidsorg met ongeveer 10,6% jaarliks vanaf 2019 tot en met 2024/25 moet toeneem. Gegewe die huidige tekort in ons begroting is dit bykans onmoontlik om te bepaal waarvandaan hierdie bykomende fondse gaan kom,” verduidelik Malan.

Solidariteit is ook verder besorg oor die regering se naïewe beraming van die omvang en kostes van die voorgestelde projek. Volgens Malan baseer die regering hul syfers op die veronderstelling dat die ekonomie deurlopend met sowat 3,5% sal groei, terwyl Suid-Afrika se ekonomie tans nie naastenby daardie groeikoers beleef nie. Verder maak hul die aanname dat die toename in die vraag na gesondheidsdienste dieselfde sal wees as wat ander lande, soos byvoorbeeld Thailand, ervaar het. Laasgenoemde ignoreer die feit dat ons ʼn besondere hoë siektelas in Suid-Afrika het volgens die Wêreldgesondheidsorganisasie (WGO) se DALYS-metode (“Disability Adjusted Life Years”).

Malan voer aan dat die voorgestelde stelsel veel meer sal kos as wat die regering se aanvanklike beramings aantoon. Volgens die regering se syfers in hul witskrif sal die NGV teen 2025 sowat R256 miljard benodig, waarvan R72 miljard ʼn tekort op huidige staatsbesteding op gesondheidsorg sal wees. Malan verduidelik verder dat dit al reeds onmoontlik is om die versekering te befonds en dat die oorbelaste bevolking nie verdere toenames kan bekostig nie. “Wat egter meer kommerwekkend is, is dat die syfer vir befondsing eerder veel nader aan R357 miljard lê met ʼn tekort van sowat R210 miljard in 2025. Dit is eenvoudig waansinnig om te dink dat hierdie tekort deur belasting uitgewis kan word,” het Malan gesê.

Volgens Malan kan die totale potensiële grootte van die NGV opgesom word as omtrent 1,2 keer die totale huidige belastingopbrengs verkry deur persoonlike inkomstebelasting of selfs 1,5 keer meer as alle opbrengs verkry uit BTW. Dit beteken meer as dubbeld hierdie inkomstestrome van die regering. “Dit is eenvoudig nie moontlik om die NGV te befonds met die huidige toestand van ons ekonomie nie, ongeag enige ideologiese wensdenkery,” het Malan saamgevat.
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