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2019/05/09
2019/05/13 11:59 AM
BUSINESS DAY

Parties campaigning for the May 8 elections are far more focused on personalities than issues, leaving the health care promises made by rivals in their election manifestos virtually unchallenged. There is no hard questioning of the government's progress in realising its ambitions for universal health coverage, which it calls National Health Insurance NHI, or public debate on the merits or otherwise of the DA's proposed alternative.

The complexity of the issues partly explains why politicians on the campaign trail shy away from health care. But for the ANC, part of its reticence may simply be down to fear of losing voters. It has gone quiet on NHI, caught between a rock and a hard place: if it pushes too hard and signals the demise of medical schemes before establishing trust in the public sector, it risks scaring off voters who value their access to private health care providers. If it goes too slowly, it risks alienating SA's biggest trade union federation, Cosatu, and all the voters it brings along with it. Thus the ANC's election manifesto plays it safe on health care. It offers no new ideas or policies, trotting out the well-worn aspirations with which voters are all too familiar: it will bring the HIV epidemic under control, achieve universal health coverage by 2025, and develop a new legal framework to deal with the rising tide of medical malpractice claims. The DA continues its opposition to NHI, suggesting an alternative system in which everyone who belongs to a medical scheme will subsidise those without.

It first flighted its "Our Health" plan in 2016, arguing its reforms would be quicker and cost less than NHI. Most of the party's other election campaign promises are fairly routine stuff digitise records, expand clinic hours, improve public transport to health facilities, and beef up health infrastructure. But it does put forward one novel idea, which is to introduce a voluntary national civilian service for young people who have finished school but do not go on to tertiary education. The programme would give young people work experience, while they earn a stipend, and help them to gain a foothold in the labour market like most political parties; the EFF's health care assurances are devoid of any discussion of how they will be paid for. It can afford to promise voters the earth because it knows it will not be elected to power, so escaping the hard reality of carving up a pie that is not big enough to go around. Its election manifesto includes dozens of health care undertakings, ranging from keeping clinics open 24 hours to providing rent free space for traditional healers to ply their trade in district hospitals. It will establish state owned firms to manufacture pharmaceuticals, ambulances and medical equipment, taking the ANC's more than a decade old promise to set up a state owned pharmaceutical company a step further. This wish of the ANC was hammered into a resolution at its 2007 national conference in Polokwane, but like so many policies born from wishful thin king rather than clear headed analysis, the project remains stuck on the drawing board. The IFP's election manifesto, like those of its biggest rivals, recognises the shortcomings in the current health care system by promising to fix the most glaring problems. It thus says it will improve health infrastructure, train more professionals and cut the prices of medicine. But it goes one step further, saying it will make traditional and complementary medicines more widely available, and implement a cancer policy in the workplace. A poll in February 2019 by the Institute of Race Relations found voters gave the ANC national government an overall score of 13% on health.

It found EFF voters were more sympathetic than DA voters, but they still scored the government badly at 24%, compared with DA voters' 57%. ANC voters gave it a score of 3%. Curiously, it found that a high proportion of ANC voters who were very dissatisfied with the government over health care still believed the ANC was best equipped to tackle the issues. This dissonance is striking, given the extent to which voters' personal circumstances deter mine the quality of services they can obtain. The well-heeled can afford to pay for private healthcare services that are mostly available when they need them, while the poor take their chances with a public health sector that is capable of providing world class organ transplants, but frequently fails to meet patients' most basic needs. Health care is complex, the issues nuanced and hard to encapsulate in a soundbite. Yet it matters to voters. Politicians would do well to remember this as they enter the final stretch of the campaign trail

  
2019/05/06
2019/05/13 11:52 AM
SPOTLIGHT

Despite the Constitutional injunction on the government to ensure that everyone has access to quality health care services, including reproductive health care, and the promise to equalize access through National Health Insurance (NHI), public health care services remain grossly under-funded. Vacant health posts, outdated or sub-standard equipment, medicine stock outs and crumbling public health infrastructure leave millions of people who rely on the public health system without access to the care they need. Over the past year, the government has tried to push ahead with implementing the long awaited NHI policy. The idea of providing affordable universal healthcare in a country with such dire inequality is important.

However, it is essential to build NHI on a solid foundation. Improving public health facilities up to the performance levels that are necessary requires adequate financing, human resources, organisational capacity, as well as accountability. Every day, there are stories of people struggling to gain access to healthcare. The narrative of a struggling public health sector is long standing. What is rarely acknowledged by those that vaunt the quality of care in the private system however, is how much money we are throwing at that private system and whether those costs are sustainable? As a country, we spend a similar amount of money on a private health system that serves only one in five people, as a public system that serves everybody else. In average per person terms, this equates to approximately R4 480 spent on each person who relies on public health care, compared to R17 225 per person who has private medical insurance. During the fifth democratic administration, spending on social services stalled overall as a result of budget austerity.

Additional funding was made subject to cuts in other areas. For example, the injection into higher education was funded in part by cuts to school infrastructure grants, as well as a hike in VAT. In health care, spending by the state increased in real terms by only R255 per public healthcare patient between 2014/15 and 2018/19. Spending per person in the private health sector increased by R1 001 during the same period. This stands in stark contrast to the doubling of spending on public health that is envisaged for the NHI transition. Our health human resources are also thoroughly unevenly split between private and public care. In 2018, one government employed doctor had to attend to 2 457 patients, while their counterparts in the private healthcare sector only had to see to 571. This situation is exasperated by the brain drain in the public healthcare sector which is a result of poor management as much as underfunding. But good health care managers are scarce too. In a country where most people depend on the public healthcare system, only 35% of registered nurses and midwives were working in the public sector.

Without adequate financial resources and medical personnel, the public health care system will continue to crumble while people seek greener pastures or better care. Our public health care system needs radical overhaul in order to provide the kind of care that the people who depend on and are entitled to by right. Corruption in the health care sector became a national concern during the 5th administration as it exacerbates the problems mentioned above – draining and misdirecting precious resources.

The arbitration process that followed the Life Esidimeni tragedy found that the need to cut costs was a red-herring excuse used by departmental officials attempting to avoid accountability for their uncaring and unlawful decisions. However, there can be no doubt that such disasters are more likely to occur in an under-resourced health system where health departments are under constant pressure to meet austere (and often arbitrary) Treasury imposed expenditure ceilings, than in one which they have sufficient resources to provide appropriate care according to need. It is clear we need increased scrutiny when it comes to the financials of the health care sector. It is also clear that we need a government that is committed to translating lofty promises for a better life for all into a programme for system-wide health care reform. Adequate funding also needs to be provided to make improved public health care a reality.

McLaren and Ndebele both work for SECTION27


  
2019/05/062019/05/13 11:58 AM
MEDBRIEF

The Health Professions Council of South Africa (HPCSA) is to hold its first National Conference from 18-19 August at Emperors Palace in Kempton Park on the East Rand from 18 – 20 August 2019. The Conference will provide an opportunity for delegates across all health sectors, health regulators, policy makers, academics and service providers among others; to engage on regulatory matters pertaining to the healthcare environment; including the shifting global and local healthcare trends. The theme for the event will be “Regulating the Health Professionals in the 21st Century” with a focus on The Role of the Regulator in Universal Health Coverage as well as looking at the Regulator’s contribution towards Advocating for Good Health and Well-being – Why it matters? What is our role in achieving these goals? The compelling programme has various interactive sessions focused on core issues specifically the emerging gaps in the current regulatory framework in relation to universal health coverage and the impact of the current ethical rules in the delivery of universal health coverage to ensure a sustainable healthcare system. Another key feature in the programme are the concurrent issue-based breakaway sessions where delegates will explore various perspectives on the workforce environment, the required skills and capabilities, the role of education and training systems in preparing the health practitioners of tomorrow, Ethical Engagement in the Digital Era and Digital Innovation and the Wave of the 4th Industrial Revolution. The Council will also be engaging on the outcomes of the Health Market Inquiry and the Presidential Health Summit 2018 as well as creating awareness with stakeholders on its mandate. Registration and additional details can be accessed on www.hpcsaconferrence.co.za and queries can be sent to conference@hpcsa.co.za

  
2019/05/052019/05/13 11:47 AM
DAILY MAVERICK

Passionate and principled, the minister of health has led massive victories over HIV during the past decade. But as SA attempts to introduce complex changes to the health system, is it time for an operations person rather than a firefighter?

Health Minister Aaron Motsoaledi is a courageous leader, emotional and passionate about trying to improve the lives of ordinary people. He has taken on pharmaceutical companies, describing their opposition to more consumer-friendly medicine patent laws as “genocide”.

He has been unrelenting in his criticism of private healthcare for being “exorbitantly expensive”. He was also one of the few cabinet ministers who spoke out against the excesses of Jacob Zuma during his presidency, something that was recently confirmed by Minister Derek Hanekom.

Last year, he sobbed into his hands at the Esidimeni hearings convened to examine the deaths of at least 143 psychiatric patients in Gauteng, saying: “The human rights breached in this manner are reminiscent of the apartheid era.”

A staunch ally of President Cyril Ramaphosa and ranked 25 on the ANC’s national election list, Motsoaledi’s reappointment as health minister seems relatively secure. But after a decade of Motsoaledi’s leadership, the health service shows no signs of improving and the National Health Insurance (NHI) scheme, the vehicle that is supposed to drive South Africans’ access to universal health care, remains on blocks parked in the Presidency.
There is significant dissatisfaction with Motsoaledi in the upper echelons of the health department. He stands accused of being a control freak who centralises power, while the feud between him and director general Precious Matsoso has eaten away at the morale of head office staff. One source described him as a “firefighter when what is needed is an operations person”.

Symbolically, the national health department has been unable to protect the health of its own employees at its headquarters in the Civitas Building in Pretoria. The building was declared 80% non-compliant with building safety regulations in 2016 and some staff members have been on strike for over a year as a result.
While all parties finally agreed recently that the department would move to a new building that has yet to happen. The strike is still on and has paralysed many important functions, such as issuing import licences to pharmaceutical companies.

Zooming out from the health minister’s doorstep, the Office of Health Standards Compliance (OHSC) – set up to evaluate health facilities in preparation for the NHI – reported that there has been little improvement in public sector health institutions over the past five years.

Only five of the nearly 700 public health facilities that it inspected achieved a pass (a score of over 80%), with facilities in Limpopo and Eastern Cape scoring 43% on average.

But not too much blame for this can be laid at the minister’s door. Constitutionally, provinces are responsible for implementing national health policies – and many health projects became lunch boxes for the corrupt to snack on. Motsoaledi once told me when I asked him about the dire state of various facilities: “Believe me, I know better than you the problems in public health,” adding that he frequently got calls from the public asking him to intervene to help their relatives at various horrible hospitals.

Reining in errant provinces has proved to be a complicated headache. The National Treasury has used conditional grants to ring-fence the HIV treatment allocations for provinces to protect this money, but it has been unable to enforce spending compliance on other issues. But the national government’s only real recourse to protect citizens from weak and spendthrift provincial departments has been to place them under administration in terms of Section 100 of the Constitution.

In the past decade, the health departments of the Eastern Cape, Gauteng, Limpopo and North West have all been placed under administration. North West is still under administration and the Free State health department may well be next as it is bankrupt and faces R1.5-billion in malpractice lawsuits. In addition, in 2017 the national department had to intervene in KwaZulu-Natal to address a massive backlog in cancer treatment. These interventions have forced Motsoaledi into the role of a firefighter as, once a department has been placed under administration, already stretched national staff members have to be sent to provinces to try to sort out their messes.

Firefighting aside, Motsoaledi’s greatest success has been in addressing HIV. He probably survived the Zuma-era Cabinet reshuffles because he was the greatest asset of the Jacob Zuma presidency – not because he aided the looting but because his appointment had an enormous impact on our mortality.

Over the nine years that Zuma was president – between 2009 and 2018 – life expectancy for women increased by a massive eight years, while the average man gained another six years of life – largely thanks to antiretroviral (ARV) medicine becoming freely available to all people living with HIV.

By last year, the average South Africa woman could now expect to live until 67,3 years (compared to 58,1 years in 2008) and while the average man will live to 61,1 years. Aids-related deaths plunged from 248,208 in 2008 to 115,167 in 2018.

Between the health department and the Treasury, South Africa has negotiated the cheapest ARVs in the world – and last week the health department managed to persuade the US not to cut its funding for our HIV programme through its President’s Emergency Fund for Aids Relief (PEPFAR) programme. But in the next five years, the government is going to need to make real progress in introducing universal healthcare. Its chosen plan is the National Health Insurance (NHI) scheme, which will be compulsory for all workers and aims to offer every person in the country the same basic healthcare.

Motsoaledi has been both belligerent and vague about his vision for the NHI, simply indicating that the Treasury must “find the money” when asked how this massive undertaking will be funded. NHI pilots have been run in various districts in all provinces, but these were not altogether successful (condoms ran out in one of the districts, many failed to spend their budgets while private health professionals baulked at working in some poorly resourced public facilities).

The NHI has since been shifted out of the health department to a “war room” in the Presidency under Professor Olive Shisana. But the NHI Bill released last year is full of gaps and a wide range of forces, including social justice organisations such as Section27 and the Rural Health Advocacy Project, have called on the government to first fix the most broken elements of public health – including shortages of health professionals, poor standards of care and poor management – as well as excessive prices in the private sector, before forcing a marriage between the two. Meanwhile, the obvious starting point for one united health system –shifting all public servants who are on the Government Employees’ Medical Scheme (GEMS) into public health – has not yet been mentioned as this is a political hot potato and the ANC still needs to win Wednesday’s election.

So – finally – is Motsoaledi the right man to lead this health service revolution? It is hard to answer that without knowing who the other contenders are. Perusing the ANC list, it is clear that we could do very much worse if we traded this man with great humanity and passion for one of the morally compromised “leaders” on the list.

But whoever the health minister is, he or she will need a dream team of skilled managers – an entire squad of Yogan Pillays (the overworked but highly competent deputy director general of health) – to fix the broken system and such people may be even scarcer in the public sector than a competent, trustworthy politician.


  
2019/05/02
2019/05/13 11:38 AM
TIMES LIVE

Six psychiatric patients are tied to their beds in two tiny, dimly lit cubicles in the emergency ward of South Africa's biggest hospital, where the country's dire healthcare crisis is starkly evident.

Some of the group are restrained using just medical bandages, while one screaming female patient is tied to a bed that is itself haphazardly secured to a pillar. The scenes at the vast Chris Hani Baragwanath Hospital, in the township of Soweto outside Johannesburg, provoke little visible reaction from hurried staff or from other patients.

Staff says the hospital always has serious mental health cases in its casualty unit waiting for a bed. According to a doctor who wished to remain anonymous, some are left for three days with little food and water -- one sign of chronic lack of resources in South Africa's healthcare system, which has been a political battlefield ahead of the May 8 general election. "We can't move psychiatric patients on fast enough because it takes a long time for them to get better and the wards are full," said the doctor. "They are the forgotten people."

Voting this year will mark 25 years since the end of apartheid rule, but hopes have been dashed that the new era would produce a modern, accessible public health service. The grim cost of the failing system was highlighted in a recent scandal when 144 mental health patients died in 2015 and 2016 in a botched government plan to relocate them from a private hospital to poorly-prepared local facilities as a cost-cutting measure. Many of the deaths occurred due to mistreatment, pneumonia, dehydration and diarrhoea.

Last year Health Minister Aaron Motsoaledi, of the ruling ANC party, broke down as he apologised for what he described as "one of the most painful and horrible events in the history of post-apartheid South Africa". When it came to power in 1994 at the end of white-minority rule, the African National Congress party vowed to introduce "affordable health care, to ensure that all South Africans are guaranteed basic treatment."

The ruling party's solution now is for a National Health Insurance (NHI) system, similar to that in many European countries. Health spending in South Africa accounts for 8, 8% of GDP. However, less than half of that is spent within the public sector and 4, 6% of GDP is spent within the private sector. In 2017, that imbalance was reflected by only 10% of the black majority having health insurance, compared to 71,7% of the white minority. But the ANC proposal is "entirely unfeasible and places the stability of the national fiscus at risk," according to the main opposition Democratic Alliance (DA) party. DA policy is to work with private healthcare insurance companies to extend low-cosy coverage to more than 50% of citizens. Speaking outside Baragwanath, DA provincial shadow health minister Jack Bloom said the flagship hospital was at breaking point.

"I know that people here can wait as long as three years to have a hip operation, and the medical negligence claims in the maternity section are sky high," he said. Over 60 vacancies for doctors and 300 for nurses have been left unfilled at the hospital -- which has a total staff strength of around 6,000 -- due to budget cuts. "They promised us they were going to build five hospitals in Soweto to take the pressure off and all they have done is built one," said another hospital doctor who did not wish to be named.

The vast and crumbling Baragwanath hospital has approximately 3,200 beds for some 1.5 million surrounding residents while also serving as a teaching hospital and a referral hospital from across South Africa and even across Africa. Deputy director-general for health in South Africa Yogan Pillay told AFP it was clear the government budget "is falling behind the need". "Budgets are allocated to a facility on the basis of the people in that catchment area but if we have an influx -- including internal migration -- then people run short of supplies," he said.

"We have to increase the efficiency in both the public and the private sector." South Africa has made strides in its treatment of AIDS and tuberculosis, but the election seems to offer little immediate hope of improvements to healthcare. The system is crippled by "poor leadership and governance at all levels," said senior lecturer and public health specialist doctor Kerrin Begg.

"It will need to be strengthened substantially, especially in terms of physical infrastructure and human resources.”

  
2019/05/012019/05/13 12:04 PM
MEDBRIEF

Private hospitals and clinics in Cape Town found themselves dealing with a different kind of client recently when sickly and poor patients arrived to demonstrate their frustration with the slow progress in implementing National Health Insurance (NHI).

Under the banner of the Movement for Change and Social Justice – a grassroots organisation from Gugulethu that campaigns for better healthcare services in townships, the Sowetan reports patients arrived at establishments including Life Vincent Pallotti Hospital in Pinelands, Netcare Christiaan Barnard Hospital in the city centre, Crescent Clinic in Kenilworth and various Melomed hospitals. The report says the organisation, which is supported by social health lobby groups such as Health Enabled and the Public Health Movement, demanded that NHI be implemented quickly and wanted clarity on how the state intends to implement universal free healthcare. Mandla Majola, who led the group and took a depression patient to Crescent Clinic, decried the public healthcare system.

State clinics in the townships were overcrowded, he said, and the government had failed to build new healthcare facilities. As a result, patients were often forced to sleep on chairs or on the floor owing to bed shortages. Due to high patient numbers, trauma patients were often treated while sitting in chairs because there were not enough beds. The report says speaking to Crescent Clinic manager Zandre Finkelstein, Majola said the protest was a “peaceful demonstration” of poor people’s plight and was not an attack on private hospitals. Finkelstein said the healthcare system was broken at the medical aid level because of the need to make profits, adding that the clinic had admitted patients who needed emergency care before they were transferred to public hospitals. Peter Benjamin, CEO of HealthEnabled – which helps government integrate life-saving digital health interventions into their health systems – said it was “unjust” that only 16% of South Africans had access to good, quality healthcare.
  
2019/04/122019/04/16 09:07 AM
NETWERK24

210 jaar.

Dit is hoe lank dit die Discovery-lid wat die afgelope jaar die grootste hospitaaleis by die fonds ingedien het, sal neem om met sy premies dié enkele eis te dek.

Die grootste enkele eis vir hospitaalopname wat die Discovery Health Medical Scheme (DHMS) in die boekjaar tot einde September 2018 ontvang het, was vir ’n 68-jarige wat vir 182 dae in die hospitaal was weens ’n infeksie.

Die eis het R5,5 miljoen beloop. Sien ook die ander grootste eise hieronder. DHMS sê in sy jongste eiseverslag R1,1 miljard is opgedok aan die eise vir hospitaalopnames van die 500 siekste gesinne.

DHMS het in die tydperk altesaam R58,4 miljard se eise uitbetaal. Byna die helfte hiervan – R28,9 miljard – is uitbetaal vir behandeling in hospitale.

Hospitaalopnames in syfers vir die tydperk:
• 671 016 opnames het plaasgevind.
• Dit was teen ’n gemiddelde koste van R43 057 per opname.
• 455 550 van die lede is in die hospitaal opgeneem.
• 835 lede van die fonds het hospitaaleise van meer as R1 miljoen elk ingedien.
• Die totale getal dae wat in die hospitaal deurgebring is, was 2,4 miljoen.

Uit elke R100 wat die fonds betaal vir ’n eis vir ’n hospitaalopname word R62,70 aan die hospitaal self betaal.

Nog R17,80 word aan spesialiste betaal. Die res is vir patologie, radiologie en ander dienste.

Die toptien- grootste hospitaaleise was:
• R5,5 miljoen vir die 182 dae wat ’n 68-jarige in die hospitaal bestee het weens ’n infeksie.
• R5,5 miljoen vir die langtermyngebruik van ’n ventilator vir ’n 48-jarige wat ’n kardiovaskulêre toestand gehad het. Dit was vir 55 dae.
• R4,9 miljoen vir die langtermyngebruik van ’n ventilator vir ’n 78-jarige met ’n gastrointestinaal-verwante toestand (215 dae).
• R4,9 miljoen vir ’n infeksie waarvoor ’n 61-jarige opgeneem is (79 dae).
• R4,8 miljoen vir ’n infeksie waarvoor ’n 58-jarige opgeneem is (189 dae).
• R4,8 miljoen vir ’n respiratories-verwante opname van ’n 54-jarige (169 dae).
• R4,6 miljoen vir ’n neurologies-verwante opname van ’n 38-jarige (203 dae).
• R4,4 miljoen vir trauma waarvoor ’n 54-jarige behandel is (118 dae).
• R4,2 miljoen vir die langtermynhebruik van ’n ventilator vir ’n 30-jarige met ’n respiratoriese toestand.

Skerp styging in dag-tot-dag-eise

Altesame R21,4 miljard is vir dag-tot-dag-eise (wat hospitaalopnames, behandeling vir kanker en chroniese siektes uitsluit) opgedok.

Dit sluit in eise vir algemene praktisyns, spesialiste en medisyne.

Hoewel dit nie regstreeks vergelykbaar is met die vorige Healthcare Claims Trackerverslag nie omdat dié een vir die jaar tot einde Maart 2018 was, verteenwoordig dit ’n styging van 22% vergeleke met die R17,5 miljard in die vorige tydperk.

’n Navraag is aan DHMS gerig oor die redes hiervoor, omdat sy getal lede die afgelope jaar met net 3,7% gestyg het. Die kommentaar sal bygewerk word sodra dit gekry is.

Meer statistieke oor dag-tot-dag-eise:
• Lede het 6,8 miljoen keer ’n algemene praktisyn besoek.
• 2,2 miljoen besoeke is aan spesialiste afgelê.
• Die besoeke aan aanvullende gesondheidsdienste (soos biokinetikus, fisioterapeute, chiropraktisyns) het 4,3 miljoen beloop.
• Altesaam 24,8 miljoen voorskrifte is berei (vergeleke met 21,4 miljoen in die jaar tot einde Maart 2018). Dit is ’n styging van byna 16%.
  
2019/04/112019/04/16 09:06 AM
HEALTH24

Rural areas bear the brunt of healthcare worker shortages and this inequality needs to be solved, before any form of National Health Insurance (NHI) is possible, a new report says.

Only 12% of doctors and less than 20% of nurses in the public sector work in rural areas, despite the fact that people living in these areas make up almost half of the country’s population. This is according to a report, Protecting Rural Healthcare in Times of Economic Crisis launched by the Rural Health Advocacy Project (RHAP) in Johannesburg on Tuesday.

The report includes a detailed summary of South Africa’s health and economic context as well as examples from other countries on how they dealt with access to healthcare in a tough economic climate.

One of the NHI’s biggest challenges is the unfair distribution of healthcare workers, said RHAP’s Russell Rensburg at the launch. He said to be in-line with the NHI, the distribution must be informed by equity, but at the moment most healthcare workers were located in urban settings and as one moved further and further away from the centre, the numbers fall.

Rensburg said South Africa has 42 health information systems in the public sector and multiple systems in the private sector making it “very difficult to get a complete picture of what our overall health needs are and what the best response is”.

“You can only measure what you can manage and you can only manage what you can measure,” he explained.

Do health workers reject rural postings?

Rensburg said healthcare workers had a responsibility to practise in areas where the need was greatest but many were unwilling to do so.

Compulsory community service is a strategy to try to increase the number of healthcare workers in rural areas, but, he said, every year without fail, a significant number of medical graduates reject rural posts.

RHAP’s Marije Versteeg said other issues played a role and sometimes people arrive in rural areas to take up an internship or community service post, only to find the position does not exist.

Occasionally this was due to administrative bungles, but more often this problem was caused by inadequate budgets compounded by faulty management of this meagre allocation.

Austerity should never disable the workforce

In response to slow economic growth since the 2008 global financial crisis, the South African government implemented austerity measures to contain costs, including the freezing or cutting of posts for medical personnel, according to the report. However, sacrificing funding directed at the health workforce only weakened the system and worsened access.

The report noted that the negative impacts on health caused by a continued “constrained fiscal environment” will become more apparent as resource demands increase with the implementation of the NHI. “At a minimum, extra resources are needed to account for the effects of inflation on prices in the health sector.

“Realistically though, more healthcare workers are always necessary to broaden access to services and to account for ever-increasing demand.” Is a ‘different way’ the solution?

Rensburg suggested the current setup needed to be rethought as South Africa moved closer towards the implementation of the NHI.

“The government keeps talking about expansion but where is the money to back this? It will take at least five to 10 years until the NHI is implemented and, in the meantime, we need a different way of approaching health. This means more (equitably distributed) healthcare workers, and more money, especially in tough economic times,” he said.
  
2019/04/112019/04/16 09:06 AM
RADIO702

Government has invited the public to share their views on the affordability of medication in South Africa for 2020.

The National Department of Health says a “fair price” is currently defined as one that is affordable for health systems and patients and at the same time provides sufficient market incentive for industry to invest in innovation and the production of medicines.

Deputy Director General of National Health Insurance, Dr Anban Pillay explains.

Each year the minister has to review what would be the price adjustment on that medicine, so no company can increase their price beyond whatever the minister determines to be a reasonable price increase. — Dr Anban Pillay, Deputy director general: National Health Insurance

The price increases will fluctuate and have been seven or nine percent over the years. Last year was three percent so, depending on what the exchange rate does – it influences to a large extent what the adjustment is going to be. — Dr Anban Pillay, Deputy director general: National Health Insurance

Pillay says the annual review also takes into account the Consumer Price Index (CPI).

But the pharmaceutical industry is not happy with the fluctuations caused by the exchange rate and wants the Ministry to use the CPI alone as its barometer.

We have put it out there as to these are the options that we could use for price adjustments - and we would like South Africans to share their views on what would be reasonable so that the minister can make a final determination, to calculate the price increase for 2020. — Dr Anban Pillay, Deputy director general: National Health Insurance

Everyone - every member of the public, the pharmaceutical industry, medical schemes... we encourage as many people (as possible) to provide input and share their views. — Dr Anban Pillay, Deputy director general: National Health Insurance
  
2019/04/102019/04/16 08:55 AM
MEDICAL BRIEF

The Council for Medical Schemes (CMS) says it’s “concerning” that Keyhealth Medical Scheme denied a member prescribed minimum benefits (PMBs) for an overactive thyroid on the basis that she needed to develop a “thyroid storm”, which is a medical emergency, before she could qualify for PMBs. Hyperthyroidism is a PMB condition, the council says. “This patient’s condition cannot validly be considered not to be a PMB just because her life is not in immediate danger,” the council’s clinical review committee says in a ruling against Keyhealth handed down earlier this year.

Business Day reports that the ruling stems from a complaint lodged by healthcare rights activist Angela Drescher on behalf of a member who Drescher says was treated unfairly by Keyhealth. The scheme at first rejected the member’s claims, saying her condition was not a PMB condition and not covered in terms of her benefit option.

The ruling says that in October 2018, the member consulted her doctor as she was experiencing severely itchy skin. Her doctor ordered blood tests to confirm a diagnosis. He diagnosed kidney problems and prescribed medication that provided no relief from the symptoms, so she sought a second opinion. A week later, a second doctor diagnosed her with hyperthyroidism (an overactive thyroid) and thyrotoxicosis with goitre. The diagnosis was confirmed by blood test results.

In a letter of motivation to the scheme, the doctor stated that the patient’s conditions were serious and could be life threatening. He also set out the treatment she may require and prescribed medication. A month later, the patient consulted a surgeon, who confirmed the diagnosis of hyperthyroidism and submitted a letter of motivation to the scheme stating his findings and treatment options.

According to the report, the ruling says the member made several attempts to claim for the diagnostic tests, the treatment and care as well as authorisation for further tests and future treatment. One of her consultations was with a specialist who is not one of the scheme’s designated service providers (DSPs) because the DSP closest to her home, in the Nelspruit area, is more than 200km away. After the member paid the account in full, the scheme failed to reimburse her in full.

After the complaint was lodged with the council, Keyhealth conceded that it had been incorrect and that hyperthyroidism was a PMB, the ruling says. The scheme said it did not know why the member had raised the non-payment of claims, contending that all disputed claims had been paid since the council intervened. But Drescher and the member said this wasn’t so and that some claims had been paid from the wrong benefits, namely the member’s medical savings account.

The report says in terms of the ruling, the scheme must fund diagnostic tests, care and treatment for the member’s PMB condition in line with PMB regulations and as per the clinical opinion by the CMS’s review committee. The scheme must also ensure that future tests, treatment and consultations for the condition are paid in line with PMB regulations, taking into consideration the level of care offered by the state, the ruling says.

The ruling notes that the scheme may payPMB claims from any day-to-day benefit the scheme provides as part of the risk benefits. But when this benefit is depleted the scheme must continue to pay yPMB claims. The scheme may never, however, pay PMB claims from the member’s medical savings account, as this is prohibited in terms of regulations under the Medical Schemes Act. If any PMB claim was paid from the savings benefit, the scheme must reverse such payment and process it from the correct benefit, the ruling says.

According to the report, the ruling ordered Keyhealth to reimburse the member for claims already paid by her for the PMB condition, which was a result of the scheme’s incorrect processing or interpretation of the claims, the council says. Lastly, the ruling ordered the scheme to pay claims for the non-DSP specialists in full if there was no DSP within reasonable proximity from the member’s place of residence.
  
2019/04/102019/04/16 08:56 AM
MEDICAL BRIEF

South Africa’s medical schemes regulator has slammed the Treasury for not consulting it on the draft Conduct of Financial Institutions Bill, saying it will render it a lame duck if passed in its current form, reports Business Day. The Bill is part of the government’s reforms to strengthen governance of the financial services industry, following the promulgation of the Financial Sector Regulation Act in 2017, which established the Prudential Authority and the Financial Sector Conduct Authority (FSCA). The Bill outlines what consumers and industry players can expect of financial institutions, including medical schemes and administrators.

The report says its proposals thus affect the role of the Council for Medical Schemes (CMS), which oversees 80 medical schemes that provide health cover to 8.9m people. The Bill was published by the Treasury in December 2018, and interested parties had until 1 April to comment.

Its explanatory note reads that the FSCA’s full powers will apply to medical schemes, but initially this role will continue to be played by the CMS, with the concurrence of the FSCA. “The FSCA and the CMS are working together to reach agreement regarding when FSCA concurrence with CMS decisions is required during this transition period, as well as more broadly on how approaches to conduct of business and consumer protection issues in the medical schemes environment can be harmonised. Medical schemes will therefore not be required to be licensed under the bill framework during this transitional period, “although this may be reviewed over time”, it said. The transitional period ends on 31 March, 2021.

But in its submission to the Treasury, the CMS is quoted as saying it was not consulted on the bill. Although it was part of a task team dealing with the Financial Sector Regulation Act, the contents of the bill were not discussed at their meetings, it said. In a strongly worded statement, the CMS said it is irritated and disappointed with the bill, because it removes its core functions.

The CMS’s mandate includes protecting members’ interests, overseeing product design, investigating complaints, settling disputes and advising the health minister on matters affecting the industry, said CMS registrar Sipho Kabane. “Removing these core regulatory functions from the CMS and placing them with the FSCA is tantamount to legislating the CMS out of existence as an independent regulator,” Kabane said in the report.

“If additional statutory or even voluntary dispute resolution mechanisms are created it will create further problems for members of medical schemes who are already overwhelmed by the complexities and asymmetry of information in the health insurance sector,” he said.

According to the report, the CMS said medical schemes do not operate like institutions providing insurance products and should not be subjected to the same conduct requirements. “The specific regulatory functions that include product design, disclosures and claims management in medical schemes should fully reside under the CMS in line with the powers accorded to it by the Medical Schemes Act,” it said.

“The CMS demands that the Treasury and FSCA properly consult with the CMS before the final version of the (Bill) is sent to parliament,” Kabane said.

The report says the Treasury had not responded to a request for comment at the time of publication.

Financial services company Alexander Forbes has voiced its support for the Treasury’s plan to bring regulatory oversight of medical schemes under the same umbrella as insurance products, as spelt out in the Bill, reports Business Day.

Alexander Forbes Health MD Butsi Tladi said a single regulator will ensure better protection for consumers and the FSCA is well placed to oversee the medical schemes industry. The current regulatory framework, in which medical scheme brokers are accountable to the CMS and the FSCA, does not provide optimal consumer protection, and its “untidiness” creates scope for conflict, she is quoted in the report as saying.

The Financial Intermediaries Association, which counts Alexander Forbes among its members, strongly advocated for the end of dual regulation in its submission to the Competition Commission’s health market inquiry. Tladi said the FSCA’s ability to regulate the market conduct of financial institutions is more advanced than that of the CMS, and that the medical schemes regulator already refers complaints about broker conduct to the FSCA.

“The FSCA has proven that it is far more capable of managing possible conflicts of interest in the provision of independent advice to consumers,” she said. The CMS is inherently conflicted, as it is charged with protecting the interests of medical schemes and consumers, she said.

The report says CMS spokesperson Grace Khoza declined to comment on the issues raised by Alexander Forbes.

The Bill is part of the government’s reforms to strengthen governance of the financial services industry, following the promulgation of the Financial Sector Regulation Act in 2017, which established the Prudential Authority and the FSCA. It outlines what consumers and industry players can expect of financial institutions and seeks to create a consolidated framework for market conduct, which is currently dealt with by several sets of laws. The report says these include the Financial Advisory and Intermediary Services Act, the Consumer Protection Act and the Medical Schemes Act.
  
2019/04/102019/04/16 09:03 AM
BIZCOMMUNITY

Healthcare sector stakeholders have long advocated for a single regulator, believing that the current dual framework creates a regulatory arbitrage not conducive to offering the consumer maximum protection.

Just as the public and private healthcare sectors need to work together for South Africa to achieve universal healthcare, the same applies to government departments and regulators. "A silo approach to these complex issues will only serve to detract the process and delay progress. The dual regulation of participants in the medical scheme industry is not ideal, and in some areas creates conflict," says Butsi Tladi, managing director of Alexander Forbes Health.

The Conduct of Financial Institutions Bill (Cofi) Bill, aimed at regulating how the financial services industry treats its customers, was published by the minister of finance in December for public comments until Monday April 1. The Bill advocates removing core regulatory functions from the Council for Medical Schemes (CMS) and placing them with the Financial Services Conduct Authority (FSCA).

A form of insurance
Tladi says medical schemes are a form of insurance, “… even the CMS acknowledges this in their submission on the Cofi Bill. Greater alignment is in the interest of the industry. Because of the varied nature of insurance products, including health insurance products, The FSCA has had to develop a depth of skill to regulate this dynamic industry.

“Had we appreciated this fact, and allowed the best suited government entity to spearhead our National Health Insurance efforts, we would have made far more progress,” she says.

Market conduct

It is also clear to Tladi that the FSCA’s ability to regulate market conduct of financial institutions is more advanced. In fact, CMS already refers compliance relating to conduct to FSCA for consideration.

“Through related legislations such as the Financial Advisory and Intermediary Services (Fais) Act, FSCA has proven that it is far more capable of managing possible conflicts of interest in the provision of independent advice to consumers.

“The Cofi Bill approach is refreshing in that it sets out the specific intention of the law, rather than setting rules for compliance. Compliance with the spirit of the law, rather than narrow technical compliance will be important. If we appreciate the efforts of the Competition Commission’s Inquiry into Private Healthcare, then we must welcome efforts that support and facilitate better competition and innovation. Furthermore, Cofi aims to promote financial inclusion and transformation, particularly that of emerging black-owned financial institutions.”
  
2019/04/10
2019/04/16 09:04 AM
DAILY NEWS

Those involved in the healthcare sector have long advocated for a single regulator, believing the current dual regulatory framework creates regulatory arbitrage not conducive to offering the consumer maximum protection.

As part of the submission to the Competition Commission's Inquiry into Private Health and the Department of Health's National Health Insurance NHI Bill, the Financial Intermediaries Association strongly advocated for the end of dual regulation. The public and private healthcare sectors need to work together for South Africa to achieve universal healthcare.

The same applies to our government departments and regulators. A silo approach to these complex issues will serve only to detract from the process and delay progress. The dual regulation of participants in the medical scheme industry is not ideal, and in some areas creates conflict.

The Conduct of Financial Institutions Cofi Bill, aimed at regulating how the financial services industry treats its customers, was published by the Minister of Finance in December for public comment until April 1.

The bill advocates removing core regulatory functions from the Council for Medical Schemes (CMS) and placing them with the Financial Services Conduct Authority (FSCA).

Medical schemes are a form of insurance – even the CMS acknowledges this in their submission on the Cofi Bill. Greater alignment is in the interests of the industry. Because of the varied nature of insurance products, including health insurance products, the FSCA has had to develop a depth of skill to regulate this dynamic industry. If we had appreciated this fact, and allowed the best suited government entity to spearhead our NHI efforts, we would have made far more progress.

It is also clear that the FSCA's ability to regulate the market conduct of financial institutions is more advanced. In fact, the CMS already refers compliance relating to conduct to the FSCA.

Through related legislation, such as the Financial Advisory and Intermediary Services Act, the FSCA has proved that it is far more capable of managing possible conflicts of interest in the provision of independent advice to consumers.

The Cofi Bill approach is refreshing in that it sets out the specific intention of the law, rather than the rules for compliance.

If we appreciate the efforts of the Competition Commission's Inquiry into Private Healthcare, we must welcome efforts that support and facilitate better competition and innovation. Furthermore, the Cofi Bill aims to promote financial inclusion and transformation, particularly that of emerging black owned financial institutions.

Butsi Tladi is the managing director of Alexander Forbes Health.
  
2019/04/102019/04/16 09:04 AM
SABC NEWS

The ANC says its election manifesto has a clear plan on how to improve the state of health care should it clinch victory in the national elections

The Minister of Health, Aaron Motsoaledi, says the present health care system needs to be changed in order to provide National Health Insurance (NHI).

He was speaking at an education dialogue regarding the African National Congress’ (ANC) health policies in Polokwane where the party’s Ike Maphoto Branch hosted him along with Limpopo Provincial Executive Committee (PEC) member, Phophi Ramathuba.

“In order to provide NHI, we need to change the present health care system. I did not use the word change, we used the word massive reorganisation. The present health care system needs to be massively reorganised because on the present platform, if you are going to put NHI, it is not going to work. The reorganisation must happen in both public and private, the story that private must be left alone it’s a myth,” says Motsoaledi.

Meanwhile, the ANC says its election manifesto has a clear plan on how to improve the state of health care should it clinch victory in the national elections.

Motsoaledi told members on Tuesday that this would include the re-modelling of the entire system.
  
2019/04/102019/04/16 09:05 AM
TIMES LIVE

An average of between 60 and 80 cases of drug-resistant fungal infections are detected in SA every month, mainly in Gauteng private hospitals, according to the National Institute for Communicable Diseases (NICD). Prof Nelesh Govender, the NICD head of the centre for healthcare-associated infections, antimicrobial resistance and mycoses, said these infections are of great concern. He was speaking after The New York Times reported on the worldwide rise of candidia auris infections, naming four countries where outbreaks had been reported, including SA.

The germ is resistant to at least one class of medication and infects the sickest people in hospitals. Govender said the NICD had been monitoring these fungal infections in SA through laboratory data since 2009.

He said an average of 60 to 80 such cases were reported in the country every month, with Gauteng – mainly private hospitals in Johannesburg and Pretoria – the most affected.

Once the fungus is inside a hospital it lives on surfaces and is very difficult to get rid of and can become resistant to some cleaning agents. In about a third of these cases infection spread to the bloodstream, and four in 10 of those patients died.

Those who contracted it were already very ill since mainly patients with a compromised immune system were affected. Classically, fungi don’t behave in this way. We have not seen this pattern of disease caused by a fungus before. Other risk factors in SA included old age, having a central line (a catheter into a large vein) and staying in an intensive care unit for a long period.

Govender said that while it was a fungal infection, antibiotic-resistant infections caused by bacteria are often taken more seriously. It is the first time in history that a fungal infection has started behaving like an antibiotic-resistant bacterial infection.

Like bacterial infections, Govender said it was easy to transmit from one person to another in a hospital. A patient could spread the fungus to the bed, bed linen, hospital curtains and window sills. If it contaminates environments and if the room is not disinfected, the next patient admitted to the room could potentially contract it.

The New York Times reported on an outbreak in SA in 2016, but Govender said hospital outbreaks did occur from time to time. There had been an outbreak among four newborns in a private hospital at the end of 2017. In 10 years in SA, the NICD has only detected two strains that are resistant to three types of medicines (triply resistant), leaving almost no treatments. Most infections in SA are only resistant to the first class of drugs to treat them but respond to other medications. Experts have just completed guidelines on the best way to manage such infections, but these are not yet publicly available.

Govender said there was a theory that the first infections in SA occurred in Gauteng hospitals. He said private hospitals have more ICU beds, so it may biased in that way. Wits professor and intensive care expert Guy Richards said the infection occurred more commonly in hospitals where doctors may use more broad-spectrum antibiotics that do not target specific bacteria. The most important way to prevent the infection is for hospital staff to wash their hands often. Richards said healthy people cannot get this disease. He said doctors put tubes and catheters into patients’ bodies and veins, which allowed an entry point into the body.

In addition, plastic devices had a much higher propensity than human tissue for attracting organisms and allowing them to grow on them. Another issue is, South Africa and hospitals have been very good at setting up antimicrobial stewardship programmes monitoring the after-use of antibiotics. However, SA was behind in antifungal stewardship - managing medicines used to treat fungi. Richards said while South Africa’s candida auris is resistant to firstline drugs, called azoles, and treated by another kind, called echinocandins, if we keep using these there will eventually be a resistance. He said it is the new superbug.
  
2019/04/092019/04/16 08:54 AM
THE CONVERSATION

By some measures – healthy life expectancy, obesity and depression, among others – South Africa is the unhealthiest country on earth. That’s a sobering fact to consider. How has the country got here? To what extent can its unenviable position be regarded as a failure of primary health care?

Primary health care can refer to the care offered by general practitioners or primary care nurses at your local clinic. But there’s more to it than that. Primary health care is underpinned by a vision. This sees health as an essential ingredient in the social foundation of society. It recognises that health is also interdependent on other ingredients: food, education, clean water, energy, social equity, safety, income and housing.

The healthy space for humanity to flourish is between this solid social foundation and our ecological ceiling, as issues such as climate change may also impact on health. Primary health care, then, requires a whole-of-society approach and is not just about health services.

South Africa is struggling with many of these issues. This means that in the broadest sense, the country has failed at delivering primary health care.

While those in the health care sector can’t fix all the interrelated issues I’ve described, they can address the quality of primary care.

So how can this be achieved? Despite a failure to adequately address the broad social and environmental determinants of health, South Africa has the potential in its current policy to improve primary care across the board. But policies on paper are not enough. These must be properly implemented.

Access to health care

About 80% of South Africa’s population depends on the public sector’s primary care services. But access to this primary care in the public sector is often limited by the sheer number of patients. It’s also restricted by opening times that do not cater for people who are working or become sick during evenings or on weekends.

South Africa has developed a policy to implement National Health Insurance (NHI). This would ensure improved access to primary care for the whole population. However, many general practitioners in the private sector are worried that the government will not be able to effectively implement and efficiently manage NHI at scale. Access is also not enough. The care that’s offered must be of a good quality.

The NHI proposals are not the only plans that have been developed to try and provide good primary care to all South Africans. The discipline of family medicine is doing a great deal in this regard. Family physicians are qualified doctors that have completed additional training to become specialists in family medicine and primary care. Despite being slower on the uptake, South Africa is now finally seeing family physicians entering the health system in increasing numbers and joining primary care teams. Their inclusion in these teams brings additional clinical skills, commitment to person-centred care, clinical leadership and improvement to the quality of care.

Ongoing care

Ongoing care refers to the continuity that patients have with their primary care providers over time. This continuity is based on a trusting relationship between primary care providers and their patients and an accumulated knowledge of the person.

A recent study of both nurses and doctors in Cape Town found that providers failed to even greet patients in more than 60% of consultations. In 90% of consultations, they made no attempt to understand the patient’s perspective. This poor provider-patient relationship is a fundamental problem that fuels poor clinical outcomes, poor adherence to medication, patient dissatisfaction, litigation and a lack of job satisfaction among providers themselves.

In Cape Town as many as 76% of doctors in primary care are suffering from burnout. The symptoms include depersonalisation: they no longer see patients as people. It is clear that the health system needs to transform to be more people-centred – for both carers and cared for alike. Again, the inclusion of family physicians in the health system can help with this.

Community orientation

A renewed focus on community-orientated primary care is also important. This approach changes primary care: rather than health workers sitting in a clinic and waiting for people to ask for help, health workers in the community pro-actively prevent disease, promote health and identify people at risk. This has worked very well in other middle-income countries like Brazil.

South Africa is taking some steps in this direction, too. Cape Town’s metropolitan district health services are busy learning how to implement community-orientated primary care at scale over the next few years.

Thinking about the community as a whole and not just individual patients is a game changer. Health workers can identify and prioritise community health needs, and address the social and environmental determinants of health in an inter-sectoral approach with other stakeholders in that community. Community participation in this process is also a key principle. If South Africa can implement this approach effectively, it could transform the health services – and the health of local communities.
  
2019/04/072019/04/16 08:52 AM
RAPPORT

Seminaar oor verskaffer-gedrewe vraag

Suid-Afrikaners gebruik gans te veel mediese dienste omdat hul dokters en hospitale hul eie beursies wil laat bult, sê die Mededingingskommissie.

Die paneel wat private gesondheidsorgkoste ondersoek (HMI), het Donderdag ’n memo uitgereik oor sy voorlopige standpunte nadat hulle voorleggings van die land se dokters,
hospitale en mediese fondse oorweeg het.

’n Seminaar wat fokus op verskaffergedrewe vraag (SID) word Vrydag gehou.

SID is een van die mees omstrede onderwerpe wat die HMI bekyk om ingrypings vir die private gesondheidstelsel te formuleer. In sy voorlopige verslag blameer die HMI in ’n groot mate die verskaffers se gedrag vir weghol-pryse.
Sedert die verslag laat verlede jaar gepubliseer is, gooi rolspelers wal.

Netcare en Discovery Health sê albei in hul voorleggings hoër hospitaalopnames en hoër vraag na private gesondheidsorg het te doen met die hoër voorkoms van sekere siektetoestande en ’n ouer bevolking.

Discovery sê verder data van Discovery Health- mediese skema (DHMS) tussen 2010 tot 2018 wys groter gebruik van mediese dienste is die hoofrede vir stygende mediese inflasie, maar hulle verskil dat dié groter gebruik deur die verskaffers gedryf word.

Hulle sê pasiënte dring aan op meer sorg en het bloot meer behoeftes.

Verskeie rolspelers bevraagteken ook die geldigheid van die HMI se studie oor SID.

Discovery sê byvoorbeeld die HMI het nie genoeg in ag geneem nie dat die gemiddelde lid van ’n mediese fonds ouer en sieker is as die gemiddelde Suid- Afrikaner.

As voorbeeld sê hulle 26,8% van die Suid-Afrikaanse bevolking is ouer as 40 jaar, maar 39,2% van mediesefondslede is 40-plussers.

Uit Donderdag se nota blyk dit die HMI is nie oortuig deur die voorleggings nie. Die paneel sê verskaffers van gesondheidsdienste, veral dokters, adviseer nie net behandeling, voorafmagtigings, netwerke vir dokters en hospitale en lyste van voorkeurmedisyne.

Die HMI sê dít is eenvoudig nie doeltreffend genoeg om SID te keer nie. Daarom gaan hulle voort met die formulering van voorstelle om SID in bedwang te bring. Dit sluit in:
• Prysregulering van dienste en produkte;
• ’n Enkele vergelykbare basiese mediesefondsopsie met ’n risiko-aanpassingsmeganisme
• om mededinging tussen skemas te verhoog,
• Meer verantwoordbaarheid van dokters om te wys dat die behandeling nodig en
• doeltreffend was.

Die HMI sê Suid-Afrikaanse private tariewe is bo die wêreldnorm vir ses uit sewe siektetoestande soos rekonstruksie van kunsmatige gewrigte, keisersneë en mangelverwydering.

Suid-Afrika het ook die hoogste koers van noodsorg-opnames in die wêreld.

Die paneel sê hy sal op die seminaar graag ander voorstelle hoor oor wat gedoen kan word om SID in te kort.

Benewens Discovery word aanbiedings verwag deur die private groepe Mediclinic, Netcare en Life Healthcare, die Suid-Afrikaanse Mediese Vereniging (Sama), die Suid-Afrikaanse Vereniging van Narkotiseurs, individuele gesondheidsorgkenners en die staat se siekefonds, Gems.

Mediclinic sê in hul voorlegging die HMI-ontleding is nie akkuraat nie, want hulle kan byvoorbeeld nie met sekerheid sê of die verskaffing van dienste nodig of onnodig was nie.

Sama het onder meer ’n probleem met die paneel wat “diskresionêre dienste” beskou as enige diens wat nie-lewensbedreigend of ’n noodgeval is nie.
  
2019/04/072019/04/16 08:53 AM
DAILY MAVERICK

How ‘universal’ is the universal health coverage envisaged by the National Health Insurance scheme? The draft law contains xenophobic rhetoric, but the country’s main political parties offer very few alternatives in the manifestos.

The ANC’s much-contested National Health Insurance (NHI) scheme has been a talking point for politicians for close to two decades since being published in the Government Gazette in 2003.

According to this model, the government will become the sole funder and buyer of health services and compulsory payments will be deducted from the salaries of all working people.

One of the big questions about the NHI is where the money will come from to pay for universal coverage, given how few taxpayers there are.

Many experts are concerned that the current version of the NHI is unworkable and that it also has far-reaching consequences for foreign nationals.

According to the bill, the NHI will be available for “all South Africans irrespective of their socio-economic status, including residents with long-term visas”. The fund will also require patients to be “registered and be identifiable at the point of use” and will “need to register through the Department of Home Affairs’ identification system” in order to access services through the country’s iteration of universal healthcare.

Undocumented immigrants, refugees and asylum seekers are excluded, and the only non-South Africans who are accommodated are “those in possession of a long-term residence visa”.

In January, the Gauteng and KwaZulu-Natal health departments issued circulars, on the instruction of the national office, demanding foreign patients to pay in full for health services. The circulars were retracted, but the language it used is in line with what the NHI is calling for, which is the exclusion of foreign nationals.

The bill implies that individuals who are asylum seekers or even those who have work permits won’t be eligible for the NHI, argues Jo Vearey, an associate professor with the African Centre for Migration and Society at Wits University.

“Non-nationals are currently facing huge challenges accessing basic healthcare. Not only is it sending a dangerous political message, it potentially has consequences for broader public health concerns,” she says.

In its current form, the NHI suggests a “regression of rights for non-nationals”, says Vearey. It suggests that only documented refugees out of all non-nationals would be covered by the NHI. This has concerned health experts, who called the language the policy uses a “slippery slope of xenophobia”.

More dangerously, these xenophobic sentiments in the run-up to elections are common across all party lines — from the Democratic Alliance’s “secure our borders” stance and the party’s City of Johannesburg Mayor Herman Mashaba’s utterances about foreign nationals, to Health Minister Aaron Motsoaledi’s unverified “anecdotal” evidence that foreign nationals “overburden” our health system.

But the ANC national communication manager, Cornelius Monama says that the party’s model of universal healthcare is misunderstood and it is not meant to be the “panacea for all our healthcare challenges”.

“The ANC proposed the NHI as a funding formula for a (universal) healthcare system. It’s not the hallmark of the system,” Monama told Health-e. “The NHI is a medical aid scheme, a financial instrument of the system, that pays for services rendered.”

According to the draft law, primary healthcare will be the “heartbeat of the NHI”, which means that, to contain costs, local clinics — instead of hospitals — will be the “first level of contact” for South Africans.

But health experts argue that unless there is a revolution in the distribution and number of health professionals — especially in rural areas — the NHI will fail. According to the latest South African Health Review report, the NHI will remain a “pipe dream” if human resources for health are not urgently addressed.

About 44% of the country’s population lives in rural areas, the Department of Health data show. But only 12% of doctors and 19% of nurses in the public sector work in those areas. Meanwhile, about only 35 out of 1,200 medical students that graduate in the country annually end up working in rural areas in the longer term.

“The NHI is good in principle, but the realities around what is feasible and if we can ever deliver on it is at the heart of the debate. We know that the public healthcare system at the moment is struggling, not necessarily because it’s under-resourced in terms of finance, (but because) of the mismanagement of funds and huge wastage,” Vearey said.

But opposition political parties don’t offer any concrete alternative to the NHI model.

The DA believes that the issues plaguing the country’s health system, such as corruption and mismanagement of funds, are “boundless and terrifying”, the party’s director of communications, Mabine Seabe, told Health-e News.

The party offers an alternative to NHI, called “Our Health Plan”, which the DA proposes will be funded “through the removal of the current tax subsidy for medical scheme contributions” and removing the means test for access to public hospital services.

According to the DA’s manifesto, “no South African will be left without medical care” — and it aims to have more than 50% of citizens covered by private healthcare by working with the private sector to “improve affordability of options for the lower and middle class”.

It also promises “a programme of revitalising public healthcare facilities” and the introduction of “a funding mechanism to provide for appropriate and accessible emergency medical services for all”.

The DA’s answer to the lack of healthcare workers is “remove racial quotas as they apply to access to medical school with the aim of increasing the cohort of doctors and nurses each year — while still ensuring diversity”.

Russel Rensburg, director of the Rural Health Advocacy Project, is wary about the DA’s proposal to remove the means test, which “is not consistently implemented at the moment, which makes it moot”.

“What the party is not saying is what it will replace the means test with,” says Rensburg. “It could mean the removal of the means test will see the introduction of a standard tariff, which is detrimental to health access for the poor.”

He adds that the DA’s opposition to the sugary drinks tax exposes its limited understanding of public health needs and the multi-faceted drivers of disease:

“Its abdication of responsibility ignores the structural drivers of ill health, such as poor housing and transport systems that leave little to no leisure time for poor healthcare users to exercise.”

The Economic Freedom Fighters’ (EFF) manifesto states its commitment to universal health coverage and increasing the life expectancy of all people in South Africa.

The party also makes bold commitments, such as ensuring that each district in South Africa has a 24-hour regional or tertiary hospital with “a minimum of 450 beds… with internal medicine, paediatrics, obstetrics, gynaecology and general surgeons by 2022.”

But it is not clear how any of its goals will be achieved or financed, and the EFF did not respond to Health-e’s numerous attempts for comment.

Rensburg describes the EFF’s plan as “well-intentioned” and points out that the focus on primary health “is in line the global movement towards universal healthcare”.

“However, its broader health strategy, which includes the production of generic medicines through a state-owned pharmaceutical entity is ambitious to say the least,” says Rensburg,

Access to healthcare is more than just physical access to a clinic or hospital, said Rensburg, and describes both the DA and EFF’s intentions to improve the ratio of people to clinics is outdated.

“What is required is to re-imagine healthcare to include health at all stages of life. For example, access to optometry services can radically transform the educational outcome and future earning potential of healthcare users. This requires a different approach which is premised on going to the patient instead of them coming to you,” he says.

“The top three political parties also ignore the institutional damage over the past decade and none of them have concrete plans or reform proposals to address the decline of the state’s capacity to dispense its mandate for all,” says Rensburg.

Meanwhile, the Inkatha Freedom Party (IFP) believes that a decentralised health system works best and provinces having more control over their health facilities would be better than the “one-size-fits-all approach” the NHI is proposing.

“The (health) department cannot micromanage from Pretoria. Health should be decentralised entirely, not partially, as is the case today,” the IFP’s media and communications head, Yaseen Carelse, told Health-e.

“Provincial health authorities (need) to localise policies, distribution of medicines, and ensure that secondary and tertiary hospitals receive the adequate financial support they need.”

The African Christian Democratic Party (ACDP) doesn’t have much faith in the ANC-led government’s ability to manage government and the party would like to see the business expertise of the private sector involved in the implementation of the NHI.

Reducing infant mortality, preventing stunting and providing more “equality in healthcare” are at the top of the ACDP’s health to-do list. The party is anti-abortion and says the country’s Choice of Termination Act is “a license for promiscuity”. In the same breath, the party lists “women’s health” as its key area.

Leading up to the 8 May elections, the critical question political parties need to answer is: How will South Africa achieve healthcare that is inclusive of everyone — irrespective of nationality? This includes putting an end to the perpetual state of emergency of the public health system.

Vearey warned:
“We’re heading in a very dangerous moment in how, once again, non-nationals are being scapegoated for the poor performance of public healthcare systems in South Africa.”
  
2019/04/072019/04/16 08:54 AM
NETWERK24

Die Raad op Mediese Skemas (RMS) sê hy is “teleurgesteld, geïrriteerd en bekommerd” oor die wetsontwerp oor die gedrag van finansiële instellings (Cofi).

Die RMS het in ’n verklaring gesê dit gaan onprakties wees om “gesondheidsorg en die finansiële sektor” in dieselfde mandjie saam te gooi.

Die waghond glo die Cofi-wetsontwerp gaan hom ontman en lam laat.

Kommentaar is tot begin April deur die minister van finansies op die wetsontwerp toegelaat.

“As dit goedgekeur word, gaan dit die RMS se mandaat wegvreet,” het dr. Sipho Kabane, registrateur van mediese fondse, gesê.

Volgens hom gaan die wetsontwerp kernfunksies van die RMS verwyder en dit die verantwoordelikheid van die Gedragsowerheid oor die finansiële sektor (FSCA) maak.

“Dit kom daarop neer dat die RMS se bestaan as ’n onafhanklike reguleerder deur wetgewing tot ’n einde gebring gaan word.”

Die Cofi-wetsontwerp is deel van die hervorming van die wetgewing wat die finansiëledienstesektor en banke beheer. Laasgenoemde het gelei tot die ontstaan van die FSCA en die nuwe owerheid in die Reserwebank wat seker maak banke en versekeraars voldoen aan die reserwevereistes om beleggingsgeld en deposito’s veilig te hou.

Die FSCA en die eenheid in die Reserwebank is kragtens die wet op die regulering van die finansiëledienstesektor opgerig.

Die FSCA moet ingevolge die wet die gedrag van alle finansiëlediensteverskaffers beheer, insluitend vir die eerste keer dié van banke teenoor hul kliënte.

Die Cofi-wetsontwerp is die volgende fase van die wetshervorming en is daarop gerig om wetgewing oor die finansiële sektor in een omvattende wet oor markgedrag byeen te bring.

Kabane het gesê die mediesefondsbedryf is baie tegnies en benodig gespesialiseerde sake-eenhede wat klagtes ondersoek en oplos. Hy meen as dit verander, gaan dit verdere probleme vir mediesefondslede veroorsaak.

“Ons is spesifiek gekant teen die dele van die wetsontwerp wat na die mediesefondsebedryf verwys.”

Hy meen mediese fondse word anders bedryf as versekeringsprodukte en moet dus nie aan soortgelyke gedragsvereistes onderwerp word nie.

Kabane meen ook die gebrek aan voldoende kommunikasie oor die “dreigende ondergang van die RMS” of sy opname in die FSCA gaan angs en onstabiliteit in die bedryf meebring.
“Dit gaan verwarring meebring oor wie mediese fondse gaan beheer . . . Gewetenlose skemas gaan voordeel probeer trek uit die situasie en lede se belange benadeel.”

Boonop is die RMS ook bekommerd dat die wetsontwerp die werk wat tans gedoen word in aanloop tot Nasionale Gesondheidsversekering (NGV) gaan ondermyn.

“Die RMS is betrokke by verskeie strategiese projekte wat daarop gerig is om die bedryf te koördineer ná die implementering van die NGV.”

Hy eis nou dat daar behoorlik deur die nasionale tesourie en die FSCA met die RMS gekonsulteer word voor die finale weergawe van die wetsontwerp na die parlement gestuur word.

Die Cofi-wetsontwerp is op 11 Desember vir kommentaar gepubliseer.
  
2019/04/042019/04/08 11:40 AM
BUSINESS BRIEF

The NHI is set to be South Africa’s version of universal healthcare where resources are pooled in order to provide health services for everyone. Apart from the many flaws in the manner in which it is being implemented, a most serious flaw is that it is going to be prohibitively expensive.

Scant attention has been paid in the South African public discourse to the structure of the proposed system and the problems inherent therein.
Market forces ignored

The NHI is a single-payer system where the government would be the sole purchaser of health services on behalf of all South Africans. The government would be responsible for certifying healthcare providers from both public and private providers. It is also envisioned that supply and demand-side measures would be implemented, presumably, to contain the economic effects that will arise from having zero prices on the demand side of the equation.

In the absence of market prices, how likely are these ‘measures’ to achieve their desired effects considering the expected behaviour of individuals on the demand side? And, how does this expected behaviour interact with the expected behaviour of South African voters in their role as provider of healthcare services by determining taxation through the political process?

Public choice theory, a micro-economic analysis of actors in their public as well as private market roles, allows us the tools to make these kinds of analyses. Even a relatively simple (minimal assumptions) micro-economic model of behaviour applied to voters and market participants allows us to arrive at conclusions that accord closely with reality. That is because we do not limit ourselves to examining only economic market participants but also political market participants, who are often the same people.

Who pays?

In South Africa the bulk of taxes raised by government are in the form of PIT (Personal Income Taxes) and in the 2017/18 tax year 1.9 million South Africans contributed 80% of the revenue. Over the years PIT has grown from roughly making up the same proportion of revenue as VAT to becoming the single largest source of revenue.

The reasons why are not difficult to see: VAT affects all voters, 80% of PIT is raised from less than 2 million South Africans out of almost 27 million registered voters.

This illustrates an important point with regard to South Africans as demanders of NHI services: At zero prices, the services offered by the NHI with the greatest elasticity of demand are going to experience the greatest demand from the public. In a country like the UK, one of the founders of public choice theory, James Buchanan, concluded that this increased demand for services in the NHS did not result in increased supply of the service because voters in their role as suppliers of the service through taxation had an incentive to keep taxes on themselves as low as possible. This mismatch led to a deterioration in the quality of service offered by the UK’s NHS.

The situation in South Africa is quite different given the fact that there is such a mismatch between the population of voters and the population of individuals paying taxes. This means that the marginal cost to the taxpayer of funding the NHI is likely to significantly outweigh the marginal utility derived from using the NHI.

Those people paying taxes then have one of two options: they can either leave the country or stay and figure out a way of reducing their tax burdens. In other words, the voters will have an incentive to impose more and more taxes on the small population paying taxes in order to fund greater and greater levels of service, especially with regard to the NHI services that have the greatest elasticity of demand. The taxpayers will get to the point where the benefit of the NHI is outweighed by the cost because of this, and they will act rationally in an effort to reduce this burden.

The demand measures, e.g. gate-keeping, proposed by the health minister in the NHI policy are not worth the paper they are written on. As long as the tax system is structured as it is now, some political competitor to the government of the day will come along and propose reducing or eliminating any demand-limitation measures.

Shared burden

The point here is that there can be no social-solidarity without shared pain in the form of the tax burden.

South Africa cannot have a system similar to the British NHS given the socio-economic state of the country where a tiny minority pay most of the taxes. Given that we are a democracy, such a situation leaves us vulnerable to the possibility of taxing the golden goose to death because any welfare measure is under the control of people who do not have to pay for it.

With everyone acting rationally in the private as well as public arenas, the introduction of a system like the NHI will destroy the South African economy.
  
2019/04/042019/04/08 11:41 AM
MONEYWEB

As prevalence of cancer and other critical illnesses surge.

There has been an increased preference among employers to include severe illness products in their group risk benefit suite over the last few years.

“We think the increased prevalence of these severe illnesses – cancer in particular – is driving this trend,” says Viresh Maharaj, chief executive for corporate sales and marketing at Sanlam Employee Benefits.

This is one of the trends that emerged from interviews with professional employee benefit (EB) consultants that were conducted during the initial stages of the annual Sanlam Benchmark Survey.

Cancer, strokes and heart attacks are some of the diseases considered severe illnesses. While employers often include disability cover as part of their group risk benefits, severe illness cover has historically not been offered as part of the group risk suite.

Maharaj says these products come at a different cost and as a result, funds or employers have looked to restructure their risk suite to affordably accommodate severe illness benefits alongside other disability-type products.

Another driver behind the trend is that decision-makers are getting older and see people in their own networks being diagnosed with severe illnesses.

Maharaj says consultants have consistently pointed out that employers as well as retirement fund members consider healthcare to be more important than retirement provision.

While most members are not on track to maintain their standard of living in retirement, the cost of private healthcare is still a higher priority as it is something that can make an immediate difference in people’s lives.

‘The most significant cause of financial stress’

Internal research conducted among Sanlam staff echoes this finding, with employees citing medical expenses as the most significant cause of financial stress.

Maharaj says five to 10 years ago severe illness cover was generally not considered relevant in the group risk market – consultants did not want to sell it. Today, consultants themselves are indicating that it is a major need.

“The costs of healthcare are becoming prohibitive and so we are seeing medical aids changing product structures to be far more conscious of how individuals can help to structure their health budgets.”

Over the last couple of years, several primary health insurance products have been introduced with the aim of providing a degree of support for private care.

Gap cover

“Gap cover is being seen as almost a necessity by consultants now as well, given that medical aids can only go so far.”

Asked what they would like to change in the industry, many consultants indicated that they would like a specialist employee benefits consulting licence to be introduced. The Financial Advisory and Intermediary Services (FAIS) Act categorisation for pension benefits is broad and doesn’t require actual specialist expertise or experience.

“The view of the EB consultants is that you’ve got a vast number of retail advisors who dabble in employee benefits who may not be providing the appropriate level of advice through to their clients and that there needs to be specialist qualification.”

Other wish-list items are that there should be greater alignment between the Financial Sector Conduct Authority (FSCA) and the industry itself to improve retirement outcomes, and that the fixation on costs should stop.

Consultants also want members to take more ownership.

“As much as we can educate and advise and influence, ultimately the individual has to take ownership of their retirement funding journey and to a large extent that is not there at the moment.”

A major blind spot is the risk of cybercrime. Consultants are not equipped to evaluate cybercrime risk when evaluating retirement funding providers. The same goes for trustees.
  
2019/04/032019/04/08 11:31 AM
BUSINESS TECH

The National Health Insurance (NHI) plan is South Africa’s version of universal healthcare – where resources are pooled to provide health services for everyone.

The scheme has been widely criticised by stakeholders in the country’s healthcare sector, but despite this, the government is adamant that the universal healthcare plan will be realised.

Health minister, Aaron Motsoaledi this week said that the NHI will be implemented by the next administration, indicating a clear plan for the scheme to be taken forward post the 2019 election.

According to Free Market Foundation researcher and data scientist, Mpiyakhe Dhlamini, apart from the many flaws in the manner in which it is being implemented, the most serious flaw is that the scheme is going to be prohibitively expensive – and will be most-used by those who are not paying for it.

“Scant attention has been paid in the South African public discourse to the structure of the proposed system and the problems inherent therein,” he said.

The NHI is a single-payer system where the government would be the sole purchaser of health services on behalf of all South Africans.

The government would be responsible for certifying healthcare providers from both public and private providers.

It is also envisioned that supply and demand-side measures would be implemented, presumably, to contain the economic effects that will arise from having zero prices on the demand side of the equation.

The scheme has been painted by the health department to be a subsidy system – with the rich subsidising the poor, the healthy subsidising the sick and the young subsidising the old.

However, because of the socio-economic make-up of South Africa – where a vast minority pay almost all of the taxes – the scheme will end up doing more harm than good.

This is because the people who will make the most use of the system are not the ones paying for it, and thus have no incentive to balance the demand on the system.

Dhlamini pointed to the UK’s NHS as an example, where increased demand for services in the NHS did not result in increased supply of the service because the country’s voters, in their role as suppliers of the service through taxation, had an incentive to keep taxes on themselves as low as possible.

This mismatch led to a deterioration in the quality of service offered by the UK’s NHS, he said.

However, in South Africa, the large majority of the country’s voters are not taxpayers.

In South Africa, the bulk of taxes raised by the government are in the form of PIT (Personal Income Taxes) and in the 2017/18 tax year 1.9 million South Africans contributed 80% of the revenue.

Over the years, PIT has grown from roughly making up the same proportion of revenue as VAT to becoming the single largest source of revenue.

VAT affects all voters – while 80% of PIT is raised from less than 2 million South Africans out of almost 27 million registered voters.

“At zero prices, the services offered by the NHI with the greatest elasticity of demand are going to experience the greatest demand from the public,” Dhlamini said.

“In other words, the voters will have an incentive to impose more taxes on the small population paying taxes, to fund greater levels of service – especially with regard to the NHI services that have the greatest elasticity of demand.”

Dhlamini said that taxpayers will, in turn, have a rational reaction to this scenario, that being to look for a way to reduce this burden – like packing up and leaving the country altogether.

“(This) situation leaves us vulnerable to the possibility of taxing the golden goose to death because any welfare measure is under the control of people who do not have to pay for it,” he said.

“With everyone acting rationally in the private as well as public arenas, the introduction of a system like the NHI will destroy the South African economy.”
  
2019/04/032019/04/08 11:31 AM
MEDICAL BRIEF

The government’s private health market inquiry was a red herring intended to create a veneer of legitimacy for further regulation, in preparation of introducing its National Health Insurance (NHI) scheme and to divert attention from the dismal state of affairs in the public healthcare sector, writes Jasson Urbach, an economist and a director at the Free Market Foundation in City Press.

In view of the costs involved – in a written reply to a question in Parliament, Economic Development Minister Ebrahim Patel disclosed that the private health market inquiry has cost taxpayers R197m – Urbach writes that the origins of the inquiry are instructive, and worth recalling.

Urbach writes: “In 2014, the Competition Commission launched the inquiry into private healthcare after Health Minister Aaron Motsoaledi approached them with his ‘hypothesis’ that private healthcare is too costly. The minister has always maintained that the two preconditions for introducing National Health Insurance (NHI) on which he was not going to compromise are ‘overhauling the quality of care in the public health system and reigning in and regulating the pricing of healthcare in the private sector’.”

Urbach writes that the health market inquiry has been a red herring from the start and its intended purpose was always to create a veneer of legitimacy to justify why government should further regulate one of the most regulated sectors in the economy, in preparation of introducing its NHI scheme and to divert attention from the dismal state of affairs in the public healthcare sector.

But, he points out, considering how much the health market inquiry cost, it was certainly not a particularly good use of scarce taxpayer resources.

He writes: “The money could have been much better utilised had it been spent directly on assisting the poor. It could have paid for 145 new medical doctors or 656 Unjani primary healthcare clinics, able to treat 1 416 960 patients a year.

“Alternatively, the money could have been spent on 1790 RDP houses and put a roof over the heads of 7163 people, or paid for 83 829 title deeds for people who, over two decades after apartheid ended, still do not own the homes that they live in.”

Urbach writes that according to the World Bank’s world development indicators, health expenditure in South Africa increased from 7.4% of GDP in 2000 to 8.2% in 2015. More specifically, domestic general government health expenditure as a percentage of current health expenditure increased from 37% to 54% over the same period. In contrast, private health expenditure as a proportion of current health expenditure declined from 62% to 44%. He says the private health sector has therefore been increasingly squeezed out of the healthcare market.

The World Bank data also reveals that South Africa’s public health expenditure per capita of $582 (about R8500) (measured in PPP-adjusted international dollars) exceeds the average upper middle country government health expenditure of $517 (about R7,557) per capita. But, he argues, South Africa’s healthcare outcomes are significantly worse than our peers.

Urbach writes: “In South Africa, the average life expectancy is 62.8 years, compared with 75.3 years in upper middle-income countries. The maternal mortality rate in South Africa is 138 (per 100,000 live births), compared with 41 in upper middle-income countries. And the infant mortality rate is 28.8 (per 1,000 live births) in South Africa, compared with 11.6 in upper-middle income countries.

“The South African government spends more per person than our peers but with far worse health outcomes. In simple terms, the government does not get a very good bang for its taxpayer buck.

“Government is so preoccupied with trying to control the private sector that it is ignoring the suffering its medical malfeasance is causing patients in the public sector. According an Office of Health Standards Compliance report, only six of the 696 government hospitals and clinics it inspected in 2016/17 complied with the department of health’s norms and standards to achieve an 80% ‘pass mark’.

“In this same report it shows that 26% of public facilities inspected were critically non-compliant with a further 36% being non-compliant.

“Unsurprisingly, between March 2015 and 2018, medical negligence claims against the state increased from R28.6bn to R80.4bn. Yet the government is intent on further marginalising the private healthcare sector by introducing its unworkable and unfeasible NHI scheme.

“Considering the fact that South Africa has a large and growing budget deficit and South Africans are no closer to understanding the material details of the NHI, including but not limited to, how much it will cost and where the additional resources (both financial and human) to administer the ambitious programme will come from, the prudent responsible path to follow is to focus on financing quality healthcare for the poor rather than attempting the wholesale takeover of the healthcare sector.

“To achieve universal healthcare the government must acknowledge the role that the private sector plays in increasing access to quality healthcare and should rather encourage the private healthcare sector to grow, innovate, and expand, which would not only be good for South Africa’s financial health, but will lead to better health outcomes for the poor, which is surely what we all want.”
  
2019/04/032019/04/08 11:39 AM
RETAIL BRIEF AFRICA

The idea of using biometrics in the healthcare sector is not new, but it is one that hasn’t been explored or exploited to its full potential.

A biometrics-based project was first piloted by health workers in three South African provinces back in 2005. The project was driven by the national and provincial health departments and made use of biometric technology, sponsored by the private sector that allowed for patient identification using fingerprints. The aim of the project involved establishing a central “infomediary” to collect and reference key medical information on behalf of patients.

At the time it was certainly recognised that this kind of technologically enabled service could boast significant benefits for patients and public and private healthcare providers, alike. Though regrettably, despite being sound in its intentions, neither the initial piloted project nor similar projects that followed have seen widespread adoption and implementation.

Fast-forward fourteen years and today, in the digital age, the opportunity for widespread implementation of biometrics across the healthcare sector is not only far greater but bodes two crucial advantages that should not be ignored.

Improved patient care

Patient identification errors – and especially cases that lead to a patient receiving inappropriate care – are not only deeply troubling, but can hold reputational, financial and even legal implications for healthcare professional and facilities, alike.

Biometric solutions offer an effective tool for patient identification and authentication – whereby a patient’s medical information can be matched to a unique identifier such as their fingerprint and stored in a master database or central patient index. Biometrics are accurate and thereby more secure than, for instance, scenarios where using an identification number which may be entered incorrectly during a multiple service provider registration process or falsifying information can be eliminated and patient information accuracy improved. Additionally, the patient information stored in the master database or central patient index can be accessed and used by a variety of verified and registered health and wellness professionals or facilities, without each needing to perform biometric enrolment multiple times. This can create far more streamlined access to up-to-date patient medical history and thereby lead to improved overall patient care.

Biometrics, in turn, can be implemented by public and private healthcare facilities for internal purposes in order to identify and verify healthcare personnel to enable compliance with industry standards regarding background screening processes, as well as, providing various audit trails for reporting purposes namely; shift work, payroll and patient allocation.

Combatting medical fraud

Medical fraud is a growing phenomenon globally – and South Africa is not unaffected. Speaking at the Council for Medical Schemes’ recent Fraud, Waste and Abuse Summit, Katlego Mothundi, MD of the Board of Healthcare Funders of SA (BHF), stated that up to 25% of the money paid by members as medical scheme contributions or premiums annually is lost due to fraud, corruption, abuse and wastage. The cumulative monetary loss is estimated at between R22bn and R28bn a year.

Medical fraud can be as a result of illicit actions by a health service provider or a patient, with intention to deceive or misrepresent medical information to the advantage of one party’s individual gain over the medical scheme provider. However, the significant monetary losses in the industry is not the only negative or detrimental effect of medical fraud – fraud can also cause genuine patients to lose out on access to quality care, loss of medical benefits and/or receiving unnecessary or incorrect treatment or medication. This can all affect the patients continued health and well-being.

It’s not surprising then that more medical schemes are deploying advanced data intelligence solutions to mine and discover patterns and trends in member and provider behaviour, alike. But what if all authorisations and full medical data pertaining to patients/members and health and wellness providers could be attached to their individual unique digital signature, such as a fingerprint.

This would certainly enforce “know your patient” values and, because the data will be trackable using a biometric digital signature, it makes it easier for medical schemes to detect trends and thereby significantly reduce occurrences of medical fraud.

Rapid technological advances – from pervasiveness of the Internet and adoption of disruptive technologies like cloud, mobility and the Internet of Things (IoT), for example – continue to facilitate biometrics adoption. Today, devices and solutions can and are being designed and built to address specific application needs. In fact, there are already examples of palm, fingerprint and iris scanning biometric solutions being implemented and tested across medical and healthcare facilities globally. And, as the local market follows the curve of this trend, we expect that more widespread adoption of biometrics with the aim of protecting patients, professionals and medical scheme providers, alike, is merely a matter of timing.
  
2019/04/032019/04/08 11:39 AM
BUSINESS LIVE

Draft Conduct of Financial Institutions Bill removes its core functions, council says, claiming it was not consulted over move

The medical schemes regulator has criticised the Treasury for failing to consult it on the draft Conduct of Financial Institutions Bill, saying it will render it a lame duck if passed in its current form.

The bill is part of the government’s reforms to strengthen governance of the financial services industry, following the promulgation of the Financial Sector Regulation Act in 2017, which established the Prudential Authority and the Financial Sector Conduct Authority (FSCA).

The bill outlines what consumers and industry players can expect of financial institutions, including medical schemes and administrators.

Its proposals thus affect the role of the Council for Medical Schemes (CMS), which oversees 80 medical schemes that provide health cover to 8.9-million people.

The bill was published by the Treasury in December 2018, and interested parties had until April 1 to comment.

Its explanatory note reads that the FSCA’s full powers will apply to medical schemes, but initially this role will continue to be played by the CMS, with the concurrence of the FSCA.

“The FSCA and the CMS are working together to reach agreement regarding when FSCA concurrence with CMS decisions is required during this transition period, as well as more broadly on how approaches to conduct of business and consumer protection issues in the medical schemes environment can be harmonised.

Medical schemes will therefore not be required to be licensed under the bill framework during this transitional period, “although this may be reviewed over time”, it said. The transitional period ends on March 31 2021.

But in its submission to the Treasury, the CMS said it was not consulted on the bill. Although it was part of a task team dealing with the Financial Sector Regulation Act, the contents of the bill were not discussed at their meetings, it said.

In a strongly worded statement, the CMS said it is irritated and disappointed with the bill, because it removes its core functions.

The CMS’s mandate includes protecting members’ interests, overseeing product design, investigating complaints, settling disputes and advising the health minister on matters affecting the industry, said CMS registrar Sipho Kabane.

“Removing these core regulatory functions from the CMS and placing them with the FSCA is tantamount to legislating the CMS out of existence as an independent regulator,” Kabane said.

“If additional statutory or even voluntary dispute resolution mechanisms are created it will create further problems for members of medical schemes who are already overwhelmed by the complexities and asymmetry of information in the health insurance sector,” he said.

The CMS said medical schemes do not operate like institutions providing insurance products and should not be subjected to the same conduct requirements.

“The specific regulatory functions that include product design, disclosures and claims management in medical schemes should fully reside under the CMS in line with the powers accorded to it by the Medical Schemes Act,” it said.

“The CMS demands that the Treasury and FSCA properly consult with the CMS before the final version of the [bill] is sent to parliament,” Kabane said.

The Treasury had not responded to Business Day’s request for comment at the time of publication.
  
2019/04/022019/04/08 11:30 AM
BUSINESS LIVE

Proposition is for small restricted schemes to pool resources for more affordable membership

The Council for Medical Schemes (CMS) is considering introducing an umbrella fund to help small restricted schemes pool their resources to try and make membership more affordable.
It is one of several measures being explored by the regulator in response to the government’s policy on National Health Insurance, which advocates industry consolidation.

The CMS initially suggested in 2017 that schemes with fewer than 6,000 members might be the first target for dissolution or mergers with larger schemes, drawing fire from industry players and activists alike.

It has since softened its position.  In a discussion document released at the weekend, the CMS said the size of a scheme alone was “not the most objective and justifiable measure” to determine which schemes should be prioritised for consolidation. The council said it planned to do further research to identify which schemes could be amalgamated, and the effect this would have on administrators.

The council also said it planned to release a discussion document soon on the creation of an umbrella fund, which would introduce a standardised benefit package across the schemes that belonged to CMS. This follows on from work it previously commissioned from consultancy Percept on medical scheme consolidation.

Among the proposals Percept made to the CMS, detailed in a draft consolidation framework it published last September, were merging public-sector medical schemes, grouping industry schemes, amalgamating vulnerable schemes with stronger ones, and the creation of an umbrella fund.

Many small restricted schemes did not want to lose their identity in mergers with large open schemes, but saw potential benefits in merging their risk pools, Percept CEO Shivani Ranchod said on Tuesday.

An umbrella fund would provide all the advantages of consolidation, such as a more stable risk pool and greater bargaining power (due to the increased scale of its risk pool), while enabling employers to maintain a close relationship with their staff, she said. Schemes that joined an umbrella fund would all offer members the same benefits, and could share resources such as provider networks to reduce costs.

“There is also a broader industry benefit, as it would allow the entry of another large player,” she said.

Restricted schemes limit their membership to a specific profession or employer group, while open schemes offer membership to anyone who can afford their premiums. There were 80 medical schemes and 331 options at the end of 2017, according to the CMS’s 2017-18 annual report.

CMS senior health economist Nondumiso Khumalo said the discussion document on the umbrella fund would provide details of its proposed structure, the schemes that could participate and the benefits they would offer members. It would be published within the next three months, she said.

She emphasised that the CMS could not compel schemes to consolidate. “We can only guide schemes, we can’t compel them,” she said.
  
2019/04/012019/04/08 11:14 AM
POLITICS WEB

A commentary on the National Health Summit 2018 Report
PJ Hamilton says summit seems to have led to a reiteration of a number of hollow promises

Introduction

On 19-20 October 2018, President Cyril Ramaphosa convened the inaugural Presidential Health Summit. The purpose of the summit was to invite key stakeholders from the health sectors to discuss the state of our health system and to enable collective planning of good health for all. In February 2019, the Department of Health released a report on the outcomes of these deliberations.

The drafters of the report reached a number of conclusions which require some analysis and comment.

A unanimous show of hands

“There was unanimous support for the principles of National Health Insurance (NHI), which include: universal quality health care, social solidarity and equity in health access, and a call for NHI and its implementation [our emphasis]”[1]

While section 27 of the Constitution guarantees each person the right to access to healthcare services, it is widely accepted that the current South African health system is unsustainable and in need of strategic reform. The NHI purports to do so and in turn, bring about Universal Health Coverage (UHC). The two terms, NHI and UHC, are, however, not mutually interchangeable. It is, though, of paramount importance to distinguish between the two.

The objectives of UHC are as follows:[2]
1. Equity in access to health services - everyone who needs services should get them, not only those who can pay for them;
2. The quality of health services should be good enough to improve the health of those receiving services; and
3. People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.

Conversely, the objectives of the NHI are:[3]

1. The consolidation of revenue;
2. Serving as the single purchaser of health services;
3. Ensuring the sustainability of funding for health services; and
4. Actively purchasing health care services, medicines, health goods and health-related products.

UHC is a goal to give effect to health as a fundamental human right. The NHI is the South African government's proposed policy to achieve this goal. It would be correct to say that there is unanimous support for achieving UHC and the need for reasonable steps to realise this goal. However, since its inception, the NHI has remained highly contested. Civil society and stakeholders alike have expressed opposition to the process. The Helen Suzman Foundation (HSF) raised a number of concerns about the NHI in our submission on the Draft NHI Bill. Although the NHI purports to achieve UHC, it is both inaccurate and misleading to state that there exists unanimous support for the NHI when the contrary is true.

Harmonious living

“Private sector has a critical role to play in the realisation of NHI, thus [a] harmonious working  relationship between private and public sectors, in a way that puts the needs of the people of South Africa first, is needed.”[4]

An approach to UHC which advocates public-private partnerships is commendable, and one which the HSF supports. The issue, however, is that under the current NHI framework, this relationship is better described as one of coercion. 

Under the NHI Bill, only those healthcare practitioners who have been registered and accredited by the fund will be entitled to claim for services rendered from the fund. As written, the NHI Bill does not make it compulsory for private practitioners to do so and, on the surface at least, it appears as if private participation in the NHI is voluntary. Issues arise, however, when the NHI Bill is read with the proposed section 34(3) of the Medical Schemes Amendment Bill.

Section 34(3) provides for prohibiting medical schemes from offering the same benefits as those provided by the NHI. This amendment has two consequences. First, it is highly exclusory as far as medical schemes are concerned, reducing their function to providing funding for complementary services. Second, it creates a situation where private practitioners are either forced to participate in the NHI process to ensure their patients can receive funded services or to charge their patients out of pocket.

It is difficult to see how, moving forward, the exclusion and coercion of two key groups of stakeholders in the private sector can be regarded as harmonious.

Crossing the Ts

“Accountability and transparency in implementing NHI interventions [were] overemphasised. This must include a plan to have consistent and comprehensive communication in ongoing engagements and to report regularly to the nation on the progress made to improve the quality of the health system.”[5]

While we are still trying to make sense of State Capture, the need for improved accountability and transparency cannot be overemphasised. The NHI policy is a radical intervention whose potential for success is an unknown as no process of its kind has been attempted before internationally. Testing of the NHI is paramount.

It is intended that the NHI be implemented in three phases. Phase 1 took place between 2012-2017 and included testing of effective health strengthening initiatives. Part of these strengthening initiatives was to establish several pilot sites that would operate under the NHI framework. The objectives of the pilot sites included: testing the ability of the districts to assume greater responsibilities under the NHI; to assess utilisation patterns; and to assess costs and affordability of implementing a PHC service package.[6]

Phase 1 of the NHI has been completed, yet, to date, no evaluation report of the pilot projects has been released into the public domain. To improve accountability and transparency – as the drafters of the report emphasised a need for - this report should have been voluntarily released. Instead, the HSF has had to resort to bringing a PAIA application to acquire such evaluations after formal requests were denied. It is also important to note that these requests were made post the 2018 Health Summit and refused in spite of the stressed need for accountability and transparency, indicating a lack of commitment to for real action.
A retold story

Part of the methodology used at the Health Summit was to identify and differentiate between actions which needed to be taken either immediately, short term or medium term to combat the declining state of our health system. Below are a few select examples:

Figure 1: Immediate and short-term actions needed, identified at the 2018 Health Summit.[7]

There is an urgent need to review the organisational design in the public sector to redress the top-heavy organisational design. There must be a separation between the political and administrative leadership in public health. [our emphasis]

Review of the policy on registration and employment of foreign-trained medical practitioners to address shortages of skills.

Review the concept of community participation in health to clarify roles and responsibilities.

Standardise (IT) systems using the health standards normative framework for interoperability and develop a policy to deal with the 42 systems currently in use in the health system across the country.

There are two commonalities between these examples, although, these commonalities and not necessarily restricted just those the examples listed here. These examples all require some form of policy implementation from the Department, and were stressed as requiring urgent or short term action.

What is disheartening about these action plans is that they are not novel. The National Development Plan 2030 (NDP), which was released in 2012, acknowledged the failings of our health systems. It stated that top-heavy centralised management, feeble accountability, inconsistent budgetary spending and poor implementation of policy had led to an inability to get primary health care and the district system to function properly.

In order to address these failings, the NDP identified a number of priority areas that highlighted the key interventions needed to achieve a more effective health system. A few examples are listed below:

Centralised guidance, technical support and monitoring should be aligned with decentralised, devolved responsibility and decision-making.

Bringing in additional capacity and expertise to strengthen a results-based health system, particularly at the district level. This should include revised legislation to make it easier to recruit foreign skills.

To achieve this model of community-based health care, the powers of conservative professional councils will have to be curtailed and the scope of practice for non-doctors, especially community health workers and nurses, enlarged.

Integrate the national health information system with the provincial, district, facility and community-based information systems.

What these examples help illustrate is that despite the consensus that these and other areas require immediate action, they have done so for several years and have yet to be rectified. The NDP recommendations themselves largely originate from the 2008 consultative process to create a roadmap for health.[9] For over a decade now there has been a lack of political will to really commit to addressing these issues.

Conclusion

It is commendable that the government is seeking to involve stakeholder participation in addressing issues plaguing the health sector. Inclusive public-private partnerships are key to reform and more processes like the Summit will be required to do so.

It is unfortunate then that the outcome of the Health Summit seems to have led to a reiteration of a number of hollow promises with a lack of commitment to follow through. Overdue policy intervention, a material commitment to accountability and transparency, and inclusive participation practices are needed to convince stakeholders and the public alike that there is a real will from government to improve the health system.

This article first appeared as a Helen Suzman Foundation Brief.

Footnotes:
[1] Presidential Health Summit 2018 Report pg 9, and as reiterated on pg 61
[2]https://www.who.int/health_financing/universal_coverage_definition/en/
[3] The National Health Insurance Bill, s 4
[4] Note 1 supra, pg 40
[5] Note 1 supra, pg 61
[6] https://www.sanews.gov.za/south-africa/10-districts-announced-nhi-pilot
[7] Note 1 supra, pg 30, 30, 55 and 59 respectively.
[8] The National Development Plan 2030, pg 337, 336, 347 and 338 respectively.
[9] A Roadmap for the Reform of the South African Health System, 2008
  
2019/04/012019/04/08 11:19 AM
EYEWITNESS NEWS

Health Minister Aaron Motsoaledi says that government is serious about rolling out the National Health Insurance (NHI) across the country in the next five years.

Speaking at the ANC’s election manifesto briefing on Sunday, Motsoaledi said that President Cyril Ramaphosa was now in charge of the project which aims to provide equal health care for all South Africans.

The minister said the public healthcare system in the country was heavily constrained and needed a complete overhaul.

Motsoaledi said that government had established a war room to finalise the bill in order to pass the NHI.

“Because how do we continue to run a health system where 4.5% of the GDP goes to only serve 16% of the population? And the remaining 4.2% of the GDP goes to serve a whopping 84% of the population.”

He said the NHI would be a reality in the next administration.

“We believe that some of the things are self-made with our structural problems because we ask ourselves the first thing that we are going to do in five years is NHI, which many of you are trying to fight against.”

Motsoaledi said the NHI will ensure that all South Africans have access to quality healthcare despite their financial situation.
  
2019/04/01
2019/04/08 11:20 AM
CAPE TIMES

NHI needs to address inequality; public institutions must be fixed

Health Minister Aaron Motsoaledi has criticised the country's health care system, saying it was riddled with disparities that did not exist anywhere else in the world.

Motsoaledi said the persisting inequalities in health care consumption were flying in the face of South Africa's massive spend on health.com pared to many countries, which he said National Health Insurance (NHI) needed to address.

He was speaking at the ANC's Luthuli House Headquarters where the party was holding its manifesto briefing on health, education, science and technology.

Motsoaledi said the country was currently spending 8.7% of its entire GDP on health, but more than 50% of it was being consumed by just 16% of the population.

"How do we continue running a health care system where 4.5% of the GDP goes to serve only 16% of the population? The remaining 4.2% of the GDP goes to serve a whopping 84% of the population. That situation exists nowhere in the world," Motsoaledi said.

The DA and several interest groups have voiced their opposition to the NHL which they said would be costly and would fail because of the state of the public health care system.

Motsoaledi said the ANC would have to make the implementation of NHI a priority, despite opposition to it, as it would ensure that the 8.7% of the GDP spent on health is distributed equitably to all citizens.

"That is basically one of the fundamentals of why we need NHI. We have never denied that there are problems in the quality in public health care."

Motsoaledi said the government was also working hard at ensuring that the problems in public health care were addressed, including through the convening of last year's health care summit by President Cyril Ramaphosa.

"We have drawn up a plan and that plan culminated in the opening of the war room in the Presidency, and we have drawn up the plan on how to fix the health care system in the country as a whole.

"But the first place of fixing health care is equity. You can't keep on having a grossly inequitable health care system which exists nowhere in the world," he said.

He said many European countries were spending 9% of their GDP on health and they had no problems.

Higher Education Minister Naledi Pandor said the government would have to work hard to make TVET Colleges fashionable in order to encourage young people to see them as alternative for tertiary education, which she said would decrease the influx into universities.

She said while universities needed more investment, TVET colleges were crucial in terms of addressing a critical skills shortage, but that they were often overlooked.
  
2019/04/012019/04/08 11:20 AM
HERALD

Health minister Aaron Motsoaledi said the National Health Insurance (NHI) might be referred to as “Ramaphosacare”‚ as the president was now in charge of the bill which would see the government roll out universal healthcare across the country.
 
Speaking on the sidelines of a media conference at the ANC’s headquarters on Sunday‚ Motsoaledi said the NHI was too big an issue to be dealt with alone by the minister of health.
 
He said he had since asked President Cyril Ramaphosa to take over the planning and the roll-out of the NHI because that would be the only way equal‚ universal healthcare in SA would become a reality.
 
Since then‚ a war room has been established in the presidency to finalise the bill for parliament to approve.
 
“In the US, universal health coverage was called Obamacare. Why? Because the team was in former president [Barack] Obama’s office. Many of you didn’t know who the US minister of health was, but you heard about Obamacare.”

Motsoaledi said some things that were required for NHI could only be done by the president‚ because the minister of health could not instruct the minister of finance for budget allocations nor instruct the minister of home affairs to change certain legislation.
 
Motsoaledi said the war room‚ headed by Ramaphosa’s health and social issues adviser Professor Olive Shisana‚ was an effort to make the long-delayed NHI a reality in the sixth administration.
 
He said part of NHI would see to the change of 12 healthcare laws, including the Health Care Act of 2003.
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