THE STAR
In an interview, Health Minister Dr Aaron Motsoaledi said that his biggest risk in the implementation of NHI is fear and lack of political will on the part of the state.

Khathu Mamaila: The health ombud paints a very gloomy picture of the healthcare system in the country. Under the current circumstances, should we really be even talking about the implementation of the NHI?

Minister Aaron Motsoaledi: It is true that I pronounced publicly that the healthcare system is under extreme distress. You may call it a crisis but there are those who prefer to call it a collapse. I am the one who came up with the idea of having a health ombud, a position that never existed in the past. Some people who did not understand what we were trying to do asked me what is a health ombud, and my explanation was that the health ombud is a public protector in our health system. Everybody is now familiar with how the health ombud dealt with the Life Esidimeni tragedy. Your main question is whether under the present circumstances we should be talking about NHI. I am very worried why it is not clearly understood that NHI is not a luxury which we implement when everything is going right. If everything was going right, then you do not need NHI.

You need NHI precisely because you want to use this universal health coverage plan to correct the wrong things in the healthcare system. Remember that we are not the first country in this planet to implement such a system. Many countries have done so for more than half a century.

All the countries who implemented it had something in common. They were prompted by very serious problems in their healthcare system. Those problems were created by the prevailing economic conditions at the time. A prime example is that of Britain. When the British started their National Health Service, a similar plan to NHI, it was three years after World War II. Their healthcare system was in tatters, with high mortality and morbidity. They had a high rate of unemployment and many poor people. That is when the government of the day decided that to save many people from death, let’s start a health system that will not only cater for the rich but will help everybody. Since NHI is the equaliser between the rich and the poor, to quote Margaret Chan, the former World Health Organisation director-general, then we should accept that this is the only system that is appropriate to address the problems in healthcare in our country, which is reported to be the world’s most unequal society.

KM: Perhaps before we get into the details of NHI, ordinary people are saying that what the health bombed said was their daily experiences. They say the quality of public healthcare has been deteriorating over the years. Some even argue that public hospitals are in a worse state than they were during apartheid. Is this fair comment?

AM: This might not be an unfair comment, to be frank. But the point of dispute among many people is what brought this situation about. A number of commentators believe that it is just because of corruption, poor management, incompetence and unskilled officials as well as under-budgeting in the public healthcare system. This sounds like a powerful argument, but really this is too simplistic. These issues that many people argue are the causes are the consequences of a deeply fragmented system. Apartheid was fragmented along colour lines, but both groups were treated in the public hospitals, which had most of the resources even though they were not equal. Nobody was getting treatment in an exclusive and extremely expensive private hospital which was also heavily subsidised. All the human resources, skilled professionals, were accessible to all.

For example, Johannesburg Hospital, now Charlotte Maxie, was an exclusively white hospital, but in terms of specialised skills that served this hospital, they were available to serve Baragwaneth Hospital, which was exclusively a black hospital. But in today's economic fragmentation, as opposed to colour fragmentation, the situation is much more brutal. In this brutal system, 4.4 percent of the GDP is spent on only 16 percent of the population, while the remaining 4.1 percent (of a total of 8.5 percent of the GDP which is spent on healthcare) is shared by 84 percent of the population. No other country in the world spends so much money on so few people. I have heard some arguing that 4.1 percent is sufficient for the poor majority. But for how long do we expect the poor majority to keep on absorbing insults like this?

KM: While the rationale for NHI is sound, does the country currently have enough resources to implement NHI?

AM: There are people propagating a misleading notion to the country that private healthcare use strictly private health money from rich people. This is an outrageous lie.

The private healthcare system is heavily subsidised by the public. There is enough money for health for everybody in the country. The problem is that it is used on too few people. But this does not mean that we are intending to ban the private healthcare system. We just want to make the healthcare resources in both private and public to be available to all people in the country. I want somebody to stand up and tell me how it is wrong, morally, politically legally and constitutionally to give equal treatment to people without regard to their economic status.

KM: If we move away from historical factors, in your view, what is the major contributing factor to the over-burden of the public healthcare system?

AM: People can gloss over the facts to maintain a particular narrative. But one fact that nobody can dismiss is that in 2004, only 400 000 people were receiving antiretroviral drugs from our public healthcare centres. That number has increased more than 10 times. Today just over 4.2-million people are getting antiretroviral drugs from our hospitals. This explains the longer queues that are a familiar sight in our hospitals and clinics. In a way we are victims of our own successes. Yes, people may complain about the long waiting periods, which we try our best to reduce, but what is not often said is that we run the biggest ARV programme in the world. We are saving millions of lives.
People need no longer die of HIV and AIDS. We have turned the corner. Statistics support the view that fewer people are dying of HIV and Aids. Life expectancy has also increased. And all these are supported by the current healthcare system.

KM: Given the concrete material conditions prevailing in the public healthcare sector, can NHI be rolled out successfully?

AM: I wish to remind the public about the White Paper. In that document we clearly said that NHI is a substantial policy shift which needs a massive reorganisation of the health system, both public and private. Without this massive reorganisation you can't roll out NHI. The reorganisation and the rollout must happen simultaneously and the NHI bill indicates how this will happen. Of course the issue of the allocation of resources is important. The shortage of doctors, nurses and other health specialists has a lot to do with how health resources in the country are distributed. Under NHI all South Africans will be able to access quality healthcare in both the public and private sectors. In other words, health expertise, which is currently reserved for the few who have medical aid, would be made available to all.

KM: Minister, would this plan not just extend the queues to the private hospitals? In other words, the overcrowding that we see in public hospitals will become a common feature in the private hospitals?

AM: That scenario you are describing assumes that we are going to leave the public health system as it is and just impose NHI on it. This would not be the case. The fear of the long queues in private hospitals is the same fear that certain people had regarding democracy. Some people feared that the blacks will dominate the public space that they used to enjoy exclusively. NHI’s objective is to eliminate the queues, not to extend the queues to other places which had no queues in the past. Part of the reorganisation would be to make primary healthcare to be the heartbeat of our healthcare system. We want to move away from a curative approach to a preventive approach. In other words, with early detection, we believe that fewer people will need to come to hospitals and many of their problems can easily be dealt with at clinics. We have already started with some of the campaigns to reduce the number of people who will need to visit hospitals.

We have been actively campaigning against smoking and tightening the regulations on smoking. And we have done the same regarding sugar and salt.

KM: Some observers argue that while resources are a major factor, pouring money into an inefficient workforce is unlikely to solve the problem. What is your view'?

AM: Everybody knows that the public health workers have to break their backs to serve the majority. About 80 percent of the specialists are found in the private sector and 20 percent must serve a huge population of 84 percent. Which one is inefficient? Under NHI we are not going to pour any money we just want sufficient allocation to serve the entire population.

KM: Now that you have presented the NHI bill to the cabinet and got cabinet approval, what do you see as the biggest stumbling block in the implementation of NHI?

AM: That would be lack of political will on the part of the state to implement NHI. Really, I see the biggest risk as fear by the state, when the state gives in to scaremongers and their total onslaught on NHI. There are many other obstacles in our protracted journey to implement NHI. In my view, the second biggest hurdle is poor understanding of what NHI is and what it intends to achieve. There are many people who are opposed to it, but when you listen to them attentively, you realise that they do not even understand the basic tenets of NHI. I think we should not take things for granted that our people know enough about NHI and how it will affect their lives. There are those who believe that I am on a mission to destroy private healthcare through NHI.

Of course this could not be further from the truth. We want to free the resources that are locked up in the private sector so that we use all the available resources in the country to deal with our health challenges. But we must increase our public education campaign of NHI. If we can get the various stakeholders, policymakers and the public to understand the theory of NHI. I think we would have won a huge battle in the implementation of NHI.

BUSINESS DAY LIVE
Fighting fires: Health Minister Aaron Motsoaledi visits a health centre in Mmabatho in the North West, amid a National Health Education and Allied Workers Union strike in April. Some critics say public healthcare has deteriorated under Motsoaledi and Cosatu is calling for him to be replaced.

Fighting fires: Health Minister Aaron Motsoaledi visits a health centre in Mmabatho in the North West, amid a National Health Education and Allied Workers Union strike in April. Some critics say public healthcare has deteriorated under Motsoaledi and Cosatu is calling for him to be replaced.

Over the past decade, "crisis" has been used to describe the provision of public health services in SA. But it would be unfair to describe the entire system as crisis-ridden. Certain sectors of the system are approaching a dysfunctional state while in others achievements have been made.

For some years now, a string of research reports have pointed to various crises in the health sector. In 2016 an Econex report warned that the number of doctors available was half the average in a middle-income country. The Office of Health Standards Compliance concluded in a 2016 study that most public hospitals were not functioning even close to adequate levels. The Future Health Index ranked SA last among 19 nations in a global survey that measured healthcare system efficiency.

Since 2011, due to the financial crisis that began in 2008, per capita expenditure on health has been static or negative, the 2017 South African Health Review published by the Health Systems Trust reads.

The sector has responded to lower budgets and rising costs by limiting or cutting personnel; securing savings on medicines tenders, administration and expenditure; reducing capital spending on buildings and medical equipment; and prioritising primary healthcare.

These cuts seem to have created the formula for producing the Life Esidimeni tragedy, in which about 144 psychiatric patients died at ill-equipped nongovernmental organisations, when there was little consideration for the human cost of trimming budgets.

The government wants to change the system, mainly through improving primary healthcare and the proposed National Health Insurance (NHI), which many stakeholders warn is unworkable. The NHI is meant to kick in from 2025 but may take 10 more years to launch.

The NHI will require policy makers, actuaries, insurance experts and others to create a workable system, but even that enormous effort will depend on administrative efficiency in the public health system.

The system is largely not working well. Some say public healthcare has deteriorated under Health Minister Aaron Motsoaledi. Cosatu is calling for him to be replaced.

Motsoaledi has an unenviable job. He has to transform and modernise an inadequate system and somehow get nurses to tackle their jobs with enthusiasm while they are easily tempted by more lucrative offers from elsewhere. The crisis in the nursing profession will be difficult to unravel.

Motsoaledi comes across as someone who is always complaining: about the inefficiencies in his sector; ineffective partners and employees; and inappropriate legislation.

Perhaps he protests too much or perhaps there is some logic to his complaint that it is impossible to get all the parts of the vast machine of public health — managed at three levels of government — working efficiently together.

The public health system requires many key players to function smoothly: doctors, nurses and other health workers; and managers and administrators of hospitals, clinics and other health systems at city, town, district, provincial and national level.

A central plank of national government policy is to improve primary healthcare, which suffered drastic reversals under apartheid. Primary healthcare is a move from a curative model to one that prevents disease. It is not an outcome that can be achieved by the health department alone — it also requires basics such as the provision of drinkable water, secure housing and safe living conditions.

Drastic effects

The success of primary healthcare also depends on immunisation programmes and school feeding schemes that could contribute to reducing the high infant mortality rate and the low rates of life expectancy (51 years for black males), which have been stubborn problems since the apartheid era.

As many of these programmes are municipal and provincial functions, recent failures of local authorities have had drastic effects on the health of the nation.

SA spends 8.8% of its GDP on healthcare — one of the highest health budget ratios of middle-income countries — yet infant mortality rates have recently been rising. Many health facilities and provincial departments have been placed under national administration, including the North West health department in April.

SA does not have enough nurses, as many leave for the UK or Saudi Arabia to earn pounds or dollars and the government is unable to compete with those wages. The Department of Health does not have accurate figures of these sojourners.

There are not enough doctors either. SA’s eight medical schools produce about 1,300 doctors annually, not counting any number of pharmacists, microbiologists, radiologists, laboratory technicians and other health professionals.

Only 30% of physicians work in the public sector, despite it serving more than 80% of the population, and public primary healthcare centres are overburdened. Doctors are leaving the public sector due to poor working conditions, poor salaries, high workloads and limited opportunities for advancement.

This becomes a vicious circle: every doctor who leaves the public service makes conditions more difficult for those who remain. This crisis extends to academia, with teaching doctors leaving academic hospitals, depleting the number of teachers who are able to pass on skills in anaesthesiology, haematology, orthopaedics and all other specialities.

Rural clinics do not have enough doctors, and the department is failing to place doctors in rural areas as part of its community service apprenticeship scheme.

SA also has its peculiarities. It has a high rate of motor vehicle accidents, with an astronomical toll in injuries and deaths; and violence and injury are the second leading causes of death. With high unemployment rates, these factors have increased the number of people suffering from mental health disorders.

Blind eye

The AIDS crisis began to emerge only when democracy arrived. The apartheid government turned a blind eye, probably because it seemed to affect only black people. It gained recognition only after the period of Thabo Mbeki’s denial.

An epidemic of huge consequences, HIV and AIDS will continue to tax the health sector for decades. As many as 4-million people are now taking antiretroviral medication, which they will have to do for the rest of their lives, and they will have to be monitored for the regimen to work with any success. SA has one of the highest rates of HIV infection, with one of the largest number of people suffering from AIDS.

Drug-resistant tuberculosis is rife, as is the older variety of TB, often linked to HIV. In 2014, TB was the leading cause of death in SA. Strangely, cardiovascular patients presenting at many clinics exceed the number with TB, while diabetes and other chronic illnesses are also showing up.

Movement of populations within the country pose problems for regional health systems. It causes large fluctuations in the number of people requiring treatment, complicating resource planning.

Among the successes of the system is the rollout of antiretroviral and especially the prevention of mother-to-child transmission of HIV. Rates of infection have plummeted from about 25%-30% before 2001 to an estimated 1.4% in 2016.

SA has excellent healthcare facilities, but they are available to a very small segment of the population. It could be argued that democracy itself prompted the crisis in the health sector: a system built for 4-million people suddenly had to service the entire population.

The system that caters to the majority of the people — 50-million of them, with 5-million enjoying private care — is semi functional, littered with intermittent breakdowns at hospitals, spates of baby deaths and cancer sufferers left untreated. This system nevertheless lurches on, the nurses doing their duty — some sullenly, some with compassion — the doctors taking naps when they can during 24-hour shifts.

It works as well as it can under the weight of SA’s history, politics and divisions. But it could do much better.

MEDICAL BRIEF
Generic and Biosimilar Medicines of Southern Africa (GBMSA), formerly known as the National Association of Pharmaceutical Manufacturers (NAPM), has appointed Erik Roos, CEO of Pharma Dynamics as vice chair to support the existing chair, Lorraine Keyser, CEO of Dr Reddy’s, as of June 2018.

Over the past 40+ years the association has played a critical role in ensuring that the pharmaceutical sector remains a key driver of economic growth, development and transformation in the country, while continuing to champion affordable and accessible healthcare through the promotion of generic and biosimilar medicines.

As chair of GBMSA, Keyser will be responsible for overseeing the committee, while Roos will support the chair in representing the association on the Pharmaceutical Task Group (PTG), which primarily deals with issues relating to legislation and pricing.

As an industry veteran, Roos brings a wealth of experience to the position and says he looks forward to the challenge of working with and representing the GBMSA member companies to shape a more favourable healthcare environment.

His two-year tenure in office will involve working alongside SAHPRA to ensure the speedy approval of medicine registrations, while evaluating the impact that the Health Charter and National Health Insurance (NHI) will have on both state and private healthcare reform in SA.

“We have ambitious plans ahead and I intend on working with all stakeholders to achieve a common goal.”

“I am also encouraged by the recently announced changes to the country’s Intellectual Property Policy, which will curb uncompetitive practices such as patent ever greening, which has hampered consumers’ access to more affordable medication for far too long.”

“The introduction of a substantive search and patent examination office will do away with unscrupulous companies that use loopholes to extend patents after the 20-year exclusivity period for their own financial gain. This move by government will see a flood of generic medicines enter the market, which will be manufactured and sold at a fraction of the price of original medicines, benefiting consumers and funders.”

“Both generic and biosimilar medication will continue to play a pivotal role in curbing healthcare expenditure well into the future,” says Roos.

AFRO VOICE
The right to quality healthcare is fundamental to the physical and mental wellbeing of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of a satisfactory standard of living.

Chapter II, Section 27 of our Constitution says everyone has a right to have access to quality healthcare services.

Our health and the health of those we care about is a matter of daily concern. Regardless of our age, gender, socioeconomic or ethnic background, we consider our health our most basic and essential asset. Ill-health can keep us from going to school or to work, from attending to our family responsibilities or from participating fully in the activities of our community.

By the same token, we are willing to make many sacrifices if only that would guarantee us and our families a longer and healthier life. In short, when we talk about wellbeing, health is often what we have in mind.

In ensuring that the public is protected, the Health Professions Council of South Africa (HPCSA) has embarked on rolling out public campaign road shows in provinces throughout the country, engaging the public on issues pertinent to them.

The focus of the awareness campaign is among others, to inform the public on the role and of the HPCSA and to educate the public in terms of their rights as patients in relation to healthcare practitioners.

Another mandate is to enforce compliance by practitioners in line with the provisions of the Health Professions Act, 1974. Through this awareness campaign the council educates the public on how to identify bogus practitioners.

The HPCSA is a statutory body, established to protect the public and guiding the professions. Its mission is to attain quality healthcare standards for all, giving a voice to those without one and also bringing together disparate voices to create a collective roar.

The HPCSA intends to address the root causes of social problems and not just their effects. The scale of the challenge is large in government healthcare facilities, with awareness on patients' rights and bogus healthcare practitioners.

South Africa is faced with an insurmountable challenge relating to healthcare. In the road shows flighted by the HPCSA, we get to hear the cries of our people relating to poor service in public healthcare. The HPCSA is there to protect the public, ensure they receive the best healthcare services and their lives are not put in danger.

It is our mandate to ensure practitioners are registered with the council. Those who practice without registering are committing a criminal offence and shall be prosecuted.

We are seeing the emergence of bogus practitioners, masquerading as doctors, who are not registered. Some do not even possess any qualifications. We believe the community should know these people and should they find any suspicious activities, they should contact the council to bring these people to book.

Once patients have a complaint to report, there is a process to be followed when practitioners contravene the code of ethics.

Some of the patient's rights include:

• Access to healthcare services that include receiving timely emergency care at any healthcare facility, regardless of one's ability to pay;

• Informed consent. Everyone has a right to be given full and accurate information about the nature of their illnesses, diagnostic procedures, the proposed treatment, the risks associated with it and the costs involved;

• A second opinion. Everyone has the right tobe referred, on request, to a healthcare provider of one's choice for a second opinion;

• Everyone has the right to complain about healthcare services, to have such complaints investigated and to receive a full response to such investigation.

The aim of the public awareness campaign is to educate and engage the public on pertinent health issues affecting them as patients.

The focus of the awareness campaign is, among others, to inform the public on the role and responsibilities of the HPCSA, to educate the public in terms of their rights as patients, to outline the Department of Health's complaint management process, to educate the public on the role of mediation in medical negligence.

Another mandate of council is to enforce compliance by practitioners in line with the provisions of the Health Professions Act, 1974.

Through this awareness campaign the council educates the public on how to identify bogus practitioners and also encourages the public members to work closely with the HPCSA to root out and report these bogus practitioners.

Tshepo Seloana is an editor at HPCSA and writes in his personal capacity.

BUSINESS DAY
Cabinet has approved the long-awaited National Health Insurance NHI Bill, the government's first and most crucial piece of legislation for implementing its goal of universal healthcare.

NHI aims to provide healthcare to everyone that is free at the point of delivery, financed in a way that sees the healthy and wealthy subsidise the poor and the sick.

The bill, which was approved by the Cabinet last Wednesday, has yet to be published in the Government Gazette.

But Business Day understands from several independent sources that it closely follows the Department of Health's second NHI white paper, which was released in 2017. Health Minister Aaron Motsoaledi declined to comment on the bill, saying he would do so at a media briefing in due course.

The bill does not provide any details about how NHI will be financed, leaving that to the Treasury to determine.

Instead, it sets out the legal mechanism for establishing an NHI Fund, which will purchase services from accredited public and private healthcare providers. Accreditation will be provided by the Office of Health Standards Compliance, which will be implementing a new set of norms and standards in 2019 that include the private sector for the first time.

The bill creates a system for registering beneficiaries, which for South Africans will be based on their identification numbers, and contains provisions that enable the fund to provide differentiated services to noncitizens.

The potentially controversial details of what benefits the fund will cover and how it will reimburse service providers are not spelt out in the bill.

That task is instead delegated to a series of ministerial advisory committees, which include an appeal committee. The work of the ministerial advisory committee on pricing will be closely watched by the private sector, as the white paper says NHI will gradually shift from the current fee for service model to alternative reimbursement models.

This could mean that a doctor could be paid a fixed fee to provide primary healthcare services to a specified number of patients, rather than being reimbursed separately for each service provided to a patient.

The sector is also keenly awaiting the release of the health market inquiry's provisional report on June 28. The inquiry was established by the Competition Commission to determine whether there are barriers to effective competition and access to services in the private healthcare industry. Observers are particularly interested in what it has to say about private sector pricing and whether it will recommend establishing a mechanism for price control. The bill also sets out the fund's governance structure, including the composition of its board.

The fund will be headed by a CEO and will report to the minister of health. It is expected to be released for public comment at the same time as the Medical Schemes Amendment Bill. The two bills go hand in hand as the department wants schemes to provide a set of mandatory minimum benefits that match those covered by NHI. The minister previously told Business Day that the NHI Bill was essentially "a legalisation of the white paper" and that far bigger changes were in the offing with the Medical Schemes Amendment Bill. It is understood that the department regards the Medical Schemes Amendment Bill as an interim measure to ensure consumers are protected as it gradually rolls out NHI.

BHEKISISA
Cosatu has called on President Cyril Ramaphosa to remove Health Minister Aaron Motsoaledi.

“While we understand that health is a provincial competency, it is the centre that has collapsed leaving the provinces feeling their way in the dark. The health system does not need more dialogue, speeches, summits or presentations but needs decisive action,” said Cosatu spokesperson Sizwe Pamla in a statement released late Wednesday.

The union's remarks make reference to Motsoaledi's repeated explanations that current legislation does not allow him to intervene in provincial health crises.

"I only come in as a sort of postmortem, because there is no mechanism for me to intervene before these things happen. Like human resources, procurement is controlled provincially,” he told Bhekisisa in May.

Instead, the minister explained the only “tools” he can use to get provincial health departments to work with him is “goodwill”. “Intervening sometimes does happen, but not with the full backing of the law. It happens maybe with some political gravitas, or goodwill, or humanity, or a sense of co-operation.”

Political analyst Ralph Mathekga said Motsoaledi is right, the law gives him very little power in provinces, he told Bhekisisa. Until now, he said, the ANC has had an implicit “gentleman’s agreement” between its officials in Pretoria and those in the provinces to keep the peace. An agreement, he warned, that could be on the wane.

At a Tuesday press conference, Motsoaledi denied the health system had “collapsed” but admitted that it was “going through hard times” with overcrowding and treatment backlogs at hospitals on the increase. “Our health system is still able to look after the largest number of HIV-positive people globally,” Motsoaledi argued.

But the minister's utterances at the conference seem to not only have provoked Cosatu but also the Economic Freedom Fighters (EFF), which has now accused him of “denialism”. The party has also questioned why he hasn’t been able to amend legislation to take back more power from the provinces — a change he has, in part, proposed under the National Health Insurance (NHI). The government must amend at least 12 pieces of legislation to allow for changes like this under the NHI.

“For some time now, he keeps blaming provincial powers and jurisdiction for failure of his intervention to fix the public healthcare. If Motsoaledi thinks centralising power is a solution, by now, he should have already proposed the necessary legislative changes. To this day, he has not, because, in reality, he is not genuine and not committed to the upliftment of the system,” said the party in a statement.

But until the national health department has more say in how provincial health departments function, Motsoaledi says he’s largely powerless to prevent provincial health crises. He sat down with Bhekisisa editor Mia Malan recently to explain.

1. Are your hands tied when it comes to provincial emergencies?

Whenever there is a crisis, like with Life Esidimeni or the oncology crisis in KwaZulu-Natal, I am called in to solve them. But I don’t have the legal mechanism to prevent these crises from happening, because Health MEC’s don’t report to me; they report to their respective Premiers.

Interventions sometimes do happen, but it happens without the full backing of the law. It happens maybe with some political gravitas, or goodwill, or humanity, or a sense of cooperation.

You can’t run a country by hoping.

2. Why is corruption so rife in procurement?

In the health department, you have to buy everything: medicine, linen, food, cleaning services, laundry services. In every corner you look, there is something that needs to be bought.

I think that’s what causes our problems. I won’t shy away from it.

Procurement is a bone of contention, especially in the North West. I [the national health minister] only come in as a sort of a post-mortem. Under no circumstances would I have agreed on a procurement like [the R190-million illegal tender to the Gupta-linked] Mediosa to take place. But I am forced to come in when it is already too late.

3. How do politics affect service delivery?

As a minister, you have no say in who gets hired and at what level. Human resources is a purely provincial function, which is exercised by the Premier – not even by the MEC.

The health minister is an executing authority only for those people who are hired at a national level. But for all the others who are working in hospitals, that's where delivery is, executing authority is the MEC.

For example in the North West, I pleaded with the Premier not to appoint the current head of health [Thabo Lekalakala]. But he insisted, and there was no law under which I could stop him. I knew Lekalakala couldn't run a directorate.

4. What’s the solution?

Our dreams of a National Health Insurance (NHI) will never happen if our provincial health systems aren’t working. In the NHI white paper, we are proposing that 12 acts need to be amended. We are targeting the issues of human resources, financial management and procurement specifically.

5. What else has to change for the NHI to work?

One of the reasons there is good quality in the private sector is because the person who buys services is not the same as the one who provides them.

In the public sector, the purchaser and the provider is one person, the MEC. The MEC is given a budget by the treasury to provide health services to citizens. The MEC must go and hire nurses, make sure there is equipment, and then go purchase the services for the citizens the same services he has provided.

Whether the services are good for the citizens or not, it doesn't matter – nothing pushes you.

Under the NHI, districts will be able to send their patients to where the best service is. That set-up will create more competition and credibility, and force people to jack up [their services].

TIMES SELECT
Charlotte Maxeke Johannesburg Academic Hospital is so desperate for radiation oncologists that CEO Gladys Bogoshi even asked journalists if they knew anyone who wanted to work for the government.

 At a media event yesterday, Bogoshi said two out of five posts for radiation oncologists were vacant at the state hospital but denied there was a crisis. She was responding to reports of long waiting lists for cancer radiation treatment, old machines that break down often, and a shortage of radiation oncology staff. She said the vacancies existed despite the hospital advertising for the positions in international journals and on “social media”. The hospital has more than 3 130 cancer patients and only three full-time radiation oncologists. But Bogoshi said the shortage of specialists was “not a crisis as the three doctors was trying their best” by working until 8pm at night to see all the patients. She said: “Is it a crisis? No. Is it a concern? Yes.”

Her comments came as Health Minister Aaron Motsoaledi this week said the health system was “distressed”. In April it was reported that there was a long backlog of patients waiting for radiation. Campaigning for Cancer oncologist Devan Moodley said at the time that the likelihood of cancer returning was high if radiation treatment was administered too late. Bogoshi said the waiting list for prostate cancer treatment was 24 months, although more urgent cases are seen more quickly. The waiting period for radiation for breast cancer is between four to six months. A Johannesburg state patient will have to wait up to four months to receive radiation treatment for gynaecological cancers such as cervical cancer. But Bogoshi denied that this was a “backlog”, arguing that patients did get other treatments such as medication, surgery or chemotherapy - or, in case of prostate cancer, hormonal therapy.

EWN
Health Minister Aaron Motsoaledi has blamed the employment of “the wrong people” in leadership positions for many of the problems in the sector.

The minister gave a briefing in Pretoria on Tuesday afternoon on the state of the country’s healthcare system.

The minister's briefing comes just days after protesting staff at the Charlotte Maxeke Academic Hospital trashed parts of the facility in a dispute over unpaid bonuses.

He has acknowledged issues of staff and provincial leadership in the country's healthcare system.
In the North West, the provincial Health Department has been placed under administration after weeks of strikes and allegations of corruption.

Motsoaledi has also highlighted the poor treatment of patients by staff at some government facilities.
“We are also painfully aware of poor management skills in most of our provinces because of wrong employment practices like appointing people in the wrong places without them having skills. This has been a perennial problem which we’ve been trying to deal with.”

NEWS24
Minister of Health Dr Aaron Motsoaledi has dismissed claims that the public health sector is on the verge of collapse. He did, however, concede that the healthcare system is very distressed.

Motsoaledi was responding Health Ombudsman Malegapuru Makgoba's comment during an eNCA interview over the weekend that many Life Esidimenis were taking place across the country.

Speaking at a media briefing in Tshwane on Tuesday, Motsoaledi said the burden of disease in South Africa had led the demand of healthcare to grow exponentially, leaving the system "extremely overloaded".

"This has resulted in very long waiting times in most of the facilities and lowering of quality in others," he added.

He said the "explosion" of diabetes, blood pressure and cancer had added to the problem.

"The battle of disease is too high. We need to put measures in to reduce it."

Motsoaledi added that they were aware of poor management and negative staff attitudes in most government hospitals and that a plan had been put in place to manage these issues.

"We are painfully aware of poor or lack of management skills in most of our hospitals. We are also aware of the negative attitudes of some staff members in quite a number of our facilities."

"As from today, we are deploying 200 officials from the head office to all our provinces to go directly into hospitals and help with management."

He said those deployed would include managers, doctors and nurses.

The minister also said some shortages were caused by sectors, such as those in the North West, but by the end of the June, 223 vacancies will be filled at the cost of R150m, the minister said.

He said Gauteng also had issues with staff numbers and added that they could not afford to not fill vacant posts.

"We have the biggest problem of human resources, which we cannot deny. After all, sub-Saharan Africa carries 80% of all infectious diseases in the world but has only 3% of human resources. We are not exempted from that as South Africa."

"Huge numbers of people coming to healthcare facilities and low numbers of staff working at them. That is a crisis. But it's not a collapse."

Dismissing claims that the health system was on the verge of total collapse, Motsoaledi said they were still providing HIV treatment for 4.2 million people, were able to treat 300 000 TB patients, and were able to take care of more than one million pregnant women.

"In 2004, a total of 70 000 babies were born HIV positive. The figure has dropped to below 4 500 now."

Additionally, the TB mortality rate has fallen by 50%, from 69 251 deaths in 2009, to 33 063 in 2015, said Motsoaledi.

"We do not then think that a collapsing or collapsed system [would] be able to do these."

"Yes, we accept and are very worried about extreme overcrowding in our hospitals and we believe that it could have been much worse if we did not take proactive steps."

Motsoaledi also rubbished claims that public healthcare facilities had run out of medicine.

He said weekly monitoring of stock, found that ARVs, vaccines and TB medication in all provinces have not dropped below 75%.

In dealing with the radiation oncology backlogs in KwaZulu-Natal and Gauteng, the minister said a programme would be launched in August and that the two provinces will each receive R50m.

BUSINESS DAY LIVE
Only one in six members of Discovery Health Medical Scheme (DHMS) is using its scoring system to gauge the quality of private hospitals before they are admitted, it emerged on Thursday.

This suggests that few patients are questioning the decisions made by their referring doctors when they need procedures, despite the attention the Competition Commission’s Health Market Inquiry has drawn to the importance of quality measures in health.

During the inquiry’s public hearings in 2016 its panel members highlighted how little information was available to patients and medical schemes about the quality of services they were paying for, with panel member Cees van Gent saying it was akin to going to a market and buying vegetables without looking at them.

For several years, DHMS has been running an annual survey of its members’ views on the quality of the care they receive when they are admitted to hospital, as it says patient experiences correlate to the quality of clinical services provided by healthcare institutions.

It uses the data to compile an annual ranking of SA’s private hospitals, which it makes available to the general public, but members can also access more detailed quality scores for specific hospitals and units within them.

"We still have a situation where 85% of patients are simply going where they are told. They are referred by a GP or specialist, but [they do not] check to see if the hospital gives a good experience," said Discovery Health CEO Jonathan Broomberg.

Discovery Health is the administrator of DHMS.

But Discovery Health deputy CEO Ryan Noach said there were signs that younger members were more actively involved in decisions about their healthcare.

"Millennials and generation-Zs are doing more research and are more digitally active. They are also more fickle in their decision-making," he said.

DHMS launched an app-based option two year ago, which was dominated by younger members. The average age of principal members on this option was 29 years, compared to the scheme average of 45 years, he said.

AFRO VOICE
The KwaZulu-Natal department of health has said that they are pleased with the progress made in the three districts piloting the National Health Insurance NHI scheme. This follows a visit to the Zululand district by health MEC Dr Sibongiseni Dhlomo and head of department Dr Musa Gumede. The visit was the second leg the department's roadshow on the NHI. The first roadshow was at Uthukela district, followed by the Zululand district.

The NHI is presently being piloted at the Amajuba, UMzinyathi and Umgungundlovu districts. Dhlomo said the purpose of the visit on the day was to give feedback to communities on NHI progress, as well as outlining the government plans to help reduce the burden of diseases in KZN and also further improve access to quality healthcare, especially for the poor. "Our purpose for this visit is thus to actually update and give a report back to our citizens, various stakeholders, leaders in various communities, amakhosi, izinduna chiefs, headmen on the progress already made as well as to table future plans and endeavours.

"I think this issue is actual fundamental revolutionary in terms of the health services in the world, and we are following many other countries who have adopted this programme. We consider it important to really keep people up to date in terms of these processes."

While giving feedback on impact of the NHI in the province Dhlomo said UMzinyathi district with its 20 GPs attended to 13 819 clients between April and December 2017.

While UMgungundlovu district, which has 31 GPs, attended to 45 984 patients and Amajuba district followed suit with 12 contracted GPs attending to 16 908 clients. The departments said they have noted that many people are already beginning to have access to better healthcare service in KwaZulu-Natal since the province started piloting the National Health Insurance in 2012. This despite people people's economic backgrounds as many had been pushed into extreme poverty because they have to pay for healthcare.

Dhlomo said although there's still much work to be done in terms of health managers and staff at hospitals and clinics are better trained and equipped, and facilities at the three pilot sites. Presently district clinical specialists teams of which 46 are already on the ground across the province. This also includes 192 school health teams; 124 wardbased outreach teams as well as contracted general practitioners and pharmacy assistants who for the first time visited the clinics.

VISION MAGAZINE
On Thursday, 24 May, Cabinet approved the Medical Schemes Amendment Bill for publication in the government gazette.

Communications Minister Nomvula Mokonyane told the media that the Bill aimed to align the National Health Insurance (NHI) White Paper and the draft NHI Fund Bill. It includes new rules on benefits, prices and governance. Crucially, the amendments will enforce uniform tariffs for services and prohibit co-payments.  

The State Liability Amendment Bill, providing for the settlement structure of claims against the state that results from the wrongful medical treatment of persons by servants of the state, was also approved.

Bronwyn Nortje commented in Business Day – 24 May 2018:  “The announcement by Health Minister Aaron Motsoaledi that a major shakeup of the medical scheme industry is on the cards raises more questions than answers.

“I can’t help but wonder why there was such a rush to announce these changes before the publication of the Competition Commission’s Health Market Inquiry provisional report at the end of May,” wrote Nortje.

“Surely after so many years and so much effort from everyone in the industry, he could at least have pretended to evaluate and interrogate the recommendations before proposing new legislation. After all, it was Motsoaledi who instigated the inquiry to investigate then rising cost of private healthcare in SA, specifically internal dynamics that may limit or restrict access to private healthcare.

“The Minister has undoubtedly had considerable pressure placed on him by the powers that be to lead the charge for a utopian dream of universal access to high-quality healthcare in the form of the NHI, but this just isn’t possible in the medium-term fiscal framework, or possibly, ever. If the Minister is serious about improving healthcare, in both the public and private sectors, he should be looking at health outcomes and not how many are serviced.

“Inefficiency and over-servicing might be the root of the problem and not medical costs. If this is the case, what is needed is an outcomes-based reimbursement structure that pays providers based on the quality of their outcomes. If doctors were evaluated more on clinical outcomes, they would be more inclined to think carefully before running expensive diagnostics.

“Until a start has been made to evaluate the public and private healthcare sectors on their outcomes rather than their inputs, a solution will not be found.”

Funding issue still the biggest stumbling block

The successful implementation of the National Health Insurance (NHI) programme hinges on its funding model, according to a legal expert Ian Jacobsberg, partner at law firm Hogan Lovells. (Fin24, 22 May 2018)

Even the Minister himself acknowledges there is a disparity between available funds and the funds necessary to achieve objectives and to get NHI fully operational, Jacobsberg said.

Currently, government subsidises employees’ medical aid through state-owned medical schemes, as a private sector employer would for its employees.

Jacobsberg said that is probably the starting point before they look at private sector medical aids.

The implementation will certainly depend on the usual problems – political will, financial resources and the correct use of financial resources and the priorities in the national budget.

Last year the Davis Tax Committee warned in a report that even though government expects NHI to cost R256-bn, this figure is set at 2010 prices. By 2025, there could be a funding shortfall of R72-bn, assumed at an average growth rate of 3.5%.

BUSINESS DAY LIVE
The outcomes of the market inquiries into private healthcare, grocery retail and the cost of communication will be ready in 2018, says Economic Development Minister Ebrahim Patel.

Reports flowing from the three inquiries would be tabled in Parliament.

Market inquiry hearings will be held on the public passenger transport sector, Patel said in Parliament while delivering his department’s budget vote speech on Thursday.

The Competition Commission has been conducting the market inquiries to determine if collusion and concentration were stifling competition.

"I expect to receive and table in Parliament this year the outcome of three ... significant market inquiries into private healthcare, grocery retail [which includes shopping malls and spaza shops] and communication data costs.

"Market inquiry hearings will be held on public passenger transport and cost of communication data," the minister said.

In December, the department gazetted a draft Competition Amendment Bill for comment.

The bill proposes mechanisms to address high levels of concentration, which excludes small business and black South Africans from the mainstream economy, said Patel.

It also gives competition authorities powers to impose remedies to address problems in the structure of the economy and to promote inclusion.

The bill also deals with practices such as price discrimination, said Patel.

Major reform

"This is a major reform of our 20-year-old Competition Act. We received more than 60 submissions on the proposed changes…. We have also engaged Nedlac [National Economic Development and Labour Council] parties — business and labour — over the past few months. We will, during this year, finalise a revised bill through Cabinet for submission to Parliament for consideration."

Patel said the department’s budget of about R1.1bn would be distributed as follows: "Just over R280m for the Competition Commission to do its work to open up the economy for all; R240m raised from the construction industry, for the new Tirisano Fund, to finance transformation, including support for black artisans and engineers, small builders ...

"[A total of] R229m for the small enterprise finance agency to make loans available to small and micro enterprises.

"[A total of] R140m to unblock investment; R102m for the International Trade Administration Commission; R35m for the Competition Tribunal; R30m for a Steel Competitiveness Fund to rejuvenate the steel industry; and R15m ... to monitor the spending and construction in the state’s infrastructure plan."

Patel also voiced optimism about the country’s economic prospects in light of the so-called new dawn ushered in by Cyril Ramaphosa’s rise.

Michael Cardo, DA MP and spokesman on economic development, said with the country’s growth forecast at just 1.5% for 2018, more than 9-million South Africans unemployed and declining business confidence levels, "this new dawn looks set to be a false dawn".

"Zuma’s legacy — state plunder, mismanagement of public finances and economic decline — still casts a gloomy shadow over the country.

"And it will continue to do so until the sun sets on an ANC government, and we see the dawning of total change under the DA," said Cardo.

FIN24.COM
Of the Economic Development Department’s R1.1bn budget this year, R282m will be allocated to the under-resourced Competition Commission, Minister of Economic Development Ebrahim Patel said on Thursday.

Patel was tabling the budget vote in Parliament, and also spoke about the progress made by the department.

This includes the Competition Commission’s role in probing abuse of dominance in sectors including pharmaceuticals, ports, railways and school uniforms.

Patel said R282m would be allocated to the commission so that it can continue doing its work to “open the economy for all”.

Competition authorities are expected to investigate 100 cases of cartels, consider 400 projected mergers and take on two additional cases of abuse of market dominance.

“I expect to receive and table in Parliament this year, the outcome of three very significant market inquiries into private healthcare, grocery retail - which includes shopping malls and spaza shops - and communication data costs,” said Patel.

In April Competition Commissioner Tembinkosi Bonakele told Parliament’s portfolio committee on economic development that the commission would have to scale back on cartel investigations due to its strained financial resources.

Affected cartel investigations into sectors included automotive component manufacturers, set top box service providers, manufacturers of edible fats and oils, as well as fresh produce and beef producers.

Elsie Coleman, chairperson of the portfolio committee on economic development, spoke during the debate following Patel’s address and emphasised that the Competition Commission must be supported in its role to ensure an environment for small businesses in South Africa to compete.

Coleman noted that the commission is facing resource challenges, and said the market inquiries it conducts are useful to unearth unethical and uncompetitive behaviour. She called for the minister to work with National Treasury to improve allocations over the medium term.

During his address, Patel spoke on the significance of the draft Competition Amendment Bill which was gazetted for public comment in December last year. He described it as a major reform to the 20-year-old Competition Act. More than 60 submissions for proposed changes were submitted.

The bill is intended to address high levels of economic concentration that excludes small businesses and black South Africans from the mainstream economy, Patel said.

“It gives the competition authorities powers to impose remedies to address problems in the structure of the economy and to promote economic inclusion.”

The bill also deals with practices by dominant firms which lead to excessive pricing, price discrimination against smaller players and “other abusive and anti-competitive practices”, he said.

The bill is expected to be finalised this year.

BIZCOMMUNITY
When implemented, the Protection of Personal Information (POPI) Act will fundamentally change the way personal data is managed. Corporate South Africa, including medical aid schemes, insurance brokers, financial advisors, marketers and even brands need to start preparing now for its impact.

"A patient’s medical information and history are particularly sensitive," says Gerhard van Emmenis, principal officer of Bonitas Medical Fund. "Which means the entire service chain, from medical practitioners to pharmacists, administrators and scheme, involved in receiving and storing this information will be required to meet the stringent POPI requirements."

Essentially POPI, based on European legislation, outlines eight general conditions and three specific conditions, which will ensure businesses and organisations take responsibility for the way they share personal information, how that data is used and stored and who has access to it. Many countries have similar legislation in place to protect information and this also governs the transfer and sharing of data internationally.

Why the introduction of POPI?

We live in an information-driven world with easy access to data and personal information via the internet, emails, Facebook, Instagram, LinkedIn and more, as well as traditional faxes and written correspondence. With an increase in cyber threats and information being leaked and shared, POPI is making sure businesses – and even individuals - are more careful with personal information and to take responsibility for this data.

The message to the public is that the new Act should be taken very seriously. "Unlawful retention, distribution, sharing or unauthorised use of personal information may result in non-compliance with the Act, which will carry onerous penalties of up to R10m in fines, and could even result in jail sentences (in some instances of up to 10 years), depending on the seriousness of the breach or non-compliance."

According to Van Emmenis, compliance with POPI is of the utmost importance for all medical funds. "This applies to both members, their brokers and those in the medical fraternity," he says. "We are ready for its implementation and have taken great care to ensure data protection is a key priority."

Storing patient information

According to the Health Professions Council of South Africa (HPCSA) recommendations, the most important factor is for stringent precautions to be taken to safeguard patient information. For this reason, when the Council for Medical Schemes (CMS) requested information for the Central Beneficiary Register last year the majority of medical schemes did not comply, mainly due to concerns of how the information will be stored and used.

The concern is that although the rationale behind the Department of Health wanting a Beneficiary Registry in terms of negating fraud and recovering payment for treatment at state facilities, there is still uncertainty around how this information will be stored and used.

The CMS has since clarified that no actual medical data is required and that an Industry Technical Advisory Group task team has been established, with representatives from medical schemes and administrators, to deal with security issues and POPI compliance. Medical aids continue to engage with the CMS to find a workable solution regarding their directive for member information.

Holistic approach to healthcare

"In order to take a holistic approach to medical aid members’ care and preventing duplication of medical tests, we embarked on a campaign in 2016 to obtain members consent to share their personal data with specific healthcare providers," explains Van Emmenis. "When all co-morbidities are taken into account it ensures that healthcare providers work together in the patient’s best interest."

Member data and healthcare providers

All healthcare providers who interact with patients are generally permitted to have access to their information to a certain extent. However, to conform to POPI regulations, medical schemes need to ensure claims, medical conditions and treatment are only shared if the member chooses for it to be.

Regarding the implementation of POPI, Van Emmenis says, "we have processes in place to securely store the data we have and are ready for the implementation of POPI and will conform 100% with the final conditions outlined in the Act. Protecting the personal and medical records of our members is a key priority."