THE CITIZEN
If a service is provided by a company rather than government, this does not automatically mean a market is at work. The point is obvious but has passed by many in South Africa.

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

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

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

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

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

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

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

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

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

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

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

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

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

This hides the reality that, in current circumstances, the challenge is not to protect private providers but to ensure they really are subjected to the rules by which markets are meant to force them to play.

Today, the DA conducted an oversight inspection at the Elim District Hospital in Limpopo. The health facility was administered under the failed National Health Insurance (NHI) pilot project in the Vhembe District.

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

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

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

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

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

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

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

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

Issued by Lindy Wilson, DA Shadow Deputy Minister of Health, 26 July 2018

THE CONVERSATION
If a service is provided by a company rather than government, this does not automatically mean a market is at work. The point is fairly obvious but has passed many in South Africa by.

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

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

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

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

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


No real choice

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

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

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

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

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

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

Pro-market moves

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

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

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

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

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

Making markets work

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

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

This article was originally published on The Conversation.

SOLIDARITY
Die vakbond Solidariteit het vandag sy kommer uitgespreek oor die geweldige negatiewe impak wat die voorgestelde Nasionale Gesondheidsversekering (NGV) op belastingbetalers sal hê.

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

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

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

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

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

FINANCIAL MAIL
Investors would do well to take note of the Health Market Inquiry’s provisional report on why medical aid prices keep rising while benefits decrease. The Competition Commission report may not bode well for the consumer but it notes that profits of the large hospital groups - Netcare, Mediclinic and Life Healthcare - are “consistent” and “sustained”, with no chance of slowing down. Even better were the profits of administrator Discovery Health, “multiple” times those of competitors “with no sign of effective challenge from incumbent or new firms”.

The numbers illustrating Discovery Health’s dominance were erased from the report and instead pictures of a pair of scissors were drawn in their place. This is no doubt due to Discovery Health’s concerns about confidentiality of its data, said by inquiry director Clint Oellermann to be a reason for the delay in the provisional report’s release. The report, released after nine months of delays, highlights that there could be a substantial conflict of interest between two of the three largest administrators, which are supposed to negotiate good value for medical aid members and drive down hospital costs. Administrators are companies that are paid by medical aid companies to manage claims, payment to doctors and hospitals, deal with fraud and recruit new members.

Shared ownership

The commission notes that both administrators in question, MMI and Discovery Health, which should be competing to provide cheaper benefits to medical schemes, have shared ownership. The commission implies that having competitors owned by the same company benefits investors and could lead to price fixing. But analysts have downplayed the conflict of interest, saying the commission did not prove any collusion. In a research note, the inquiry explains why cross-ownership of competing companies matters, saying that if a firm has participation in a competitor, even without controlling it, the scope for collusion will be enhanced.

Falcon & Hume competition lawyer Heather Irvine says there is a reasonable amount of economic theory which indicates that cross-ownership (common shareholders) may have anti-competitive effects in certain circumstances. However, she says, this risk arises only when the companies in which the common shareholder holds shares are competitors (because then it may lead to information exchange between competitors, which in turn leads to price-fixing or other collusive conduct). Both MMI and Discovery have large shareholders that are themselves owned by investment group Remgro. It gets complicated. Remgro has a 28 percent shareholding in RMB Holdings, which through Firstrand has an unknown stake in MMI. Remgro also has a stake in Rand Merchant Investment Holdings, which has a 25.8 percent stake in Discovery and a 25 percent stake in administrator MMI. It gets worse. Remgro, with 42 percent, is also the largest shareholder of hospital group Mediclinic. This raises the question: Do Discovery Health or MMI have an interest in driving down hospital prices for medical aid members or keeping profits high for their shared owners of Mediclinic? Do the two administrators compete in adding shared value to medical aids for which they pay claims; or choose not to compete as they share shareholders? The inquiry poses these questions but doesn’t answer them. It does, however, describe the links between owners of MMI, Discovery and hospital group Mediclinic as substantial, saying that a substantial commercial relationship therefore exists between the largest and most influential owners of Discovery Limited, the owners of MMI and one major hospital group, Mediclinic.

Not convinced

But whether the ownership of Mediclinic makes Discovery Health less likely to bargain for good prices for hospital stays is never proven. Irvine is not convinced. She says that this concern about cross-shareholding would not arise in relation to, for example, a medical scheme and a hospital group, which are not competitors in the same level of the market. Irvine says the commission loves to focus on cross-ownership, but the small number of institutional shareholders in SA means many companies share owners. She says the Competition Commission is obsessed with cross-ownership and likes to draw diagrams showing that there are lots of common interests held by shareholders throughout the SA economy. That is of course true - large institutional shareholders like the banks and the PIC all hold some shares in almost every listed company. However, this doesn’t necessarily lead to a lack of competition. The commission gives no evidence that administrators are allowing Mediclinic to charge more than other hospital groups. It finds that out of all the administrators, Discovery Health was the only one with enough clout to drive down hospital prices, including those of Mediclinic.

No evidence of collusion

In a statement, Discovery Health CEO Jonathan Broomberg noted that the Health Market Inquiry made “the observation that Discovery Health is the only administrator that has been able to use countervailing negotiating power to achieve lower hospital tariffs for its client schemes”. Investment analyst Warwick Barn says the commission failed to show that Mediclinic is paid more by Discovery (due to shared owners) than Life Healthcare and Netcare. He says cross-ownership “would only be a problem for consumers if there is evidence of collusion or anti-competitive behaviour due to the cross-ownerships and cross-directorship between Remgro [with shares in Discovery and MMI and Mediclinic. Barn says it should have been evident to the Health Market Inquiry whether Mediclinic’s rates or utilisation data differed from those negotiated with Netcare and Life Hospitals, implying bias from the group structure. In other words, no evidence is revealed that proves Mediclinic gets more business or is paid more by Discovery Health than competitor hospital groups. The Health Market Inquiry report merely suggests there could be a “chilling effect” on competition. It says that though
MMI and Discovery Health have provided some examples of competition between them, the HMI panel believes that common ownership between two of the largest administrators and of the large hospital groups might influence strategic direction and can have a chilling effect on competition over the long term. Despite failing to provide evidence of collusive conduct, the commission is adamant that consumers may be getting a raw deal at the expense of firms that look out for each other. It says administrators are not driving hard enough bargains on prices.

In perpetuity

The report says stakeholder-led negotiations have not yielded outcomes with a positive impact on expenditure and there remains a possibility that sector participants may continue to settle for mutually beneficial pricing levels at the expense of the consumer. The examination of Discovery Health by the inquiry does not end there. The report is concerned that no matter how it performs in driving bargains for its medical aid Discovery Health Medical Scheme (DHMS), it is guaranteed business from the scheme in perpetuity. This is contrary to what the law suggests. Discovery Health, unbeknown to most consumers, is an administrator that gets paid about 10 percent of medical aid premiums to pay the claims of DHMS. It negotiates prices with hospitals and doctors and exposes medical aid fraud. If it is too expensive it could be fired by DHMS and a new administrator hired in its place. But this is unlikely to happen, giving Discovery less incentive to compete for business or drop its fees. The report says it is unlikely DHMS will ever get a new administrator and in the same way Bonitas will keep Medscheme as its administrator.



“Scam”

Trustees don’t have the skill to fire their medical aid administrators, it suggests. Speaking after the release of the report, panel member Ntuthuko Bhengu called the idea as described in the law - that medical aids are run as not-for-profit entities a “scam”. The inquiry found what everyone in the industry knows: those medical aids are run by for-profit administrators. One of the report’s major recommendations is that medical aid members get involved in voting for trustees, who are supposed to run the scheme, rather than let the administrator do this. It suggests trustee elections take place after hours, or on weekends when ordinary members can attend. It also wants a change in trustee pay so that the millions they earn are linked to their independence and the work they do in holding the administrator to account - and serving members’ interests. GTC healthcare consultant Jill Larkin added her support to the demand that trustees do more to keep administrators on their toes.

Long-term investments

Discovery Health says the long-term relationship with the scheme allows it to make long-term investments in technology, infrastructure and human resources. The report says the dominance and stability of the administrators hasn’t benefited the consumer through “economies of scale”. Discovery Health says its fees have been reduced in real terms each year. In the end, many of the report’s recommendations are largely focused on government. It states that the Medical Schemes Bill, 2008, which sought to strengthen scheme governance, has not yet been implemented. Much of what government can do is already allowed for in the National Health Act and Medical Schemes Act. Former chief justice and panel director, Sandile Ngcobo, said that what remains to be done is to implement these provisions. But at the launch of the report, Health Minister Aaron Motsoaledi blamed medical aids, hospitals and doctors, saying that stakeholders “don’t like to be regulated”. Back to top

MEDICLINIC DISAGREES WITH INQUIRY OVER COMPETITION
25 July 2108
Business Day
Page 4
Tamar Kahn

Mediclinic disagrees with inquiry over competition Tamar Kahn Private hospital group Mediclinic has taken issue with the health market inquiry's concerns about market concentration in the sector and its call for submissions on possible divestiture and a moratorium on issuing new licences.

Mediclinic does not agree with these findings ... and does not believe the proposed remedies are appropriate: it said in a statement issued on Monday. The inquiry was launched by the Competition Commission four and a half years ago to investigate the barriers to effective competition in the private healthcare market It released its preliminary report on July 5.

Mediclinic said it believed there was robust competition between the four big players: the National Hospital Network and the three JSE listed hospital groups Netcare, Life Healthcare and Mediclinic. "Hospital groups are able to leverage on economies of scale, enabling the provision of high quality, cost efficient care to the benefit of the patient," it said.

Mediclinic agreed with the inquiry's finding that healthcare expenditure was rising faster than consumer price inflation due to an increase in utilisation, but disputed its view that supplier induced demand played a significant role in driving this trend. "Mediclinic's economic and actuarial experts do not support the accuracy of the calculations and data under pinning these findings: it said. Increased utilisation was due to other factors, such as the increasing burden of disease, an ageing population and new technology, it said.

Supplier induced demand refers to a phenomenon in which increased access prompts additional use of a service that would not have otherwise occurred. In the case of hospitals, this could mean increased bed numbers trigger a surge in hospital admissions. Mediclinic said it supported the inquiry's recommendation that bilateral tariff negotiations be maintained between medical schemes and hospital groups. In a separate development, the health market inquiry said on Tuesday that it had received numerous requests for access to the underlying data considered in preparing its report and it would open its data access room to stakeholders during August.

BIZCOMMUNITY
Bonitas Medical Fund (the Scheme) reported a solid surplus of R730.20 million for 2017, recouping the R16.9 million deficit from 2016. Gerhard van Emmenis, Principal Officer of Bonitas, says, "2017 was an exceptional year for us in terms of financial results. This was largely due to several key cost-saving strategies and initiatives implemented during the 2016-2017 period."

This bolstered Bonitas reserves from R3.2 billion to R4 billion. "This surplus will be invested back into the Scheme and will allow us to offer our members access to healthcare of the highest quality."

Van Emmenis says, "Medical schemes need to be proactive in curtailing costs. Even though healthcare inflation continues to outpace general inflation by about 5% (12.5% in 2017), we cannot simply say, ‘It’s not our fault or our problem.’ We need to constantly be looking for different methods to contain costs and offer our members maximum value for money."

Quick overview:

"Although we took a multi-pronged approach to cost-saving, our main focus was on:

• Hospital negotiations, which delivered savings of R242 million.
• Fraud, waste and abuse (FWA) initiatives were also a significant focus and delivered recoveries of R31.2 million, with a potential preventative savings of R75 million.
• Other cost-savings initiatives of R59 million (examples of this included the benefit adjustments).
• A return on investments of 8.9% also contributed to the healthy fiscal outlook for Bonitas Medical Fund.

"The net healthcare results of R345.9 million and investment income of R394.3 million, underpin the Scheme’s ability to implement strategies in order to remain resilient during difficult financial periods. This, not only to help limit contribution increases, but also deliver on our mandate of making healthcare affordable for all South Africans."


Reserves increase

"From 3.2 billion in 2016, this has increased to R4 billion for 2017, which places us in a stronger, more robust financial position where we are confident of our ability to meet member claims."

Public healthcare in South Africa continues to operate far below optimum levels

"The current public health systems’ ability to provide the foundation for an NHI in the near future is questionable. The reasons include lack of economic growth, increasing unemployment, a large gap between rich and poor and a stark contrast between first- and third-world elements. It therefore stands to reason that the public healthcare system cannot carry any more of the burden. While public health gets its house in order, it is essential that private medical aids keep private healthcare costs as low as possible to make it affordable for as many people in South Africa as possible."

Hospital negotiations

During the 2016 financial year, the Scheme experienced an increase in the utilisation of healthcare services, particularly hospital admissions and related benefits. "We embarked on a hospital negotiations strategy at the end of 2016, which resulted in a savings of R242 million in 2017, without compromising members’ access to quality healthcare.

"We will continue to negotiate robustly with healthcare providers based on our size, to contain costs as far as possible, and negotiate the best possible rates for members," says Van Emmenis.

Fraud, waste and abuse (FWA)

It is estimated that 15% of claims in the healthcare industry contain an element of FWA. For a scheme of Bonitas’ size, this translates to a loss of R190 million. "To address this, we implemented initiatives against FWA including hospital and pharmacy claim analytics. The result was the identification of FWA of R129 million, with R31.2 million recovered in 2017."

The Scheme further benefitted from R75 million in potential savings. Five imprisonment sentences have been handed down by the judiciary – clearly indicating a zero tolerance approach to this white-collar crime.

Preventative care initiatives

There is an increased prevalence of lifestyle diseases such as diabetes, hypertension and cardiovascular disease as well as HIV/AIDS, cancer, chronic medicine management, back and neck pain, hip and knee replacements and mental illness. The old adage that "prevention is better than cure" cannot be more apt than in the healthcare industry.

For this reason Bonitas has a number of programmes aimed at predicting and preventing conditions before they become chronic and managing them in the most clinically appropriate way.

The Scheme bolstered its Managed Care initiatives in 2017, with the introduction of the Diabetes Management Programme.

The success of the diabetes programme is underpinned by the Scheme’s ability to identify potential diabetic patients and enrol them on the programme as well as actively manage them through support, testing and education. The Scheme and its partners have worked tirelessly to improve actively managed diabetes patients by 31% between May and December 2017.

The way forward

"In 2018, we will carry out a secondary initiative to identify hospitals on our networks that are not cost-effective and work towards improving their efficiency," says Van Emmenis. "We have introduced a Managed Care programme focussed on mental health and will explore other options to introduce alternative reimbursement models for procedures such as knee and hip surgery.

"During the year ahead we will seek to identify other opportunities to grow Bonitas and retain our existing membership base. This will include the possibility of amalgamations as well as developing new distribution models and channels.

"Connecting with our customers remains a key focus area as we seek to improve our digital capabilities to improve our members’ experience and communicate effectively to keep them informed and engaged. We will use the best technology available to make things simpler and more efficient.

"Attracting younger and healthier members is vital to ensuring the sustainability of the Scheme. To assist in this regard, we introduced BonFit in 2016 as well as several benefits to appeal to younger individuals and families in 2017.

"As rising healthcare costs continue to be a prohibitive factor in making quality healthcare affordable, we will continue finding innovative and sustainable ways of reducing expenditure," concluded Van Emmenis.

Top-line points of interest:
• A solid surplus of R730.20 million for 2017, recouping the R16.9 million deficit from 2016.
• 8.6% increase in claims in 2016.
• Net healthcare results of R345.9 million and investment income of R394.3 million.
• Robust reserves of R4 billion.
• 44.9% of all claims were for hospital admissions and 11.7% for specialists – these were the two highest cost-drivers.
• Savings from fraud, waste and abuse (FWA) amounted to R31.2 with a potential savings of R75 million.
• A savings of R242 million for 2017 from strategic negotiating strategy.
• 348,0088 principal members and 753,514 beneficiaries.

MONEY MARKETING
The GTC 2018 Medical Aid Survey (MAS) analyses and rates medical aid schemes according to a standardised comparison and ranks the choices available to members.

When analysed purely in terms of premiums – the survey’s micro ranking – Fedhealth emerged as the medical aid which held the most top positions across all the classifications. Discovery was ranked in first place for the survey’s macro rankings, which analyses a medical aid’s overall ‘health’ and longevity in terms of factors such as its solvency level, membership growth, net healthcare result and member satisfaction. When combining both the GTC micro and macro rankings, Discovery claimed the highest number of top positions among all categories – for the second consecutive year since the survey’s release eight years ago.
“While the overall results appear to tell a similar story to last year, it is encouraging – when drilling down into the details – to see such a variety of participants offering options across all sub-sections of the medical aid spectrum,” says Jill Larkan, Head: Healthcare Consulting, of wealth and financial advisory firm GTC.

“This means consumers can confidently access more schemes and plans offering private healthcare, and so decrease the burden on the government. In the past, the larger and more established companies tended to dominate the majority of the categories.”
Larkan ascribes this to companies becoming more innovative in their offerings in an attempt to differentiate themselves.
“We always welcome more competition among schemes, as it indicates a growing market and more variety for members with changing healthcare needs. However, this does add more complexity to a healthcare arena that is already difficult to navigate for the majority of members.
According to Larkan, this year’s survey proved again that the medical aid market continues to be a complicated space to navigate.
“What is worrisome is that many of the plans attempt to attract members concerned with the high cost of healthcare, by offering ‘manageable premiums’, perceived to be of good value, which in fact have far fewer benefits than their more ‘traditional’ counterparts. It is now more important than ever for members not only to look at price – which remains the most important consideration for many members under ever increasing financial strain – whilst also considering which benefits they are forfeiting for their lower premium,” she adds.
This year’s survey includes a comparison of average annual salary increases over ten years – according to The South African Trends Report 2017 by remuneration consultancy, 21st Century – against average annual medical aid premium increases since 2006.

“Over this period, medical aid premiums increased by 104.87% cumulatively, while salaries increased by 80.20%, which clearly demonstrates the pressure that consumers have been under in trying to keep up with healthcare costs,” says Larkan.
The MAS analyses plans based on a number of classifications, namely entry level, hospital, saver and comprehensive plans. Some of the entry level plans are salary-based and only cover prescribed minimum benefits (PMBs) whilst others restrict hospitalisation to state facilities.
“These entry level plans are a good option for members who are new to the private healthcare market and are happy to have a combination of a primary healthcare and hospital plan. Those members who expect slightly more comprehensive coverage but limit themselves to the cheaper plans, as a means to minimising cost, will be disappointed when they find out that they are not covered for a number of procedures they might have expected. In healthcare, the mantra ‘you get what you pay for’ could not be more apt.”
The Council for Medical Schemes (CMS) reported to Parliament earlier this year that complaints from medical aid members increased by 29% from 1 017 to 4 536 during 2017-18, compared to the previous year. This was largely attributed to a lack of understanding of the cover provided by their medical aids.
“This is in line with our experience: one of the biggest reasons for members’ unhappiness about a selected scheme does not know what their plan pays for. As there is no standardisation in the medical aid industry, it is very complicated for members to analyse medical aids, without the help of experienced professionals,” she says.
This year’s survey reviewed 21 open schemes and one closed scheme (Profmed) covering 22 plans divided into five categories, eight subcategories and three micro categories. Many of these were further split between network and non-network schemes, whilst some of them go on to reflect day-to-day spending levels. The full range of plans have been graded according to GTC’s ‘likelihood of support’ and offers a simplified method of comparing options and cost for members.
Larkan explains that, in addition to factoring in complaints received from members on social media sites such as Hellopeter.com– as an indication of members’ satisfaction with their medical aids – this year’s macro grading also took into account the compliments that schemes received, as well as the Hello Peter Index.
Bonitas moved up seven places in the macro rankings as a result of Liberty’s members being amalgamated into the Bonitas scheme. “This greatly enhanced the number of members on the scheme, which carries the highest weighting in the GTC macro rankings. The long-term effect of this amalgamation on measures such as net healthcare results will remain to be seen in the next year, when the claiming patterns of the new members are experienced in the Bonitas scheme.”
Larkan is also encouraged by the number of schemes that are giving due consideration to maternity benefits. “There are generally good benefits for young families, which means they can cover many items – including ante natal classes, maternity scans and consultations – out of the general risk carried by the scheme, without having to dip into their savings accounts.”
Larkan says: “Given the complexity of the medical aid industry and the varying needs of members, it is more important than ever for members, with the help of their healthcare adviser, to do a thorough analysis of their needs and means; and compare this to the options available in the healthcare market, before deciding on a scheme and then a plan option for their future.”

MEDICAL BRIEF
Private hospital group Mediclinic has taken issue with the Health Market Inquiry’s preliminary concern about market concentration in the sector, and its call for submissions on possible divestiture and a moratorium on issuing new licences, reports Business Day. “Mediclinic does not agree with these findings and will be engaging further with the health market inquiry on this topic. Mediclinic does not believe the proposed remedies are appropriate,” it said.

The inquiry was launched by the Competition Commission four-and-a-half years ago to investigate the barriers to effective competition in the private healthcare market and released its preliminary findings on 5 July.

Mediclinic is quoted in the report as saying it believed there was robust competition between the four big players – the national hospital network and JSE-listed hospital groups Netcare, Life Healthcare and Mediclinic. “Hospital groups are able to leverage on economies of scale, enabling the provision of high-quality, cost-efficient care, to the benefit of the patient,” it said.

Mediclinic said that while it agreed with the inquiry’s finding that healthcare expenditure was rising faster than consumer price inflation due to an increase in utilisation, it disputed its view that supplier-induced demand played a significant role in driving this trend. “Mediclinic’s economic and actuarial experts do not support the accuracy of the calculations and data underpinning these findings,” it said. Increased utilisation was due to other factors, such as the increasing burden of disease, an ageing population, and new technology, it said.

The report says supplier-induced demand refers to a phenomenon in which increased access prompts additional use of a service that would not have otherwise occurred. In the case of hospitals, this could mean increased bed numbers trigger a surge in hospital admissions.

Mediclinic said it supported the inquiry’s recommendation that bilateral tariff negotiations be maintained between medical schemes and hospital groups. “The company maintains its position that these negotiations are robust and concurs with the inquiry that regulated price determination between these groups would preclude strategic purchasing and stifle much-needed innovation within the industry,” it said.

It also supported the proposal to establish a supply-side regulator, provided it was independent and functioned in a transparent manner. “This body could add value in clarifying the current uncertainty in the hospital licensing regime,” it said.

BUSINESS LIVE
Private hospital group Mediclinic has taken issue with the health market inquiry’s preliminary concern about market concentration in the sector, and its call for submissions on possible divestiture and a moratorium on issuing new licences.

"Mediclinic does not agree with these findings, and will be engaging further with the health market inquiry on this topic. Mediclinic does not believe the proposed remedies are appropriate," it said on Monday.

The inquiry was launched by the Competition Commission four-and-a-half years ago to investigate the barriers to effective competition in the private healthcare market, and released its preliminary findings on July 5.

Mediclinic said it believed there was robust competition between the four big players — the national hospital network and JSE-listed hospital groups Netcare, Life Healthcare and Mediclinic.

"Hospital groups are able to leverage on economies of scale, enabling the provision of high-quality, cost-efficient care, to the benefit of the patient," it said.

Mediclinic said that while it agreed with the inquiry’s finding that healthcare expenditure was rising faster than consumer price inflation due to an increase in utilisation, it disputed its view that supplier-induced demand played a significant role in driving this trend.

"Mediclinic’s economic and actuarial experts do not support the accuracy of the calculations and data underpinning these findings," it said.

Increased utilisation was due to other factors, such as the increasing burden of disease, an ageing population, and new technology, it said.

Supplier-induced demand refers to a phenomenon in which increased access prompts additional use of a service that would not have otherwise occurred. In the case of hospitals, this could mean increased bed numbers trigger a surge in hospital admissions.

Mediclinic said it supported the inquiry’s recommendation that bilateral tariff negotiations be maintained between medical schemes and hospital groups.

"The company maintains its position that these negotiations are robust and concurs with the inquiry that regulated price determination between these groups would preclude strategic purchasing and stifle much-needed innovation within the industry," it said.

It also supported the proposal to establish a supply-side regulator, provided it was independent and functioned in a transparent manner.

"This body could add value in clarifying the current uncertainty in the hospital licensing regime," it said.

FIN24.COM
Health Minister Dr Aaron Motsoaledi should withdraw the Medical Schemes Amendment Bill, until the Competition Commission finalises the Health Market Inquiry, according to Andre Jacobs, an executive at ASI Financial Services.

There are currently three key documents affecting the healthcare sector in South Africa, the National Health Insurance (NHI) Bill and the Medical Schemes Amendment Bill published for comment in June and the Health Market Inquiry preliminary report released on July 5.

The preliminary report of the four-year investigation into the private healthcare sector, by the Competition Commission found that the market “displays consistently rising medical scheme premiums accompanied by increasing out-of-pocket payments for the insured ... and a progressively decreasing range of services covered by medical scheme options."

Stakeholders in the private healthcare sector and the public have until September 7 to comment on the 800-page report and the Health Market Inquiry will then consider all representations and publish the final report by the end of November.

Jacobs said that the comment period for the Medical Schemes Amendment Bill ends on September 20 and this will prevent relevant sections from the Health Market Inquiry’s final report being included in the bill and could duplicate the process.

Mark Arnold, Principal Officer of Resolution Health Medical Scheme warned of the timing clash between the Health Market Inquiry and the amendments to the bill regulating medical schemes.

 “There is significant risk that the regulatory environment being created through the legislative amendment process currently underway could conflict with the lessons learned in the course of the HMI’s work, which will only be fully apparent on the release of its final report,” Arnold said in a statement on Friday.

The Medical Schemes Amendment Bill proposes an end to co-payments by the client and the medical aid for healthcare services, increased cross subsidisation of members across age groups and income levels as well as the barring of medical aid brokers.

Arnold questioned why the work of the Health Market Inquiry, which was the “most comprehensive assessment of the private healthcare sector ever undertaken in our country” was not being considered by the bill amending medical schemes.

The Health Market’s preliminary report found that despite SA consumers having 22 open medical schemes to choose from, just two dominate the market. Discovery Health has nearly 55% of the market, while Medscheme is a close second.

The inquiry also stated that there was a lack of players in the private hospital sector with just three groups- Netcare, Mediclinic and Life Healthcare — holding a combined market share of 83%, which disadvantaged patients.

Fin24 previously reported that financial services company GTC in its eighth annual Medical Aid Survey found that the subscriptions for members are outstripping salary increases.

FA NEWS
Timing of medical schemes legislative amendment risks putting the cart before the horse.

The release of the National Health Insurance Bill, the Medical Schemes Amendment Bill and the provisional findings of the Health Market Inquiry, all within the space of three weeks, has provided much food for thought about the future of South African healthcare.

“A considerable amount of time, resources and expertise have been invested in the Competition Commission’s Health Market Inquiry [HMI],” says Mark Arnold, Principal Officer of Resolution Health Medical Scheme.

“In the four-and-a-half years since the HMI began, it has had input from every relevant stakeholder. The inquiry represents the most comprehensive assessment of the private healthcare sector ever undertaken in our country.

“With the HMI’s final report due for release in November, however, there is a risk that the full benefit of these insights could be lost due to the timing of these inter-related developments, as the period for submissions on Medical Schemes Amendment Bill and the National Health Insurance Bill close in September.”

Arnold points out that there is significant risk that the regulatory environment being created through the legislative amendment process currently underway could conflict with the lessons learned in the course of the HMI’s work, which will only be fully apparent on the release of its final report.

“As it stands, the HMI findings might be considered when fine tuning the proposed amendments to medical schemes law. However, far greater value could be added if the final HMI findings and recommendations are embraced and incorporated as the foundation for the amendments in the creation of a fresh approach to healthcare for the country.

“Closing the submission period on the Medical Schemes Amendment Bill, which specifically deals with the private healthcare sector, before the HMI’s final report is available is analogous to putting the horse before the cart.

“Such an approach squanders the opportunity to strengthen legislation with the full benefit of wisdom garnered during the lengthy and expensive inquiry and the best chance we have of making informed decisions that will shape the future of healthcare in South Africa for all.”

Andre Jacobs, an executive at ASI Financial Services, adds: “The Minister of Health requested that the Competition Commission conduct the HMI, which, after several delays, published its preliminary report for public comment on 5 July 2018 and the public and stakeholders have until 7 September 2018 to make comment. The HMI Panel will then consider all the recommendations and comments and is expected to publish its final recommendations by 30 November 2018.

“Considering public comment on the Medical Schemes Amendment Bill (‘MSAB’) must be provided before 20 September 2018, this not only eliminates the opportunity to include the relevant HMI findings in the MSAB but also duplicates effort and threatens to fundamentally weaken public comment.

“In addition, the Constitution and the Promotion of Administrative Justice Act (PAJA) prescribe that this process needs to be fair and there is a concern that excluding the findings of the HMI may not be aligned to this.

“It is our view that it may be prudent for the Minister to consider withdrawing the Medical Schemes Amendment Bill until the findings and recommendations of the HMI are finalized,” Jacobs asserts.

“Market experts have been involved in, and unanimously commended the HMI’s work in reviewing the private healthcare market. Even if certain commentators dispute some of the specific conclusions and recommendations, overall appreciation of the inclusive and comprehensive process is widely accepted.

“Therefore, the attention of society and stakeholders should be to focus on the HMI report and the comment leading up to 7 September 2018. This will enable society to further participate in a meaningful debate on the industry as access to healthcare is of national importance,” Jacobs adds.

“Acknowledging that there is significant political pressure for legislative certainty that will pave the way for the full implementation of the National Health Insurance (NHI), Arnold notes that a better integrated process would be more likely to achieve a successful and sustainable new healthcare paradigm in the long run.

“If we are to overcome the challenges facing private healthcare – some of which also threaten to derail the goals of universal health coverage – we need to develop a balanced and well-informed piece of legislation, and this is a process that should not be rushed,” he adds.

“More haste in finalising the Medical Schemes Amendment Bill is likely to result in a framework that could hold up progress towards a truly progressive health system that will benefit generations to come,” Arnold concluded.

Daily Dispatch
Adrian Gore's Discovery has enjoyed rapid growth since its inception some 26 years ago, broadening its product offering beyond medical aid into insurance and financial products and, this year, banking. The company's diversification away from its core healthcare product is drawing more intense investor interest as the long term prospects for that business are muddied by the impending National Health Insurance (NHI) . So pervasive has Discovery Health's growth been that the recently completed Health Market Inquiry, which looked into competition in the private healthcare market, described it as "an indication of market failure" and that the market showed no signs of self-correcting.

The company, founded by Gore and a colleague in 1992 after leaving Liberty Holdings, is made up of a medical aid arm, life insurance, a Vitality health programme and some other financial products. Its insurance arm has already overtaken its healthcare business, and, according to Bloomberg data, makes up more than 50% of the company's revenue. As part of its ever evolving and diversifying business, the firm is set to launch Discovery Bank this year.

The bank will face stiff competition from existing banks as well as the soon to be launched TymeDigital bank, owned by the Commonwealth Bank of Australia, and former FNB CEO Michael Jordaan's Bank Zero.

 Wayne McCurrie from FNB Wealth and Investments said healthcare companies were unlikely to feel the impact of the NHI for about a decade.

McCurrie said Discovery had a loyal customer base in South Africa, to which it is now cross selling its other products. However, banking might be a tough nut for Discovery to crack. "The problem with Discovery is they don't have enough capital to truly be a big player in the banking market," he said, adding the bank might start small and to truly become big, would need to raise capital by selling shares.

CITY PRESS
About a month ago, the department of health released the white paper on the National Health Insurance (NHI), which saw critics immediately going into overdrive, raising at least three issues.

The first was that the NHI was a non-starter because of the poor quality of public healthcare. Actually, they went as far as saying that it was unworkable in our country. Two, that the NHI was unaffordable. Three, that the whole idea of the NHI was a ploy to destroy private healthcare, which had no problem and was the only hope for the nation.

The first two issues are being brought as new observations, but actually they are not new. The National Development Plan (NDP), our socioeconomic blueprint that has been adopted by virtually all political parties in Parliament, clearly stated that we need universal health coverage (UHC), in which funds are pooled to provide access to good quality healthcare regardless of socioeconomic background. In their wisdom and research, the 25 commissioners of the NDP said that, in order to achieve UHC, South Africa would need to solve two major problems of the healthcare system. These are the exorbitant cost of private healthcare and the poor quality and lack of efficiency in the public healthcare system.

As the government, we embraced the findings of the commissioners, but the critics of NHI only acknowledge one problem and turn a blind eye to the other problem of the high cost of private healthcare. We are painfully aware that NHI will never be successful without improved quality and efficiency of the public healthcare system, which serves the majority of the population. Everything we are planning is in that direction. Unlike our critics, we want to argue that the second problem can only be ignored at our own peril.

Last week, no less a person than former Chief Justice Sandile Ngcobo released a report on the findings of an extensive inquiry that took four years to conclude. On more than two occasions, he received input from the World Health Organisation as well as the authority on competition law, the Organisation for Economic Co-operation and Development. Their advice was very clear – that we are running one of the most expensive private healthcare systems in the world, but, further, that we are the only country that is spending so much money on so few people. The methodology used to arrive at the findings by the Ngcobo commission has been used for more than 30 years in Europe, but still hardliners, who are driven by their own desires to defend and perpetuate their own positions of huge benefit and privilege at the expense of the overwhelming majority of our people, want us to believe that there was something wrong with the findings.

It is instructive to note that the people who argue that the NHI will be unaffordable to the country are actually basing their argument on the belief that the cost of private healthcare is a world gold standard which nobody can change and hence, in calculating the cost of NHI, they take this high cost, largely discredited by these reputable bodies in the world, and extrapolate it mathematically to the rest of the population. This is not the route that the NHI is designed to follow.

These hardliners accuse the state of using the Ngcobo commission to pursue the rich, who, they argue, are by and large content with whatever they are paying and have no problem with the cost. What is being missed here, whether through ignorance or deliberately, is that the so-called rich people who are being targeted include ordinary teachers, nurses, doctors, policemen, magistrates and judges, politicians, clerks, managers, and trade union leaders.

With the exception of some in the last group, all of the above are employed by the state. And when the cost of private healthcare increases exponentially, the state has to subsidise them. It does not end there. The state also offers tax rebates to any South African who has medical aid, whether they are employed by the state or not. Hence, in 2015, the state subsidy to private healthcare was R26bn and the tax rebates were R20bn – a total of R46bn. Three years later, in 2018, the state subsidy has increased to R31bn and the tax credits to R26bn. All these are driven by the ever-escalating cost of private healthcare, and the state is obliged to tag along in terms of the laws of the country.

And because the state is legally obliged, its capacity to finance the public healthcare system has equally diminished over that same period. In simple language, the state is ratcheting up its financial support to private healthcare for a selected few who are, by and large, self-sufficient on their own, while at the same time reducing its support for the majority who are poor and dependent on the state.

If you want to see why the country is said to be the most unequal society in the world, you do not have to look further than the healthcare system. It is inconceivable that, with all the evidence provided, a democratic and caring state should leave such gross inequality unattended.

As the state, we will continue to plan, through the NHI, a massive reorganisation of the current healthcare system, both public and private, to bring about affordability and access to good quality for all.

PRETORIA NEWS
A new group made up of health professionals and academics is piling pressure on Health Minister Aaron Motsoaledi ahead of the introduction of the National Health Insurance (NHI) scheme.

The 99 individuals on the list - seen by Independent Media - are calling for a review of the NHI.

Motsoaledi has hit back saying opposition to the NHI and calls for his head are being orchestrated by some medical aid societies that do not want it to be implemented.

In a nine-page document, the pressure group blasts the public health management and NHI given the nod by cabinet last week.

Motsoaledi was expected to make the NHI scheme’s contents public this week but will now probably only hold a media briefing next week. Health spokesperson Foster Mohale said it would be difficult to comment on the document before this briefing. He urged the group to wait for Motsoaledi to unpack the NHI bill and then participate in public comments.

This is the second round of organised criticism directed at Motsoaledi and his department, particularly concerning NHI, in less than a week.

Last week Cosatu pleaded with President Cyril Ramaphosa to get rid of Motsoaledi, accusing him of dragging the implementation of NHI. The labour federation also blamed him for the general collapse of public health facilities across the country.

In the latest attack, Dr Amilcar Juggernath, part of the group of 99, said they had collective concerns about the poor state of public health. “We are a collective who wanted to collaborate in the fight for better healthcare."

In the document, the group argues that the creation of the NHI was unclear. Also, that it was “unresearched” and merely there to address the current crisis with no future plans.

“The most striking observation is that the government has lost control of the NHI narrative. It will have to adopt a new approach to regain that control. It is now also common cause that implementation of the NHI has been characterised by a lack of transparency, equivocal Treasury support and, paradoxically, a deteriorating public service,” reads the document.

The group said it supported Universal Health Coverage (UHC) that would have been cost effective and easily accessible to all compared with the NHI.

Among their calls is for the formation of an inter-sectoral cabinet committee to manage the provincial and municipal health budgets, administration and service delivery in public health. “The swift transfer of industrial scale health institutions, such as academic complexes and specialised institutes, to a national authority under presidential mandate,” they said.

The move has been perceived as bordering on a drastic call to put Motsoaledi’s health ministry under administration.

The document emerges against the backdrop of Motsoaledi’s presentation to the SACP Central Executive Committee (CEC) on June 2 which showed how billions of rand was being channelled to private health companies at the expense of the poor.

His presentation came as the country’s GDP plummeted by 2.2% in the first quarter of this year. The leaked presentation shows 8.5% of the country’s GDP went to healthcare of which 4.4% was gobbled up by private health that services only 16% of the population. A whopping R46.7billion is allegedly spent on government employees’ medical aid schemes with the remaining 4.1% of the GDP going to a public health sector that accommodates 84% of the population.

Motsoaledi’s document also accused private hospital groups of squeezing the independent group of hospitals formed by township doctors out of business from the mid-1990s to 2006 through rigorous commercialisation. The independent group had more than 50% of beds in the private sector in the early 1990s and this number shrunk to 12.3% by 2006.

BUSINESS DAY LIVE
The party has asked Cyril Ramaphosa to set up a judicial commission to get to the bottom of challenges crippling the country’s system.

The DA has called on President Cyril Ramaphosa to establish a judicial commission of inquiry into the state of public healthcare, after its random survey of hospitals and clinics revealed significant gaps in patient care.

Chronic understaffing, equipment shortages and long waiting times characterised many of the facilities the DA visited. Its observations tally with the problems highlighted by provincial health MECs in presentations to Parliament this week, which revealed that even the tightly managed Western Cape health department was struggling to cope with demand.

“Public health facilities are no longer places of healing. They have become death traps for the poor, who have no other options available to them,” said DA spokeswoman Refiloe Nt’sekhe.

“While inspecting the RK Khan Hospital in KwaZulu-Natal, we learnt that waiting times for CT [computed tomography] scans are three months, while the next available mammogram appointment is in 2019.”

Emergency medical personnel in Mpumalanga told the DA that they were using their own money to buy vital equipment such as blood pressure monitors, while in the Northern Cape staff at Kimberley Hospital complained about a lack of basic supplies such as toilet paper.

The DA’s Gauteng health spokesman Jack Bloom acknowledged achievements such as the roll-out of HIV and tuberculosis treatments, but said many patients were being short-changed. “There are pockets of excellence in Gauteng where staff are doing their best and patients get top-rate care. But the problem is the waiting times: you can wait five years for hip surgery at [Chris Hani] Baragwanath,” he told Business Day.

Gauteng had excellent academic hospitals, which attracted patients beyond its borders, increasing pressure on a stretched service. The DA had written to Ramaphosa requesting a judicial commission of inquiry as it would have the scope and power to get to the bottom of the mismanagement and corruption plaguing public health, Bloom said.

The DA said its plan for universal healthcare offered patients a better deal than the government’s proposed National Health Insurance (NHI).

Published in 2016, the plan promises universal healthcare quicker and cheaper than NHI.

It proposes scrapping medical aid tax credits and using the money to improve public healthcare and subsidise medical scheme membership for more people.

“Our health plan is the most practical approach to universal healthcare as it aims to keep what should be kept, fix what should be fixed and smartly extend services that should be extended within the limits of the national purse,” said Nt’shekhe.

Meanwhile, the National Education, Health and Allied Workers Union is planning mass action in Limpopo after the province’s health department failed to pay staff R160m in performance bonuses for 2016-17.

The union’s Limpopo spokesman, Jacob Adams, said the department had offered to pay R90m. “We told them to go to Treasury [and ask for more].”