DAILY MAVERICK
We listened carefully to your stimulus package announcement last week and we welcome your commitments, among others, to fill more than 2,000 critical vacancies in the health system and buy hospital beds and linen. This is good news. It is not a secret that the health system needs drugs and other complex supplies, but also linen and beds. However, we have a couple of red lights, issues we believe important, to urgently bring to your attention.

Dear President Ramaphosa,

We apologise up front for sending you another letter. We know you have been receiving a lot of mail lately… some writers asking you to fix the dire and tragic state of our school sanitation, while others asked you to think carefully about how to save the health system.

We listened carefully to your stimulus package announcement last week and we welcome the details stating that you will among others be filling over 2,000 critical vacancies in the health system and buy hospital beds and linen. This is good news. It is not a secret that the health system needs drugs and other complex supplies, but also linen and beds. However, we have a couple of red lights, issues we believe important to urgently bring to your attention.

You may ask why you need to read even more bad news, news you probably know. Well, we believe that amid this “bad news” that we are sharing with you there are opportunities to cut off the dodgy connections enabling the looting in some provinces, to recover some much-needed money and to ensure our money ends up in the right hands and serving our people.

While our media counterparts have rightly and fortunately been spending much time on reporting on State Capture, the #GuptaLeaks and the looting of our state owned enterprises, Spotlight (a Treatment Action Campaign and SECTION27 publication) has been doing a series of investigations under the banner #Health4Sale. We think it is important that we bring to your attention what we unearthed, because we believe by acting now, you could quite quickly find some much-needed rands to redirect while at the same time ensuring only quality beds and equipment are purchased for our hospitals.

One of Spotlight’s main focuses has been the gangster provinces — we don’t use this term lightly — of the Free State and North West where our investigations reveal that money is being looted and siphoned off without the actual services or supplies reaching the health system.

A Gauteng-based ambulance operator, Buthelezi EMS, that is currently the subject of both Hawks and Treasury investigations, has scored both road and air ambulance contracts in the so-called Premier League provinces amounting to more than R1-billion since 2013. Worryingly, we understand that the company is a frontrunner to secure a lucrative new three-year tender in the Free State. Even after being exposed earlier this year, and after strong words from the Minister of Health, Buthelezi EMS is at this moment still doing business with the state in at least four provinces. Mister President, the looting continues as we speak.

So even while billions is being paid, well-placed sources allege that Buthelezi EMS often transports multiple patients in a single ambulance as part of their inter-facility transfer service. Sometimes as many as five patients will be transported in one ambulance, but Buthelezi allegedly bills as if five different ambulances have been used and writes invoices with five different reference numbers. At other times, patients who could safely be transported in cars are allegedly transported at great cost in ambulances.

It is also alleged that Buthelezi often charges for distances that are longer than those travelled. We have seen devastating figures to this effect that have been presented in a provincial department of health management meeting. Spotlight was told of a case where a 2km trip was charged for as a 100km transfer.

So, Mr President, you may be asking how Mr Thapelo Buthelezi’s companies (he has registered more than six versions and names) managed to score these lucrative tenders and cushy, backdated increases? There are clearly many enablers when the signatures were inked, including we believe, possibly some folk at Treasury and the SA Revenue Service — one dot worth joining is look no further than down the passage in Luthuli House where Comrade Secretary-General former Free State Premier Ace Magashule may be able to shed some light.

Spotlight found that Buthelezi EMS netted more than R15-million from two suspect back-dated price increases from the Free State Department of Health, apparently without much scrutiny. Documents that Spotlight has had sight of reveal how the increases were signed off during a five-day period, when it seems the Free State Department of Health was temporarily taken out of administration by decree of then Premier Magashule.

In a signed memorandum dated 3 February 2017 seen by Spotlight, Magashule effectively takes the provincial department of health out of administration for five days by appointing the head of the department of health, Dr David Motau, as acting accounting officer from 6 February 2017 to 10 February 2017. In this five -day window, Motau signs off on what procurement experts describe as two highly unusual back-dated 8.5% price increases for Buthelezi EMS. One cannot help but ask how many hospital beds this money would have brought in a province where we know patients often sleep on hospital floors.

Spotlight sent a photographer to Buthelezi’s Bloemfontein ambulance base. The base does not have any external signage. The outside of the suburban house in Bloemfontein was in a shocking state with rubbish, mud and a yard full of ambulances, some seemingly no longer in running order. Aerial photographs show a backyard littered with rubbish and no sign of any waste disposal.

Spotlight asked the Free State Department of Health whether they visited and inspected Buthelezi’s ambulance bases. One would imagine that if you pay someone hundreds of millions you would want to do some checks? No, said head of department Dr David Motau:

“Sites visits was not a requirement as per the tender document”. See Ambulance Bases of Shame.

How do we ensure that stimulus money, or any government money, any money for that matter, is not wasted on shoddy businesses such as this that don’t only waste money, but degrade the level of healthcare services delivered to the people? How do we insulate public procurement from this kind of looting?

President Ramaphosa, now zooming in on those new hospital beds you want to buy. Spotlight recently reported on a story, again in that gangster province the Free State, which involves hospital beds and other important equipment.

Doctors in the Free State have told us that newly purchased theatre beds are breaking in hospitals within months of installation, making it hard to perform critical surgery.

President Ramaphosa, at one hospital, a height-adjustable orthopaedic theatre bed got stuck on too high a setting, forcing doctors to stand on benches while operating. In other cases, new theatre lights are installed too low, resulting in some of the theatre personnel often knocking their heads while performing surgery.

Doctors also report that a number of newly purchased anaesthesia machines are gathering dust because anaesthetists are not willing to use the machines since they are missing components and various alarms do not work. Anaesthesia machines typically have multiple components and a sophisticated set of alarms to ensure that nothing goes wrong while someone is under general anaesthetic. This is equipment and beds worth millions.

The tender in question was awarded in August 2016 to a company named Mediquip SA Hub. According to the Free State Department of Health, they have paid Mediquip just more than R100-million under this contract in the less than two years it has been running.

Mediquip appears to be a relatively small company, employing only 10 people. However, it has a running contract to supply all kinds of equipment to all hospitals in the Free State. Mediquip has no online presence although its lawyer claimed that a “new website is under construction and will be operational in due course”. (This was in May, they still have no online presence). The Free State health department also indicated that it has no plans to cancel the tender.

But wait Mr President, there is more.

The two key local directors of Mediquip are two people you may have come across in your political life, George Sebulela and Bernard Tefetso Phitsane.

Sebulela is the president and chief executive of Sebvest Holdings, secretary-general of the Black Business Council and a current member of the Eskom Board. Yes, Eskom, which we know needs leaders beyond reproach. Spotlight sent Sebulela a list of questions. He acknowledged receipt and said he would ensure that Mediquip staff respond. That was the last we heard.

We did however, receive answers to questions sent to Phitsane via a lawyer’s letter. Phitsane is a man whose name delivers many Google hits. He is a senior ANC politician in the Free State and currently the chairperson of the beleaguered Bloem Water and is a close ally of Ace Magashule. Phitsane is also listed as a director of Dinaka Trading 5 CC, a company of which Ace Magashule is a former director — and his son Tshepiso Magashule is still listed as a director.

Speaking through his lawyers, Phitsane denied to Spotlight ever having been in business with Ace Magashule, in apparent contradiction of Companies and Intellectual Property Commission records. According to information revealed in the #GuptaLeaks articles published by Amabhungane, Tshepiso Magashule (Phitsane’s co-director of Dinaka Trading 5 CC) has been linked to various deals with the Gupta family, for whom he worked.

Phitsane also happens to be married to Nelisiwe Phitsane, the chief director supply chain management and asset management in the Free State Department of Health. According to Bernard Phitsane this relationship was disclosed when bids were submitted to the Free State Department of Health. The department confirmed this to Spotlight, but failed to provide proof when requested.

But it doesn’t end there, Mr President.

In April 2016, a few months before being awarded the medical equipment tender, the Free State tender bulletin announced Mediquip was awarded its first major tender in the province. This was for the provision of mobile medical units (a kind of mobile clinic), or “China buses” as they are commonly referred to in the province. The department indicates that it has paid Mediquip a total of just more than R70-million under this tender for six of these mobile medical units (adding up to close to R12-million a unit).

However, while the announcement was made in April 2016, this tender had in fact already been awarded in October 2015. In all other cases where Spotlight looked at the award of tenders, the award was announced the next month and not six months later. The Free State Department of Health failed to respond to a question about why the announcement was delayed.

The October 2015 date is also only half-a-year after Phitsane and Sebulela became directors of Mediquip.

Meanwhile, OFM News reported last week that these R70-million mobile units are parked at the Free State Psychiatric Complex in Bloemfontein where they are gathering dust. It is reported that these buses cannot travel on rural roads. Instead some of the mobile “clinics” are rolled out at political jamborees.

As you will know mister President, this is the tip of the iceberg.

We have not even touched on the Gupta-linked Mediosa, or any of the other tip-offs that have been flooding in since we started publishing the #Health4Sale articles. We have also not zoomed in on how Buthelezi managed to get air ambulance contracts in Mpumalanga and Limpopo and how National Treasury got caught up in, and eventually lost badly, in lengthy court cases concerning these dodgy contracts.

We can also disclose to you that four provinces have recently advertised new tenders for air ambulance services and that Thapelo Buthelezi has attended all pre-bid briefings, indicating that he fully intends to again get a slice of the pie.

So, Mr President, what are the solutions?

We agree there are no easy fixes to the endemic corruption in many of our provinces. Insulating procurement from political influence is both urgent and something that cannot be achieved overnight. A good start however, and something that can happen right now, is to ensure that the Buthelezis and the Mediquips of the world are properly investigated — something that unfortunately cannot be left to the Free State or North West Hawks.

These companies are still receiving millions of our rands and are no doubt hoping for some of the new stimulus money. By acting decisively against these companies you may save quite a bit of money and at the same time flush out some crooks. In fact you may buy those hospital beds and linen at much better prices and still have some change. As one of your ministers reminded us so famously during the height of State Capture: Join the dots.

Yours in the spirit of Thuma Mina,

Anso Thom and Marcus Low, Spotlight Editors.

MONEY MARKETING
Women’s health, men’s health, chronic disease management, innovative plans, catching criminals and a digital revamp – Bonitas reflects on 2018 and launches its 2019 plans and strategy

 Bonitas Medical Fund (Bonitas) announced a weighted increase of 8.9% for 2019. ‘This,’ says Gerhard Van Emmenis, Principal Officer, ‘despite a challenging year for the healthcare industry, against a backdrop of uncertainty around the NHI, the recent Health Market Inquiry and current tough economic conditions faced by consumers.’

‘The past 12 months have been extremely trying, with a number of uncertainties and changes anticipated. In addition, consumers have been heavily impacted by the increase in VAT and escalating prices which resulted from this.’

In July Bonitas announced its financial results for 2017, the best in its 35-year history, with a solid surplus of R730.20 million, having recouped a deficit of R16.9 million from 2016.

’This turnaround was due to several key cost saving strategies and says Van Emmenis. ‘It bolstered our reserves from R3.1 billion to R4 billion which means that we are able to invest back into the Scheme and offer our members access to healthcare of the highest quality.’

The Fund has announced a number of additional benefits for its members for 2019, while keeping increases as low as possible. ‘We know that it’s not only the monthly premiums that affect the consumer’s pockets but the value they get out of their medical aid plan,’ says Van Emmenis. ‘Some of the benefits have been tweaked, others increased, one plan has been discontinued and two new options have been introduced, all aimed at helping members take control of their health and lead better lifestyles.’

Working together to reduce healthcare costs

‘We continue to seek partnerships with healthcare providers to ensure we are part of the same value chain, rather than being part of the supply and demand of the healthcare economy,’ says Van Emmenis. ‘In addition, we are focused on educating role players to balance the triangle of affordability, quality and cost efficiencies. We are developing an incentive model to motivate service providers to eliminate activities that do not add value to members.’ Over the past few years, Bonitas has taken a multi-pronged approach to cost saving, focusing on:

Hospital Negotiations

Hospital claims account for half of Bonitas’ annual claims, around R6 billion a year. For this reason we negotiated a pricing structure with the main hospital groups, to deliver a savings of R242 million last year. We project that this saving will increase to approximately R550 million over the next two years in present value terms.

Managed Care

We place great emphasis on our Managed Care initiatives to help members, with chronic conditions, manage their health better. It takes into account the best clinical and treatment protocols while containing costs. Our back and neck, oncology, hip and knee and HIV/AIDS programmes respectively, continue to offer our members emotional, clinical and financial support.

Chronic Conditions

The Council for Medical Schemes (CMS) cites chronic conditions – with diabetes in particular, as one of the key contributors to a rising disease burden in South Africa and escalating healthcare costs. 80% of the Scheme’s diabetic patients have associated chronic conditions such as high blood pressure and cholesterol, heart disease and depression which need to be managed on a unique basis. ‘Through our Diabetes Programme, hospital admissions related to diabetic patients having reduced by 11.6% year-on-year,’ says Van Emmenis.

Prevention is better than cure

We have a keen focus on preventative care as early detection is a critical factor in ensuring our members get the support they need to manage any serious conditions timeously.


Women’s Health

Last year, we kept a firm focus on women’s health introducing cover for pap smears on all our plans. Since cervical and breast cancer continue to be most prevalent, we have continued our efforts towards early detection by ensuring mammograms for women over 40 will be covered once every two years on all our plans from 2019.

Men’s Health

In addition, we have placed the spotlight firmly on men’s health, especially in light of a prevalence of prostate cancer, by adding the prostate screening antigen test to all options for men aged between 45 and 69.

GP Network

We have South Africa’s largest GP network which ensures our members get value for money and stretch their benefits.  Our online provider locator tool has been enhanced so that members can find network hospitals, doctors and specialists in their area quickly and easily.

Fraud, Waste and Abuse (FWA)

Our ongoing efforts to reduce FWA have been successful, with a number of convictions and sentencings. This significant focus delivered recoveries of R31.2 million with a potential preventative savings of R75 million. We will continue to ensure that all outstanding money is successfully recovered and repaid to the Fund, so that it can be put to better use to benefit our members.

Going Digital

Digital remains a key driver for member and broker communication with Member, Broker and a newly introduced Corporate Zone available on the website.  The online application has been revamped, we’ve introduced an electronic membership and a live chat function has been added to assist current and potential members with any questions they may have.

Besides enhancing the Member Zone as from January 1, 2019 members will have access to the Bonitas App – a revolutionary cell phone application that will offer the full benefits of the Member Zone. Making it easier for them to view their benefits and claims as well as submit claims, obtain authorisation, find a network provider, resolve queries and so much more while on the go.

As a value-add for members, Bonitas has aligned itself with strategic partners to offer a comprehensive and holistic solution to help members take care of their financial health and wellness, without paying anything extra. ‘This is not another loyalty programme,’ explains Van Emmenis, ‘but rather real added value aligned to member needs, with no fee or points scoring.’ The model includes a Multi-Insurer Platform offering Medgap, exclusive gap cover with a discount of up to 48% discount for Bonitas members and a wide range of life, funeral, disability cover products through Sanlam Indie with exclusive benefits in the form of free investments up to 110% of monthly contributions. And finally, a variety of free monthly discount vouchers from 30 participating partner retailers through Electronic Line.

In conclusion, Van Emmenis says, ’Our plans have been restructured to meet market demand, consumers are looking for options that offer attractive benefits at a more affordable rate.

Summary of key changes for the year:

• A weighted increase of 8.9%
• A new multi-insurer platform with exclusive deals and offers for Bonitas members including gap cover
• Two new plans introduced – Primary Select and BonEssential Select. These use dedicated networks and are both are priced around 15% lower than the Primary and BonEssential options respectively
• The Hospital Plus plan has been discontinued
• Mammograms for women over 40 will be covered once every two years across all the plans
• Prostate screening antigen tests for men aged between the aged of 45 and 69 have been included across all plans
• Childhood immunisations according to the EPI schedule, are now offered to members on BonClassic, Standard, Standard Select, BonComplete, BonSave, Primary, Primary Select and BonFit – paid from risk
• The introduction of the My Family Modelwhich contains a full suite of care – such as maternity consultations, 2D scans, antenatal classes, newborn hearing screening – all paid from risk
• The day-to-day benefits on Primary has been increased by 15% for 2019
• A family benefits of R31 500 has been introduced on BonEssential for internal prosthesis, it is also included on BonEssential Select
• BonClassic has been re-aligned to fit in with other options with radiology and pathology combined into one benefit

For more information on the range of medical plans available from Bonitas, or to compare options, go towww.bonitas.co.za.

POLITICS WEB
In a similar vein to the land reform debate in South Africa, health reform is also filled with populist rhetoric, seemingly in the lead up to the 2019 national elections. In February 2018, President Ramaphosa singled out the urgency of National Health Insurance (NHI) in his first State of Nation address. Publication of the draft National Health Insurance Bill (NHI Bill) followed shortly, with the simultaneous release of the Medical Schemes Amendment Bill (MSA Bill).

In brief, the NHI Bill provides for the establishment of a single health financing system, the NHI fund, which will be the single purchaser and financier of the population’s personal health services. The NHI fund will pool funds and purchase undefined “comprehensive health services” on the population’s behalf from accredited health establishments and suppliers. All South African citizens, permanent citizens and their dependants will be obliged to register as NHI fund beneficiaries at accredited public/private health care establishments and will be entitled to “quality health service benefits” free of charge. Refugees and asylum seekers will be entitled to emergency health care services, treatment of notifiable conditions, and paediatric and maternal services at primary healthcare level. A person will not be able to directly utilise hospital or specialist services without referral by a primary healthcare provider, unless in an emergency.

One must keep in mind that the NHI is the governing party’s answer to ensure universal health coverage (UHC). UHC is defined by the World Health Organisation (WHO) as ensuring all people have “access to health services” (ranging from prevention and treatment to rehabilitation) of “sufficient quality” without exposing them to “financial hardship”.

The NHI Bill maintains that the NHI will give effect to the State’s constitutional duty of “progressive realisation” of the right to have “access to health care services including reproductive health care”. The NHI will apparently be the solution to South Africa’s dire state of healthcare which, according to the 2011 Policy on National Health Insurance (NHI Green Paper), is caused by the unequal provision of quality healthcare in the public and private sector and costly private healthcare.

The fact that the NHI is the governing party’s solution to realise universal health coverage is important, as the public has never had the opportunity to participate with a politically neutral forum evaluating different proposals. The official opposition, for instance, has an alternative to the NHI scheme (“DA Health Policy ‐ Affordable, accessible high‐quality healthcare for all”) which uses the Western Cape model, providing free quality health services in the public health system but retaining and reforming the medical aid system. The opposition’s model might similarly be problematic, but there has never been an objective comparison for the public’s advantage.

The NHI Bill, which will be implemented over three phases, provides very little detail with which to meaningfully engage at this point, as critical elements will only be provided in regulations. This includes the nature of health service benefits to be funded; payment mechanisms; the NHI Fund’s budget and the relationship between the NHI Fund and Medical Insurance Schemes (MIS). The role of MIS is vaguely described as providing “complementary health service benefits” not covered by the NHI Fund, which a user may purchase. Only if a user failed to either comply with the NHI referral pathways or seek services “not deemed medically necessary” must they pay directly or through their medical aid.

Detail about costing, NHI implementation plans, and the healthcare benefits to be funded are pivotal to evaluate the NHI’s feasibility. Lack of this particular detail was already emphasised in the Davis Tax Committee’s (DTC) March 2017 report on the White Paper: National Health Insurance for South Africa 2015 (White Paper). In brief, the DTC considered the NHI’s tax revenue dimensions and the financing proposals via direct taxation, indirect taxation, payroll taxation, or premiums.

The White Paper, using 2010 prices and assuming a 3.5 % GDP annual growth, estimated that a R256 billion per annum funding increase was needed and that there would be a R72 billion shortfall by 2025. The DTC stressed that “the proposed NHI, in its current format, is unlikely to be sustainable unless there is a sustained economic growth”. Since the DTC’s report the current economic situation has worsened. According to Statistics South Africa, South Africa is currently in a technical recession, with a 0.7% decrease in the GDP in the second quarter of 2018, following a 2.6 % decrease in the first quarter. This reality coupled with a staggering unemployment rate of 26.7 % could cripple any hope of the NHI being successful.

In the DTC’s report, an interesting mention was made of Ireland’s Universal Health Insurance Plan which could be quite relevant. The DTC cautioned that lack of detail on costing and health service benefits could see the NHI fail, similarly to Ireland’s 2011 White Paper on Universal Health Insurance which also lacked this particularity. The Irish Government, according to the DTC, subsequently abandoned this in 2015 after a study indicated that it was unaffordable. However, since the DTC report, Ireland has taken an interesting approach.

A parliamentary select committee was established in 2016 with representatives from all political parties (the Oireachtas Committee on the Future of Healthcare) aiming to achieve cross party consensus on healthcare reform and fulfilling universal health coverage. The Committee worked with international health policy specialists to address various aspects such as funding and integrated care and their report (the Sláintecare plan), concluded in May 2017, provides a 10 year health reform plan.

The vision of free of charge quality healthcare in South Africa is a vision aligned to the Constitution in so far as the right to access healthcare services is concerned. The reality, however, is that by solely focusing on NHI, which appears to be economically unfeasible, we lose sight of the fact that a solution is desperately needed. It might be time to follow the Irish example, as the future of health reform should not hinge only on the feasibility of the NHI.

*In Part I and III, health initiatives undertaken in the NHI pilot phase and proposed NHI governance concerns will be analysed respectively.

Christine Botha is Legal Officer, Centre for Constitutional Rights.

BUSINESS DAY
The Council for Medical Schemes is proposing consolidation of all medical schemes for public servants into the Government Employees Medical Scheme GEMS in line with government policy on National Health Insurance.

The proposal is contained in a discussion document released for public comment on Wednesday and is likely to run into opposition from industry players and public servants alike.

The state contributes significand to public servants' medical scheme contributions. Unionised workers are likely to resist moves they see as a threat to their current benefits. State sector schemes make up about 30.3% of the industry and include Polmed for the police and Parmed for MPs and judges.

The council identified 10 schemes that could be amalgamated with GEMS, including those of state affiliated entities such as the SABC and Rand Water. It said that consolidating public sector medical schemes with GEMS offered potential savings; a larger scheme would have more negotiating power with health care providers.

GEMS was best placed to absorb other public sector schemes because of its size and relatively young and healthy membership, the council said. Gems had 1.833 million beneficiaries at the end of 2016, providing cover to more than half 56.8% of all eligible public servants. The council said it was aware that many state employees might be reluctant to move to a new scheme but it was important to press on as it would provide an example to private sector schemes.

It suggested that troubled Transmed, for staff and pensioners of state owned rail company Transnet, could be used as a test case for "fast tracking engagement strategies". Transnet had a high pensioner ratio, with a large proportion of older and sicker members, and had to reduce benefits and raise contributions to cover their needs, said Insight Actuaries & Consultants joint CEO Barry Childs.

Merging public servants' medical schemes with GEMS was likely to be difficult, "but not impossible", he said. "I can't see Polmed easily rolling into GEMS: it is a business in and of itself." The council proposed that non- state schemes consolidate, and then, like GEMS, reduce the number of benefit options. Acting council registrar Sipho Kabane said consolidating medical schemes would improve their sustainability and was an important step towards realising the government's universal health care goal of having a single payer for health services.

"We are just doing the technical work to get the discussion going," he said. Wits University professor Alex van den Heever panned the council's latest proposals, saying they were at odds with the health market inquiry's interim findings, published in July.

"There is plainly no understanding of the health market inquiry report. This proposal will drive up costs in the private system by removing all semblance of competition. You do not enhance efficiencies by consolidating purchasers. You destroy them by creating unregulatable monopolies: he said.

BUSINESS DAY
The original deadline for the release of the Competition Commission’s final report was November 2015, but it has been repeatedly delayed

The Competition Commission’s long-running health market inquiry has announced yet another delay in the release of its final report, saying it wants to give stakeholders more time to comment on its provisional findings published in July.

The deadline for the publication of its long-awaited report has been pushed out by two months, to November 30.

The inquiry began in January 2014 and set out to investigate the barriers to effective competition in the private health-care market and why annual health-care inflation consistently outstrips consumer price inflation by several percentage points.

The original deadline for the release of its final report was November 2015, but it has been repeatedly delayed — partly due to legal challenges, but also because it has been at pains to show it is taking heed of concerns raised by stakeholders at every step of the way.

"Following the publication of the inquiry’s provisional report, the inquiry received several requests for extensions for submissions from various stakeholders and has considered these on a case-by-case basis," said the inquiry in a notice published in the Government Gazette on September 6.


DATA ACCESS PROCESS

"Moreover, the inquiry received various requests for access to underlying data and information considered in preparing the provisional report, through the data room. The data room process is still ongoing.

"The data access process and extensive engagements that are required in respect of the provisional report necessitate a further amendment to the inquiry completion date. All comments and submissions made on the provisional report will be considered and, if necessary, the report will be revised," it said.

The inquiry has received 47 written submissions from stakeholders in response to its provisional report, released on July 5, and a further 17 are expected from stakeholders who requested an extension to its original September 7 deadline for comments, according to a notice on its website.

Section 27 attorney Sasha Stevenson welcomed the inquiry taking more time to consider inputs. "There is a need for better understanding and regulation of the private sector to ensure the realisation of health-care services," she said.

"That will be important when services start being purchased from the private sector by the state [under National Health Insurance] because it should mean assured quality and lower prices, but it is equally important now when [individuals] are buying services," she said.

The provisional report found a lack of competition in the medical scheme market and evidence of over servicing by providers, and concluded that the private hospital sector is so highly concentrated it inhibits effective competition.

It recommended interventions aimed at increasing competition, improving consumer protection and ensuring greater efficiency in the market.

DAILY MAVERICK
With a wave of populism and an election around the corner, there is a risk that we will not navigate the tricky waters ahead with sufficient care and end up blundering into dead ends or running those still functioning parts of our healthcare system on to the rocks.

Healthcare in South Africa is in a tenuous state. The public healthcare system is in crisis — provinces are underfunded, corruption is rife, in many areas posts are effectively frozen. Meanwhile, in the private sector premiums keep going up at a rate well above inflation and a lack of competition means there is little prospect for improvement in the market — both in terms of quality and cost.

Into this context two bills and one ground-breaking provisional report have now been introduced (all out for public comment). With a wave of populism and an election around the corner, there is a risk that we will not navigate the tricky waters ahead with sufficient care and end up blundering into dead ends or running those still functioning parts of our healthcare system on to the rocks.

One positive that has emerged in recent months, is that most people seem to be on board with the idea that everyone in South Africa should have access to quality healthcare. Many commentators seem to concur that, in principle at least, National Health Insurance (NHI), or something like it, is ultimately part of the correct solution to our healthcare woes. Of course, a minority believes healthcare should be privatised as far as possible.

Of those who support NHI in principle, the key fault line seems to be between those who back the NHI proposals and those who consider them to fall short in key areas.

There are good reasons to be concerned about the current plans for NHI as described in the NHI Bill and variously coloured papers and other gazetted documents.

It will set up a large fund that will be complicated to manage and tempting to loot from. It will create many contracts that will require skilled human resources and capacity to manage — skills we don’t have in the public service.

It will leverage excess capacity in the private sector to serve the public sector, but how this will be done in practice remains opaque. And maybe most importantly, it will do little to address the underlying political and governance challenges that are the sand in the gears of our public service.

In one future scenario the ruling party pushes ahead with NHI regardless of these concerns and a bill roughly in the form of the current NHI Bill becomes law in a year or two. Given the populist mood in the ANC, pressure from the EFF and the fact there is an election around the corner, this is probably the most likely scenario.

While the vision of NHI is inspiring, it appears that in the bright light of an on-coming election many in the ruling party are blind to the realities around them.

The Life Esidimeni tragedy, the short-sighted cancellation of the Limpopo government’s contract with the Ndlovu Care Group (with potentially disastrous consequences for 4,000 people living with HIV), the outsourcing of a multimillion rand ambulance service to the controversial and possibly corrupt Buthelezi EMS in several provinces all contain elements of the contract management and outsourcing that will become commonplace under NHI.

That NHI will be secure from looting and more such cases of gross mismanagement seems delusional in a political climate where people like former provincial health MECs Brian Hlongwa and Benny Malakoane have not been held accountable.

Granted, there is a not altogether unreasonable argument to be made that NHI will disrupt the looting by moving power away from provincial departments of health, where the rot often runs deepest, upstream to national structures (where supposedly there is more capacity) and downstream to sub-districts (closer to actual service delivery).

Under the right conditions the disruption caused by such a rearranging of the chairs might be leveraged productively, but under present conditions it might well deepen the dysfunction in the public healthcare system — and the rot might well end up migrating along with the chairs.

There are obviously good short-term political reasons for the ruling party to rearrange the chairs and implement NHI nevertheless, given that it will create the impression that the healthcare crisis is being addressed — while in fact dodging the more fundamental governance and political problems plaguing the system. Of course, such short-term political expediencies may pale in comparison to the social and political consequences of a failed NHI five or 10 years from now.

That is one scenario. A second, politically much less likely scenario, sees NHI being placed on hold for maybe three or four years while we go back to the drawing board to more thoroughly map out a more realistic and less risky road to NHI.

It may sound absurd, but despite the white and green papers, a ministerial committee and the bill, the case that has been made to the public has mostly been rhetoric and idealism.

We have not seen the careful weighing up of policy options and the weighing of evidence from other countries that one might have hoped for. Instead, we have seen the very slow ramming through of a set of idealistic ideas without any real critical public engagement on how to actually make it work. This is particularly jarring given that we have world-class experts in academia and civil society who would love to contribute to making NHI a success.

Taking a few years to rethink NHI does not mean that progress toward better healthcare for all is also placed on hold. While we figure out the best way forward with NHI we can go full steam ahead with a major anti-corruption drive in our provincial healthcare systems and make a plan to employ more skilled people to run provincial health departments.

There is no reason to wait with the urgent work of making the Hawks and the National Prosecuting Authority more independent so that people such as Hlongwa and Malakoane are held accountable.

We can start new programmes to train more healthcare workers and to rebuild morale in the public sector. None of these things needs to wait for NHI. In fact, the introduction of NHI will be much smoother if we have already made progress on these issues.

Another key consideration in this back-to-the-drawing board period is to face the elephant in the room head on — the elephant of course being private healthcare. Here, however, we already have a pragmatic, non-ideological roadmap in the form of the provisional report of the Competition Commission’s Health Market Inquiry. While some seem intent on ignoring the inquiry since the ruling party’s priority is ramming through NHI, this is foolhardy and ultimately counterproductive.

The inquiry provides a set of recommendations that will help make private healthcare more affordable while simultaneously improving the quality of healthcare services. It will allow more people to access private healthcare, and thereby probably in the short to medium term have the net result of ensuring more people in South Africa have access to quality healthcare than would be the case otherwise.

It is also simply wrong to think that reform of private healthcare would commit us to a future where the public-private divide is further entrenched. In fact, through many of the mechanisms proposed in the NHI (such as the supply-side regulator) we can start building the infrastructure required for NHI and in fact bring the public and private sectors closer together rather than further apart.

Far from strengthening the private sector, the recommendations of the Health Market Inquiry will bring stricter and more sensible regulation that will ultimately reduce the power of hospital groups and medical scheme administrators, empower scheme members and eventually government.

An important practical question is how one would actually go about rethinking the road to NHI. Another ministerial advisory committee such as the previous one clearly won’t take us forward. While people are rightly sceptical of commissions, the excellent work of the Health Market Inquiry has now provided a blueprint of how we can go about having an inquiry that actually gets to the bottom of things and provides us with well-informed and evidence-based options for the way forward.

With the right panellists and the right terms of reference, a commission of inquiry that receives public submissions both orally and in writing would not only help spark a more meaningful public debate but could ultimately put us on firmer ground when implementing the drastic changes that NHI will require.

Under this second scenario the ruling party will of course have to deal with the problem of explaining to the public why yet more time is required to ensure that NHI is built on solid foundations and how such a delay is in fact part of the most plausible and shortest path to quality healthcare for all.

While the ruling party may consider a rethink to be a problem electorally, my sense is that even among poor people dependent on the public healthcare system confidence in the state is so low as to make promises of better health through NHI ring hollow.

On the other hand, in a best-case scenario where the NPA prosecutes a few of the worst looters, a credible HR turn-around strategy is implemented in the public healthcare system and a commission chaired by a respected judge delivers a set of evidence-based recommendations, public appetite for and belief in NHI might be much greater three or four years from now.

DIE BURGER, BEELD, VOLKSBLAD
Na verlede jaar se blaaskans van vorige jare se skerp premiever hogings, moet lede van mediese fondse hulle vanjaar staal te oor deel na Discovery Health Medical Scheme (DHMS) se verhoging van gemiddeld 9,2%.

DHMS gee die verhoging in die BTW koers en die onbeheer de uitbreiding van hospitale die skuld vir die skerp premieverhogings vir 2019. Ander mediese fondse sal ook oor die volgende paar weke hul verhogings vir volgende jaar bekend maak en sal na verwagting in DHMS se voetspore volg.

DHMS is die grootste mediese fonds in die land met 2,7 miljoen hooflede en afhanklikes. Hy het 'n geweegde gemiddelde verhoging van 9,2% vir 2019 aangekondig teenoor 7,9% vir 2018.

 Geweegde gemiddelde verwys na die gemiddelde prysstygings van al die opsies, met inagneming van hoeveel lede elke opsie het.

Volgens dr. Jonathan Broom berg, uitvoerende hoof van Discovery Health, is die grootste by draer tot die verhogings die 1 persentasiepunt styging in die BTW koers in April.

Die onverwagse BTW verhoging het 'n impak van R350-miljoen op DHMS gehad, waarvoor nie begroot is nie. Mediese fond se hef nie BTW op hul lede se premies nie, maar die belasting word op elke eis gehef.

Broomberg sê DHMS se eise het tot dusver vanjaar met meer as verlede jaar gestyg, en word ook in 2019 se premieverhoging weerspieel. Hy skryf die skerper styging in eise aan 'n toename in hospitaalopnames toe.

Dit is een van die redes hoe kom die Coastal plan se premie met 9,9% styg. Eise op hierdie opsie het vinniger gestyg as die van ander opsies.

"Die hoofrede hiervoor is dat te veel nuwe hospitale in sommige dele van die kusstreke gebou word." Die afgelope twee jaar is meer as 2 000 hospitaalbeddens tot Suid-Afrika toegevoeg die selfde getal as in die voorafgaan de tien jaar.

Broomberg meen die hele hospitaallisensieringstelsel "is buite beheer" en dat lisensies te maklik uitgedeel word.

Mediese fondse "kan net so veel doen" om opnames te be heer. "As 'n dokter sê hy wil 'n persoon opneem, is dit uiters moeilik om nee te se.

Ons het protokolle en wys opnames af, maar ons kan net so ver gaan."

Die Raad op Mediese Skemas RMS se riglyn vir premiever hogings vir 2019 is 8,7%.

Volgens Broomberg het die RMS nie die BTW verhoging in sy riglyn in ag geneem nie. "Uiteindelik moet trustees pre mies vasstel wat eise kan betaal sonder dat die reserwes wegge vreet word."

Sonder die BTW verhoging sou DHMS se verhoging wel in ooreenstemming met die riglyn gewees het, se hy. Voordele is hoofsaaklik vir die Executive en Comprehensive plan verbeter en behels verbeterings vir kankerbehandeling.

BUSINESS DAY
Pharmaceutical manufacturers are anxiously waiting for health minister Aaron Motsoaledi to make a decision on their request for an extra price increase on medicines to compensate for the rand’s slide, after an advisory committee submitted its recommendation to him last week.

Manufacturers usually get one increase a year for private sector prices, but the minister has the power to allow an extra increase, and has previously done so.

He will have to weigh up the concerns of an industry that says it was hard hit by a January price increase that failed to cover rising input costs against the prices charged to consumers and medical schemes.

The weak rand has made imports more expensive and squeezed pharmaceutical manufacturers’ margins: they cannot pass on their increased input costs to consumers because medicine prices are controlled by the health department.

The rand has shed 19% of its value against the dollar since the start of 2018 and closed at R15.24/$ on Friday.

Pharmaceutical manufacturers raised their concerns with the minister and his officials in August, before meeting the medicines pricing committee, which advises the minister. The committee’s chair, Fatima Suleman, said at the weekend that it had made its recommendation to the minister.

The health department’s deputy director-general for National Health Insurance, Anban Pillay, said a decision on whether to allow an extra price adjustment had yet to be taken.

Pharmaceutical Task Group spokesperson Stavros Nicolaou said the weak exchange rate threatened the continued supply of some products. He conceded regulatory provisions allowed drug makers to seek permission to raise the price of individual products if they had become unprofitable, but said the process was bureaucratic and companies have had "marginal success" with it in the past.

The Pharmaceutical Task Group represents SA’s key associations for drug manufacturers.

IOL
South African students who study medicine abroad will have to go back to university on their return home after graduating.

Since July 1, a new policy by the National Department of Health compels all foreign-trained doctors to complete a one-year bridging course at a local university.

While some have accepted the policy, many foreign-trained students and returning graduates, are disgruntled.

They claimed that no proper consultation process took place and that the policy was “up in the air”.

Health department representative Gavin Steel said the reason for the policy guidelines was that at some foreign universities, especially in China and Mauritius, students did not receive sufficient practical training. Steel also said graduates were not exposed to diseases such as HIV/Aids and tuberculosis at foreign universities, while they were prevalent in South Africa.

The policy states graduates who study at foreign universities must declare this with the Health Professions Council of South Africa (HPCSA) going forward and that the foreign university should be recognised by the council.

Spokesperson Fezile Sifunda said there were 1570 foreign-qualified South African medical practitioners registered with the council.

Annie Tooray of Pravda and Knowles Attorneys, who is acting for some foreign-trained graduates, said the guidelines lacked a consultative nature.

“Information will be requested from the department to challenge it. Graduates would now have to face another wasted year of clinical bridging. There is no mention of costs or where this programme will be done as yet,” said Tooray.

She said the graduates would still have to face HPCSA board exams, two years of internship and one year of community service.

Steel said it was important that the policy was implemented as some graduates had never worked on human bodies before.

Opinion:
The Health Market Inquiry report has been published at a rare moment of opportunity for a new dawn in health reform in South Africa. In the context of a crisis in the public and private health systems, it is the time for active citizenship – or forever hold your peace.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What is to be done?

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

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

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

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

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

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

The HMI has done its work. Now is the time for your active citizenship – or forever hold your peace.

BIZCOMMUNITY
An alternative reimbursement model has been launched that will benefit patients and encourage best practice among clinicians in the private healthcare sector.

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

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

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

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

Protects the patient without adding cost

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

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

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

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

"The Sasa EBC is an example of a positive move towards enhancing and placing value on the integration of anaesthetic services in holistic patient care, supported by an innovative fixed-fee reimbursement model. The approach provides regulatory certainty and societal peer review, and entrenches quality-of-care principles through the monitoring of team processes and care outcomes," says Darren Sweidan, Discovery Health’s head health professional unit.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

BHEKISISA
The famous African proverb, “It takes a village to raise a child”, is absolutely true. There is nowhere that this sense of community - of common responsibility - is stronger than in Africa.

As Africans, we draw our strength from each other.

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

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

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

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

But there is strength in numbers.

Especially with vaccines.

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

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

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

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

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

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

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

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

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

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

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

Keith Klugman is the director for pneumonia at the Bill & Melinda Gates Foundation. You can follow him on Twitter @findingpneumo. [Full disclosure: The Bill & Melinda Gates Foundation funds the Bhekisisa Centre for Health Journalism]

BIZCOMMUNITY
The "startling costs" of South African private healthcare is at the heart of the Competition Commission's Health Market Inquiry (HMI) draft report released in July. While cost is a key theme, the report also describes a sector lacking the vital force of authentic, robust competition.

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

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

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

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

Competition is cosmetic

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

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

Runaway medical inflation

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

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

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

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

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

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

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

NHI

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

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

Value-centric transformation

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

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

“As an industry, we know what we need to do. We need to take the first step towards a value-centric structure, to change the market for the better, before it’s is too late,” Grillenberger says.

INDEPENDENT ONLINE
At a time when South Africa's hospitals are faced with critical staff shortages which impact on the health-care system, some intern and community service doctors remain unemployed.

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

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

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


“We understand this, but it is our view that there should be no problems with regards to placing other folks, such as those who have been naturalised,” said Sonderup.