MEDBRIEF AFRICA

It is back to the drawing board for the Department of Health on the National Health Insurance (NHI) Bill after Cabinet decided to send it back to the department for more work. The Bill was presented to Cabinet yesterday, but statements on its website indicate that it was not approved during yesterday’s session with various other draft legislation destined for Parliamentary approval.  Presidential spokesperson, Khusela Diko confirmed to MedBrief Africa last night that the Bill was presented to Cabinet but that it was not approved and will only be finalised early next year.

According to a report by Health-e News government sources have confirmed that a special Cabinet meeting will now be held at the end of January next year to discuss the Bill and decide on the way forward.

The decision by Cabinet to refer the Bill back comes amidst fierce criticism from stakeholders in the healthcare sector and civil society warning that rushing the legislation through in its current form could lead to a total collapse of the healthcare system. However, in a strongly worded statement last week, Health Minister Aaron Motsoaledi slammed critics of the Bill and media reports that a team led by presidential advisor Dr Olive Shisana made changes to the document initially approved by the then Minister of Finance, Nhlanhla Nene and the Health Minister for presentation to Cabinet.

This was confirmed in a letter written by the deputy director-general of Treasury, Ismail Momoniat to Shisana and leaked to the media last month. It was also revealed that the Director-general of Health, Precious Matsoso was side lined in the process and not provided with a copy of the revised Bill as it made its way to Cabinet. A version of the Bill which contains the changes referred to in the letter to Shisana is dated 5 October indicating that the Department of Health couldn’t possibly consider the hundreds of comments on the draft Bill released in June this year as the deadline for submissions was only the 21st of September.

The delay of the Bill comes only a few days after the Health Market Inquiry into the private sector announced that it had postponed the release of its final report and recommendations to the end of March next year to provide it with enough time to seriously consider all input it had received from stakeholders on the provisional report. It was expected that the Department of Health would consider the final recommendations of the HMI report for inclusion in the NHI Bill.

IOL
A new procedure that can drastically improve the lives of leg amputees was recently performed for the first time in South Africa.

The procedure involves a revolutionary new type of prosthesis that does away with traditional suction sockets by directly attaching an amputee’s prosthetic limb to their skeleton.

Professor Nando Ferreira from Stellenbosch University’s Division of Orthopaedics, who was the lead surgeon, collaborated with the Institute for Orthopaedics and Rheumatology at Mediclinic Winelands, prosthetist Eugene Rossouw, and associate professor Munjed al Muderis of the Osseointegration Group of Australia, to perform South Africa’s first osseointegration prosthesis implant on November 5.

The recipient was a 28-year-old woman who suffered a traumatic above-knee amputation in 2009. Since then, she has struggled with her socket prosthesis, which interferes with her occupation and daily life.

The patient has progressed well, and her first prosthesis fitment was done two weeks after the surgery.

She has begun a 12-week rehabilitation protocol that involves progressive weight bearing while using two crutches for six weeks, followed by another six weeks using one crutch.

The procedure was originally developed in Australia by Al Muderis, the Australian surgeon who pioneered osseointegration and developed the Osseointegration Group of Australia Osseointegration Prosthetic Limb (OGAP-OPL) prosthesis, the surgical technique, and the rehabilitation protocol over the last decade.

About 750 surgeries have been performed, mostly in Australia.

“The OGAP-OPL is a revolutionary prosthesis that does away with traditional suction sockets by attaching an amputee’s prosthetic limb to the skeleton. This affords amputees unique advantages and can drastically transform their quality of life,” Ferreira said.

Amputees frequently suffer problems with traditional suction sockets, including skin irritation, poor fit due to sweating and volume changes of the stump throughout the day, discomfort while sitting, and the time it takes to attach and remove a prosthesis.

These socket-related problems are eliminated with an osseointegration prosthesis.

Recipients also have a better perception of the body’s position and movement and can feel the surface they are walking on, allowing them to walk with more confidence.

The osseointegration prosthesis restores the normal anatomical alignment of the thigh bone, which significantly reduces common gait deviations in above-knee amputees.

However, the procedure is not without complications, most significantly infection around the implant and fractures of the remaining bone.

“Candidates are carefully screened for suitability and currently only individuals suffering severe socket problems that significantly interfere with work and daily life are considered for this procedure,” Ferreira said.

“The unique design, materials and manufacturing process of the OGAP-OPL allows bone to grow into the surface of the implant.”

DAILY MAVERICK
The opinion piece by Busani Ngcaweni is misplaced, inaccurate and at best wishful thinking.

In an opinion piece, Busani Ngcaweni contends that the National Health Insurance (NHI) is a cure-all to all South Africa’s health needs while the reality is that the public healthcare system is on life support.

While the goals of providing universal healthcare are important it is clear that the ANC government lacks the political will and capacity to deliver it. Plans by the Minister of Health, Dr Aaron Motsoaledi, to push ahead with the National Health Insurance are an act of desperation and form part of the ANC’s electioneering tactics. It is a decision doomed to failure from the outset.

The NHI proposal has never been properly costed with Motsoaledi admitting that he had no idea how much it would cost or where the money would come from. Meanwhile, NHI pilot projects have failed abysmally wherever they have been trialled.

What Ngcaweni fails to mention is the backdoor dealings of Motsoaledi following the introduction of the NHI Bill. It was reported that Motsoaledi had made substantive changes to the Bill and presented a new version to Cabinet without consulting with National Treasury or senior members of his own department. Instead, reports suggest that the changes are the brainchild of Motsoaledi and presidential adviser Dr Olive Shisana.

The Minister made substantive changes to the existing Bill that effectively kill the private healthcare system. This includes restricting medical aid or other private health insurance schemes to providing only complementary cover, effectively making NHI the only game in town. The effect of this is nothing short of nationalising the private healthcare industry by making the State the sole purchaser of healthcare services. The Minister did not take any input from the public seriously, as the proposed changes are substantive, and the public and other stakeholders have not had an opportunity to raise their concerns.

The proposed creation of a single National Health Insurance Fund is little more than the creation of another enormous state-owned entity (SOE). This is greatly concerning considering the government’s dismal performance in managing SOEs, endemic corruption and its equally dismal performance in providing healthcare. Much like government’s failed management of Eskom, South Africa will surely be heading towards a healthcare “blackout” if NHI is fully implemented.

The Minister is completely out of touch with the crisis in the South African public health system, and this was highlighted by his denial of the ongoing health crisis.

DA visits to hospitals and clinics around the country have exposed medicinal shortages, equipment shortages and a severe shortage of beds. In most hospitals visited, infrastructure is collapsing and lack of maintenance in facilities is painfully obvious. Doctors are leaving the public health sector in droves. They cannot work under the present conditions with lack of resources, very long hours due to lack of effective personnel and maladministration at every level. While the Western Cape has 33 specialists per 100,000 residents, Limpopo only has 1.3 specialists per 100,000. The MEC of Health in Limpopo stated: “If people are one day sick and require a specialist, they will wish they were born in the Western Cape.”

The current and revised NHI Bill fails to address the real crisis in the health sector.

First, it cannot be implemented due to failure in the current health sectors which cannot deliver effective healthcare to the majority of South Africans.

Second, the Minister himself cannot tell us what the costs of implementing the Bill will be and advises that it will take up to 15 years to effectively implement. The provinces cannot manage current budgets and have all declared they are under-financed.

Third, the NHI pilot projects have failed abysmally already. If a pilot project is unsuccessful, there is no chance that it will be successful nationally. Lastly, the NHI aims to put a cap on the amount of private health insurance providers and medical aids. This creates a risk of monopoly in the industry, price fixing and collusion.

There is however hope for quality universal healthcare.

After extensive consultation with both academia and the industry, the DA’s offer, titled Our Health Plan – to uplift the health sector and introduce a practical and sustainable health plan – is far more effective. It can be rolled out and put into effect within five to eight years, takes into account the needs of all South Africans and, where put into practice, has proved itself.

Furthermore, Our Health Plan will provide quality healthcare which is affordable and can be implemented using our current health budget. This would mean that medical aid contributions would no longer be tax deductible. The additional revenue would go to reducing the costs of medical aid.

Where the Our Health Plan is implemented in the Western Cape, the province has shown that it can deliver better healthcare than in any other provinces, a fact recognised by the MEC of health in Limpopo. Mortality rates are lower – half of any other province, it has attracted the highest number of South African doctors and has the highest number of specialists per capita. Hospitals and clinics are better maintained and have far better resources.

The Minister aims to rob Peter to pay Paul. The current health system has collapsed and is in the severe financial crisis. It can be fixed but will require proper leadership, less corruption and better management and appropriate use of budgets.

The DA health plan is the only alternative to resuscitate a broken system.

Lindy Wilson DA Deputy Shadow Minister of Health.

NETWERK24
’n Opwindende nuwe prosedure wat die lewe van mense met onderste ledemaat-amputasies drasties kan verbeter, is onlangs vir die eerste keer in Suid-Afrika uitgevoer.

’n Professor aan die Universiteit Stellenbosch (US), in samewerking met die Instituut vir Ortopedie en Rumatologie (IOR) by die Mediclinic Winelands, die prostetikus Eugene Rossouw, en medeprofessor Munjed Al Muderis van die Osseo-integrasiegroep van Australië, het op 5 November vanjaar Suid-Afrika se eerste osseo-integrasie-prostese-inplanting uitgevoer.

Die US se fakulteit geneeskunde en gesondheidswetenskappe (FGGW) sê in ’n verklaring die prosedure is oorspronklik in Australië deur Al Muderis ontwikkel, en behels die chirurgiese inplanting van die Osseo-integrasiegroep van Australië se osseo-integrasie- prostetiese ledemaat (OGAP-OPL).

“Die OGAP-OPL is ’n revolusionêre nuwe soort prostese wat wegdoen met die tradisionele prostetiese vassuig-sok deur die prostetiese ledemaat direk aan die persoon se skelet te heg. Dit bied unieke voordele wat die lewensgehalte van mense met amputasies drasties kan verbeter,” sê prof. Nando Ferreira van die US se afdeling vir ortopedie aan die FGGW.

Ferreira is die chirurg wat die prosedure gelei het.

Mense met amputasies ervaar gereeld probleme met die tradisionele sok-prostese, insluitende velirritasie, probleme met hoe dit pas weens byvoorbeeld sweet en veranderinge in die volume van die stompie deur die loop van die dag, ongemak wanneer hulle sit, en die tyd wat dit neem om die prostese aan te sit en af te haal.

“Kandidate word versigtig gekeur vir geskiktheid en tans word slegs individue vir die operasie oorweeg wat ernstige sok-probleme ervaar wat groot inbreuk maak op hul werk en daaglikse lewe.” prof. Nando Ferreira

Probleme wat verband hou met sok-prostese is iets van die verlede met ’n osseo-integrasie-prostese aangesien dié prostetiese ledemaat direk aan die skelet geheg word. Ontvangers het ook beter propriosepsie (persepsie van die ledemaat se posisie en beweging) en kan die loop-oppervlak voel, wat hulle toelaat om met meer selfvertroue te loop.

Die osseo-integrasie-prostese herstel ook die normale anatomiese lynrigting van die dybeen (femoraal) (sien beeld hierby), wat algemene loop-afwykings verminder in mense met amputasies bo die knie. Die prosedure is egter nie sonder komplikasies nie.

Infeksie rondom die inplanting en frakture in die oorblywende been is die mees beduidende komplikasies wat ná osseo-integrasie kan voorkom. “Kandidate word versigtig gekeur vir geskiktheid en tans word slegs individue vir die operasie oorweeg wat ernstige sok-probleme ervaar wat groot inbreuk maak op hul werk en daaglikse lewe,” sê Ferreira. Die ontvanger van Suid-Afrika se eerste osseo-integrasie-prostese-inplanting is ’n 28-jarige vrou wat in 2009 ’n traumatiese amputasie bo haar knie gehad het. Sedertdien sukkel sy met haar sok-prostese, wat inbreuk maak op haar werk en alledaagse aktiwiteite. (Die pasiënt verkies om anoniem te bly.)

Só werk dit:
“Die OGAP-OPL se unieke ontwerp, materiaal en vervaardigingsproses laat toe dat daar been binne-in die oppervlak van die inplantasie groei en so “integreer” die prostese met die skelet.

’n Spesiaal ontwerpte stut wat dan deur ’n opening in die stompie steek, wat chirurgies gemaak is, vorm ’n koppelingspunt vir die eksterne komponente van die prostetiese ledemaat,” verduidelik Ferreira.

Al Muderis is die Australiese chirurg wat die baanbrekerswerk oor osseo-integrasie gedoen het en oor die afgelope dekade die OGAP-OPL-prostese ontwikkel het, asook die chirurgiese tegniek en die rehabilitasie-protokol.

Tot nou is die prosedure al ongeveer 750 keer uitgevoer, meestal in Australië.

“Prof. Al Muderis se entoesiasme om die lewe van mense met amputasies te verander, is sigbaar in sy onvermoeide werk en gewilligheid om ander chirurge op te lei in sy tegniek,” sê Ferreira.

Prof. Al Muderis se entoesiasme om die lewe van mense met amputasies te verander, is sigbaar in sy onvermoeide werk en gewilligheid om ander chirurge op te lei in sy tegniek. prof. Nando Ferreira Ferreira het na Sydney, Australië, gereis saam met die egpaar Eugene (prostetikus) en Fransien (fisioterapeut) Rossouw, om opleiding van Al Muderis te ontvang in die chirurgiese prosedure, prostetiese passing en rehabilitasie. Hierdie span is tans die enigste groep wat gesertifiseer is om die OGAP-OPL-prosedure in Suid-Afrika uit te voer.

Vir die chirurgie op die plaaslike pasiënt is Ferreira bygestaan deur dr. Gerhard Pienaar, ’n ortopediese chirurg van die Instituut vir Ortopedie en Rumatologie aan die Mediclinic Winelands, en Al Muderis, wat van Australië gereis het om toesig te hou oor die operasie. Die pasiënt sterk goed aan en het haar eerste prostese-passing twee weke gelede gehad. Sy het begin met die 12 week lange rehabilitasie-protokol wat progressiewe gewigslading vir ses weke met twee krukke behels, gevolg deur ses weke van bystand-mobilisasie met een kruk.

Die span is van plan om hierdie prosedure aan nog pasiënte te bied, in die openbare, sowel as die private gesondheidsektor, en hoop dat dit ’n goed aanvaarde opsie sal word vir Suid-Afrikaners met amputasies, volgens die verklaring.

BUSINESS REPORT
It is a fascinating time for healthcare globally. Shifting demographics, cost pressures, policy changes, consumer ism, and rapid advances in technology will change the face of healthcare as we know it.

South Africa has its own unique challenges and opportunities. The triple threats of poverty, inequality and unemployment mean many citizens are simply unable to access quality healthcare.

The introduction of National Health Insurance NHI in South Africa aims to address this issue, presenting real opportunities for public private partnerships and innovation.

Shifting global demographics and the demand for healthcare:
People are living longer, many with chronic conditions. We also see population growth, particularly in developing markets such as Africa expected to grow by 2.4 billion by 2050. Populations are becoming increasingly unhealthy, driven by sedentary life styles, high personal stress levels, and poor dietary habits.

The result is an increasing disease burden on health systems. In South Africa alone, 50 people die every day due to diabetes, while an additional 35 lives are lost daily due to respiratory diseases.

At Life Healthcare we are seeing increasingly complex cases, both in terms of diagnoses and treatment. We recognise that our patients require quality care, not only in acute facilities, but across the entire continuum of care.

For this reason, in addition to maintaining the highest quality of care in our hospitals, we are also focusing on building our non-acute offering from primary care services to mental health, rehabilitative care and diagnostic services.

Rising cost pressures:
Healthcare costs are rising globally, jeopardising affordability of healthcare for many. Most healthcare systems are looking at ways to cut costs, and improve disease prevention in society.

At Life Healthcare we pride ourselves on our operational efficiency. We continually work hard to ensure that we remain an effective, productive healthcare provider, without ever compromising on our commitment to quality patient care.

We are also strengthening our offering across the continuum of care to empower patients to take ownership of their health, and to support prevention as well as cure.

Changes in policy and regulatory environments:
Globally the healthcare regulatory environment is complex and evolving. In South Africa, the NHL Medical Schemes Amendments Bills, and outcomes of the Health Market Inquiry will change the healthcare landscape fundamentally.

The goal of universal health care will require strong partnerships between public and private players. If we look for creative solutions and leverage the best from the public and private sector, we have an opportunity to significantly improve healthcare access and affordability in the country.

While we at Life Healthcare appreciate the challenges of execution, we are excited to help deliver on new healthcare models to benefit population segments we don't currently serve.

Consumer centricity:
As people become accustomed to personalised, digital offerings in retail and banking, they will expect similar experiences when it comes to their healthcare. Connectivity and access to information mean healthcare consumers are becoming more knowledgeable and better able to compare quality and outcomes across clinicians and medical service providers.

Patients also demand convenience. In Europe, for example, home based care is gaining traction, while personalised care, walk in services and virtual queueing are also becoming popular.

Evaluation and measurement of patient experience has fast become international best practice and assists in ensuring patient centred care remains a priority for healthcare service providers globally. At Life Healthcare, we are commit ted to clinical excellence and patient centricity.

To this end, in South Africa we publish our patient experience scores in real time, giving insight into the hospital stay and the level of service.

Technology and healthcare access:
The World Health Organisation WHO predicts rapid advancements in technology will drive better quality of healthcare and enable greater access to services by providing more diverse treatment models while lowering costs.

Similarly, the 2018 Philips Future Healthcare Index FHI finds that technology and digital innovation, artificial intelligence, and connected care will be important enablers of healthcare access and ground-breaking treatments, despite the impact of rising costs on affordability.

At Life Healthcare we believe in the potential of technology to transform healthcare. We continuously seek ways to source cutting edge technology to improve patient quality, patient experience and efficiency.

One area already benefiting from technological advancements, and which will continue to grow is diagnostic imaging. Making use of smarter technology means healthcare providers can enhance the patient experience by lowering the risk of diagnostic errors while speeding up the provision of better, more affordable treatment.

We have seen the growing impact of diagnostics within integrated care and Life Healthcare has invested in these capabilities by acquiring the leading European provider of complex molecular and diagnostic imaging services, Alliance Medical Group, to strengthen our offering in this field and provide the best experience to patients across the whole continuum of care. Furthermore, advancements in surgical technology are making a positive impact on surgical outcomes for both the patient and the surgeon.

Life Healthcare's investment into robotics aligns to our strategy to invest in appropriate and proven technologies to remain technologically relevant and drive clinical quality and improved outcomes for our patients. Robotic assisted surgery, for example, allows minimally invasive procedures which reduces the need for blood transfusion and benefits patient outcomes in term of less postoperative pain, reduced risk of wound infection, as well as a shorter hospital stay and faster recovery. To this end, Life Healthcare has invested in a robotic assisted surgical system which will allow us to offer this technology at Life Kingsbury Hospital.

Setting up for future growth:
As healthcare providers, we must develop innovative healthcare models, while continuing to focus on efficiency, quality and patient centricity. We must also build strong partner ships to improve healthcare access and affordability. Despite its challenges, the future of healthcare in South Africa can be bright.

Dr Shrey Viranna is the chief executive of the Life Healthcare Group.

DAILY MAVERICK
On the eve of a quarter century of freedom and democracy, South Africa is engaged in yet another project of transformation that will bring us closer to the fulfilment of our constitutional objective to create a caring, inclusive and more equal society.

Cabinet is shortly expected to consider the National Health Insurance (NHI) Bill, which sets out to create, as Health Minister Aaron Motsoaledi has said, a funding system for healthcare that will guarantee that every individual living in South Africa has access to a free and good quality healthcare at the time of need.

At the core of this initiative is to ensure the widest possible pooling of resources – financial resources to pay for healthcare, and the effective and efficient use of available human and other resources to provide quality healthcare to all.

In pursuing this policy initiative, South Africa is by no means out on a limb. Indeed, South Africa is seeking to align itself with global best practice as experienced in a number of developed and developing economies. The country seeks to answer the call of the World Health Organisation (WHO), which asserts that good health is essential for sustained economic and social development and poverty reduction. The WHO maintains that access to much-needed health services is crucial for maintaining and improving health, and propounds that people need to be protected from being pushed into poverty because of the cost of healthcare.

The WHO defines universal health coverage as ensuring that all people have access to much-needed health services (including prevention, promotion, treatment, rehabilitation and palliative care) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship. Universal health coverage has therefore become a major goal for health reform in many countries and a priority objective of the WHO.

For South Africa, the development and adoption of the NHI is an intervention that aims to end the inequality that is adversely affecting households and workplaces when people are denied certain levels and categories of healthcare, including access to certain technologies, purely because they cannot afford them.

Stories abound of patients being turned away from some health facilities because they cannot afford upfront payments running into tens of thousands of rand or of those critically injured being asked if they have medical aid before paramedics can decide where to take them for treatment. This is a sad violation of a basic human right to access medical treatment that our nation needs to deal with.

The status quo within the medical schemes industry and private healthcare system in general requires a complete overhaul in terms of pooling, purchasing and provisioning of care.

As demonstrated by the Council for Medical Schemes’ (CMS) annual reports and other publications, and to a large extent the Health Market Inquiry Provisional Findings over the past years, medical schemes’ membership growth has stagnated and has recently been declining. The medical schemes have either been amalgamating or liquidating.

Some schemes within this industry are also troubled by bad-risk profiles, and this often leads to increases in claims ratio and inevitably affects premium increases. All this occurs within the context of increased rates of supply-induced demand, excessive profiteering by third parties like administrators, dumping on the state (when beneficiaries run out of benefits), nomination of public healthcare facilities to provide healthcare without having service-level agreements with some medical schemes or the capacity to bill the medical scheme.

This industry is also plagued with issues related to fraud, waste and abuse across the entire healthcare value chain.

At an individual level, members are also experiencing increased rates of out-of-pocket payments and unaffordable premium increases are among other phenomena that leave millions of South Africans not just vulnerable to market forces but to worsening health status and mortality as well.

This has been demonstrated by a recent outcry from some medical schemes members like Zelda la Grange who have used social media to vent their frustration:

• “… I pay R5,000+ per month, and I was told last month that my chronic allowance is depleted, and I must now pay the last two months out-of-pocket. I haven’t been to the Dr once this year. The NHI starts looking attractive…”
• “… A family of 5, I pay R12,000 per month and my kids haven’t seen a doctor in the last 3 months, but our Medical Savings Account is depleted …”
• “… NHI has always been attractive. I pay R6,700 per month. Few months ago, I had to spend 3 days in a hospital and the medical scheme told me to pay R9,000…”
• “… I pay R4,000 with no dependants, I was told by my doctor that I need glasses and my medical scheme asked me to pay R800 over and above R4,000… Never thought I’d see the day when I say it, but NHI is looking attractive…”
• “… Utterly disgraceful, besides paying R12,000 every month, I must pay an extra R2,000 per month for chronic medicine… I ended up paying an additional R20,000 or so…”

Some of these principal members reduce the number of dependants covered, whilst others exit medical schemes due to different affordability challenges. Once these members exit the medical schemes environment, their financial protection against catastrophic healthcare costs diminishes and they now become beneficiaries of the public healthcare system.

All these issues occur within the context of excessive risk pool fragmentation (through multiple schemes and benefit options) and differences within medical schemes in respect of benefit option entitlements (or richness) and limited financial protection for the covered lives, especially the old and sick.

This is the segment of the population that tends to require more protection against catastrophic healthcare costs.

In response to this volatile environment, some medical schemes use benefit design to recruit the young and healthy population whilst the old and sick members will experience entry barriers such as paying late joiner penalties.

It is therefore understood that underwriting is meant to protect the schemes against adverse selection; one needs not forget that it can be viewed as discriminatory as well, especially for the segment of the population that enters the labour market late in their lives due to unemployment.

Unless addressed efficiently through effective implementation of the NHI, where there will be a single pool offering one benefit package being accessed by different types of risk profiles, risk pool fragmentation will continue being a barrier preventing progressive achievement of universal coverage in South Africa.

It is within this background that the WHO recommends that health-financing reforms should consider policy options to encourage risk-pool consolidation, otherwise, implementing other measures (such as increasing the level of prepayment funding) without paying proper attention to changes in risk pooling can result in increased fragmentation, and compromised equity and efficiency goals.

The legislative provisions included within the published NHI Bill should therefore be read in context alongside the NHI Green Paper and NHI White Paper and Policy Document.

Since the publication of the NHI Green Paper in 2012, changes in the current pooling, financing and purchasing mechanisms within the national health system were mooted.

Paragraph 395 of the NHI White Paper states that “… the role that medical schemes will play within NHI must be considered within the current context of the existing two-tiered health system. The establishment of NHI will ensure that the State optimally uses available resources to benefit the national population, including post-retirement entitlements. This requires government’s strategic and decisive intervention to eliminate fragmentation in funding pools which has been shown to adversely impact the performance of the current health system…”

Paragraph 399 further states that “in line with international experience, individuals and households will have the opportunity to purchase voluntary private medical scheme membership to complement this universal entitlement if they choose to. Private health insurance coverage, such as that offered by medical schemes, can play various roles within South Africa’s universal health coverage system… Once NHI is fully implemented, medical schemes will offer complementary cover to fill gaps in the universal entitlements offered by the state…”

These provisions seek to optimise utilisation of available resources, including financial and human resources, and to ensure that people do not insure against the same healthcare costs twice.

It is therefore important to ensure that services provided by medical schemes are rolled out in tandem with the NHI Fund to secure value for money, address current pooling inefficiencies and eliminate duplicative cover or double-dipping.

The recently published Medical Schemes Amendment Bill envisions how the role of medical schemes in our national health system will change and outlines a new interplay between the NHI Fund and the CMS.

This re-organisation of the health system is designed to address long-standing shortcomings within the health system in the areas of human resources, financial management, procurement and supply chain management, and the maintenance of infrastructure and equipment.

This effort to level a critical playing field in our society should be welcomed by all South Africans who respect our Constitution and wish to be part of a healthy, productive and more equal South Africa. DM

Busani Ngcaweni is head of policy in the Presidency, writing in his personal capacity.

MEDBRIEF AFRICA
The Health Market Inquiry’s (HMI) final report and recommendations on the private healthcare sector have been delayed to 31 March next year. Confirming the postponement of the report that was scheduled to be released today, Competition Commission spokesperson Lydia Molefe told MedBrief
Africa that the formal notice of the extended deadline will be published in the Government Gazette today.

According to the HMI Panel, the postponement will allow the inquiry sufficient time to review the 64 submissions received from stakeholders on its provisional findings and recommendations with the seriousness they deserve.

Senior healthcare consultant at HealthMan, Dr Johann Serfontein says although the delay is disappointing, it is not unexpected.

“It does provide insight that the various submissions made by stakeholders following the interim report are being robustly engaged with by the HMI. This is an important engagement step, which cannot be rushed through in any project of this nature,” Serfontein said.

He however expressed concern that a similar robust consideration of stakeholder submissions is not being applied to submissions on the NHI. According to him, procedural issues, such as apparent non-consideration of stakeholder comments are likely to be raised in court at a later stage, as is currently happening in the land expropriation without compensation process.

It was hoped that the HIMI’s final report would be taken into account in the National Health Insurance (NHI) Bill that is expected to be presented to Cabinet next week.  However, this doesn’t seem to have happened with Health Minister Aaron Motsoaledi this week slamming media reports that changes were made to the version of the NHI Bill agreed on by him and former Finance Minister Nhlanhla Nene by a team led by presidential health advisor, Dr Olive Shisana.  He was reacting to statements civil societies, including the Treatment Action Campaign and SECTION27, that the hundreds of submissions on the draft Bill released in June this year were not taken into consideration and that he was adamant to rush it through Parliament before next year’s general elections.

Referring to a letter from Treasury to the Presidency that was leaked to the media earlier this month, expressing serious concerns about the alleged changes to the Bill, Motsoaledi blamed the criticism on “the enemies of the NHI that will do everything possible to cast serious aspersions on the credibility of the NHI process to stop it from becoming a reality”.

Section 27 deputy director Umunyana Rugege told Business Day that although they welcome the HMI’s decision to delay the report to ensure extensive consideration of stakeholders’ submissions, there was a need to conclude the deliberations of the panel as expeditiously as possible in light of the speed of the processing of the NHI Bill.

“As we have argued before, the two processes are linked and should influence each other in the interests of advancing access to healthcare in South Africa” she told Business Day.

BUSINESS DAY
It is unsurprising that the latest National Health Insurance Bill is being rushed through the legislative process without adequate thought. The rush has little to do with meeting the healthcare needs of South Africans. Rather, the aim is to help the ANC win votes in the 2019 election through the false promise of free, quality healthcare for all.

The public submissions on the bill have generally been ignored. Even important points made by the Treasury were thrown into the rubbish bin, it seems.

The people in the government now arguing about the NHI Bill are united in supporting a particularly dangerous idea: that medical aid schemes should be confined to covering health services "complementary" to those offered by the NHI.

Since the NHI is intended to include a vast range of health services, there will be few "complementary" services that medical schemes can cover. Most medical schemes will thus cease to exist when this restriction takes effect.

But medical schemes are the main source of funding for SA’s excellent private healthcare system. Private healthcare will thus also largely come to an end under NHI. This will deprive South Africans of choice and force most to use the dysfunctional public healthcare system.

The government should aim at expanding access to private care. This can be done in various ways, including tax-funded health vouchers, permitting low-cost medical schemes, and making greater use of public-private partnerships.

In seeking to provide all South Africans with decent healthcare, the government should treat the private sector as an ally rather than an adversary.

Marius Roodt: Head of campaigns, Institute of Race Relations

SAKE24
Daar is geen ongerymdhede in die proses van die wetsontwerp oor nasionale gesondheidsversekering (NGV) nie, se dr. Aaron Motsoaledi, minister van gesondheid.

Hy verwerp mediaberigte waarin bewerings van onreelmatighede uitgespreek is in 'n verklaring en meen dit is 'n poging om die geloofwaardigheid van die proses te "beswadder" en die openbare mening daaroor te verander.

Dit kom na berigte oor 'n brief van die nasionale tesourie aan dr. Olive Shisana, raadgewer van die president oor NGV, waarin kom mer uitgespreek is oor veranderinge aan die wetsontwerp wat nou op pad is na die kabinet.

Motsoaledi sit in sy verklaring die feite rakende die konsultasie proses uiteen:

Kommentaar is van belanghebbendes en van die publiek gekry. Dit is deur sy departement hersien en vir die hersiening van die NGV wetsontwerp oorweeg.

Verdere konsultasie met belang hebbendes is gedoen. Dit sluit in 'n beraadslagende vergadering waar op pres. Cyril Ramaphosa op 24 Augustus met meer as 300 partye geskakel het. Op die vergadering het Ramaphosa aangekondig hy sal die NGV proses as staatshoof lei.

Die media het vrae gehad waarop Motsoaledi se hy het Ramaphosa persoonlik gevra om die proses te lei omdat dit 'n "seismiese gebeur tenis" is wat die leiding van die staatshoof benodig.

"Daarom is daar niks sinisters vir die presidensie om in die NGV proses betrokke te wees nie. Dit is ontwerp om so te wees," sê hy. Motsoaledi se die NGV is 'n "vlagskipprogram van die staat wat ontwerp is om te verseker dat ons ons grondwetlike mandaat van ge sondheid kan lewer as 'n reg van elkeen in die land".

Sedert die Verenigde Nasies VN die beginsel van universele gesond heidsdekking aanvaar het as een van die 17 doelwitte vir volhoubare ontwikkeling, het "staatshoofde in die meeste groot demokratiese lan e die verantwoordelikheid aan vaar om dit te bereik".

Die NGV is Suid-Afrika se uni versele gesondheidsdekking. "Dit sal agterlosig wees van ons presidensie om afsydig te staan teenoor so 'n groot poging."

Na die beraadslagende vergade ring het Motsoaledi met burgerlike organisasies, akademiese instel lings, dekane van fakulteite van ge sondheidswetenskap, tradisionele leiers, vakbonde en professionele mediese verenigings gepraat.

Daar was wye konsultasie tussen die nasionale tesourie en die departement van gesondheid wat deur die presidensie gefasiliteer is.

"Soms was dit deur briefwisseling. Dus was daar niks onbetaamliks aan die brief wat die tesourie oor die kwessie geskryf het nie.

"Die soort gesprekke sal voort gaan tussen staatsdepartemente in die wetgewende en die beleidma kende proses." Hy ontken dat "enige wetgewing oortree is of dat daar enige onwet tigheid of onreelmatigheid" in die wyse is waarop die wetgewingspro ses tussen die departement, sy amp tenare, die tesourie, die presidensie en die res van die regering plaas vind.

Motsoaledi glo dit is sinister dat die brief aan die media uitgelek is. Hy se dit is deur gewetenlose amptenare gedoen wat voorgee hulle het iets "boos" in die gesprek tussen staatsdepartemente blootgele.

POLITY
Solidarity’s Occupational Guild for Health Practitioners today expressed their dissatisfaction with the irresponsible way the National Health Insurance Bill (NHI) is dealt with. This followed the Health Department’s attempt to get the proposed bill approved without proper public participation and consultation.

According to Morné Malan, senior researcher at the Solidarity Research Institute (SRI), the Health Department’s conduct indicates that this department is increasingly willing to push through harmful policies despite their negative impact on the fiscus and the health of South African citizens.

“Minister Motsoaledi reacts to criticism as if he believes he is at war with organisations that try to promote and protect citizens’ rights. Perhaps he should ask himself what is giving rise to this perception. The department has been acting in bad faith ever since the bill was released in June. They are cryptic about finances, practical matters, the nature and extent of the NHI fund, the impact on health practitioners and more. They clearly also do not pay attention to comments or suggestions to improve the current system. Furthermore, the estimated costs of the NHI are not yet known, but it will be an enormous amount,” Malan explained.

Solidarity emphasised its opposition to the NHI Bill and the nationalisation of health care by effectively expropriating the resources of private health care. “We refuse to accept the narrative that the department seeks to make South Africa a healthier country because this bill in particular has several shortcomings that will have countless conceivable – and probable – negative consequences – economically and especially with regard to the health of South Africans. When governments act in this way, they must be treated as ideologists or megalomaniacs, or both,” Malan said. 

In addition, Solidarity rejects the efforts of the department to classify the debate regarding the NHI as a struggle between different classes. “This issue is not about rich versus poor. It has to do with being sick versus being healthy. At present, our public health care is so sick, it is almost terminal, and no-one will benefit by transferring all health care to these bureaucrats. It will merely nationalise the service that has led to the Esidimeni tragedy and the countless public hospitals already falling apart, until nobody can escape the government’s incompetence any longer,” Malan emphasised. 

BUSINESS DAY
President Cyril Ramaphosa's ambitions of getting a blueprint for fixing SA’s health system in the next two weeks have hit a stumbling block.

The Presidency has delayed the signing of this "health.com pact" until the end of January, spokesperson Khusela Diko confirmed. Healthcare professionals had complained that the deadline was unworkable.

The commitment to crafting this plan emerged from a two day health summit convened by the president in late October, which drew 600 delegates from the public and private healthcare sector as well as labour and civil society organisations.

The gathering was cast as a high level meeting to thrash out ideas for tackling the crisis confronting SA's public health system, which is grappling with corruption, staff shortages, and stock outs of even basic medicines such as contraceptives.

However, there is growing disquiet and suspicion that the government is seeking to spin the event to create the impression that participants endorsed its National Health Insurance (NHI) plans.

NHI is its flagship policy for achieving universal health coverage, and its first piece of enabling legislation is due to be tabled in cabinet next week.

Health minister Aaron Motsoaledi told Radio 702 earlier in November that the summit had given NHI the green light.

"Everybody endorsed NHI and said it must go ahead," he said at the time.

Fazel Randera, a member of the Progressive Health Forum, said focus should be rather spent on multiple crises facing the health service, rather than the NHI.

"At the end of the summit we were given a slide session summary of what had come back from the various commissions.

"One read that there should be one health service for one country and that NHI was no longer a debate.

"Now there was no discussion on those particular points," said Randera, who is a member of the summit task team chaired by presidential adviser Olive Shisana.

A power point presentation entitled "Way forward health summit", provided to Business Day after the summit, said participants were "committed to one country one health system", and that universal healthcare coverage" is not negotiable and NHI is a means to get there".

The SA Medical Association Sama was so concerned about the December 10 deadline that it convened a meeting of more than 60 associations representing healthcare professionals a fortnight ago, at which they resolved to seek a four month extension.

Sama chairperson Angelique Coetzee said the deadline had been unrealistic as the views of more than 100 healthcare associations and societies needed to be canvassed.

The health system had to be fixed before implementing NHI, she said. Separately, Motsoaledi issued a statement on Wednesday defending the government's handling of the NHI Bill, which has been mired in controversy after a leaked Treasury letter revealed it was butting heads with Shisana over a host of measures she and her team had changed after the public comment period closed in September.

Motsoaledi said he rejected "with contempt" reports of alleged irregularities in the manner in which the legislation was being processed.

BUSINESS DAY
The hotly contested bill paves the way for the establishment of a central fund that will purchase services on behalf of patients.

The DA plans to seek legal advice on the National Health Insurance (NHI) Bill, which is due to be tabled before the cabinet on December 5. The hotly contested bill paves the way for the establishment of a central fund that will purchase services on behalf of patients, and is a vital step towards the government’s ambitions of providing universal health coverage.

The bill is now mired in controversy, after it emerged in early November that Treasury officials were butting heads with the president’s adviser, Olive Shisana, over a host of measures she and her team had introduced or changed after the public comment period on the bill had closed.

The Treasury also raised concerns over the extent to which public submissions were considered. The extent to which the Treasury’s concerns have been addressed is not clear at this stage, as cabinet documents are classified and rarely leaked.

The controversy was heightened last week after health director-general Precious Matsoso revealed that she had been side-lined and had played no role in revising the bill after it had been released for public comment in June, despite being the department's accounting officer. 

“If the ANC government continues to push through the NHI Bill without proper public participation and consultation, the DA will seek legal advice regarding the highly irregular process followed in revising the NHI Bill,” DA deputy health spokesperson Lindy Wilson said.

“The minister’s backdoor dealings subsequent to the closure of public comment period, effectively mutes any input from the public, as the proposed changes are substantive, and the public and other stakeholders have not had an opportunity to raise their concern.”  Wilson said the revised NHI Bill should be made public, and the public participation process reopened. 

CAPE TALK
Health Minister Aaron Motsoaledi has fired back at critics who have protested over the speed at which the National Health Insurance (NHI) Bill is being processed.

In a statement issued on Wednesday, the ministry said there are those who have sought to cast aspersions on the integrity of the process.

This follows reports about apparent breaches in protocol in the development of the latest version of the Bill, which was submitted to Cabinet’s social development sub-committee.

Motsoaledi joined Karima Brown on her show to respond to this and other questions related to the bill.

“It puzzles me. It is true that there were robust discussions between health and treasury. Even on Monday afternoon, I had a meeting with the finance minister and presidency. We meet quite often.” — Aaron Motsoaledi, health minister

“This is a flagship government programme which has been commissioned by the ruling party as far as 2007.” — Aaron Motsoaledi, health minister

“It is written, it has been developed over a long time.” — Aaron Motsoaledi, health minister

“It is not something that is going to be left to chance, it is a huge thing. A seismic shift.” — Aaron Motsoaledi, health minister

Click here to listen to the full conversation.

IOL
The Health Ministry has condemned those who have criticised the speed at which the National Health Insurance (NHI) Bill is being processed, claiming they want to “delegitimise” the process.
 
“We have no doubt that enemies of NHI will do everything possible to try to stop NHI from becoming a reality, failing which, they will try to cast doubt and aspersions on the integrity of the process,” according to the ministry statement issued this afternoon (28 November).

“We wish to reassure the nation that no law is being breached nor any illegality or irregularity committed in the manner in which the legislative process towards the realisation of the NHI is being conducted between the Department of Health, its officials, the Treasury, The Presidency and the rest of government.”

This follows a week of media reports about apparent breaches in protocol in the development of the latest version of the Bill, which was submitted to Cabinet’s social development sub-committee yesterday.

Last week, a letter written by acting Director General of Treasury, Ismail Momoniat, to NHI Presidential advisor Dr Olive Shisana was leaked to the media. In it, Momoniat said that Treasury could not support the latest version of the Bill as it had been “very substantively amended in October”, removing various agreements reached between the Ministers of Finance and Health.

After the publication of the leaked letter, Treasury said “we have reached agreement on most of the major issues,” and “we are confident that we will soon publish this important Bill for tabling in Parliament.”

However, on Monday, civil society organisations said that the three-month comment period on the Bill had been too short, and called on Cabinet to “send the NHI Bill back to the Department of Health and to require a proper and thorough consultation process and consideration of options available for improvement of access to and quality of health care services in the country”.

The Treatment Action Campaign (TAC), SECTION27, Rural Health Advocacy Project (RHAP), People’s Health Movement (PHM) and Lawyers for Human Rights (LHR) also said that the current Bill “risks damage to the functional elements of the health system – public and private” and that “government needs to focus on fixing the crises in private and public health rather than on hastily passing legislation that, in its current state, takes the country in the wrong direction”.

But the Ministry said that the Health Minister had already explained that “whatever outstanding issue that could not be raised through public participation within that period of three months will still be achieved when Parliament conducts public hearings throughout the length and breadth of our country. Such public hearings are still coming.”

It also explained that the Presidency was driving the NHI at the request of the health minister because “NHI is a huge seismic event which will need the guidance of the Head of State”.

“NHI is not just an ordinary government programme. It is a flagship programme of the state which is designed to ensure that we deliver on our constitutional mandate of Health as a right of all citizens regardless of their station in life,” said the Ministry.

“Ever since the United Nations adopted the concept of Universal Health Coverage (UHC) as one of the 17 world's sustainable development goals, in all major democracies of the world, Heads of State have taken over the responsibility of being the major advocates and drivers of the process towards the achievement of Universal Health Coverage which in our country is NHI.  It will be remiss for our Presidency to stay aloof from such a major world endeavour.” 

BUSINESS DAY
Health director general Precious Matsoso broke ranks in truly remarkable fashion last week when she accused President Cyril Ramaphosa's adviser, Olive Shisana, of sidelining her in the development of the National Health Insurance (NHI) bill.

The director general is the department's accounting officer and will be tasked with defending the proposed legislation when it is introduced in parliament. Yet she says she played no role in revising its release for public comment in June, a statement confirmed by Shisana

For the director general to be left out in the cold in this manner is truly astonishing. And for her to lay bare the dysfunction in the government by further claiming Shisana has ridden roughshod over the public consultation process makes it even more so.

The bill is a key aspect of the government's ambitions for realising universal health coverage as it sets out the legal framework for establishing a central NHI fund that will purchase health services on behalf of patients from public and private sector providers. It is vital that the government gets it right, both in terms of the content and the public consultation process that informs the final draft presented to parliament. If the government gets either aspect wrong, it lays itself wide open to legal challenge. There were signs of trouble even before Matsoso spoke out.

A leaked letter sent from the Treasury to Shisana on November 9 exposed sharp division, with the Treasury complaining that Shisana had removed key aspects that it had previously fought to include.

According to the letter, she reintroduced several problems that the ministers of finance and health had resolved previously, including immediate relegation of medical schemes to a complementary role once the bill was enacted, thus limiting them to providing cover only for services not offered by the NHI.

The Treasury quite rightly warned that her approach would be perceived as a threat to the private sector, medical scheme members and tax payers. The result, it said, would leave the bill open to legal challenge.

The Treasury also warned that far reaching proposals to shift a host of functions from provincial health departments without consultation with the bud get council and provinces were in breach of the Intergovernmental Fiscal Relations Act and it raised concern about the insertion of an uncosted proposal to establish 300 contracting units that would purchase services for patients.

Shisana appears to have hastily bludgeoned together a revised bill, with the help of just two people, selected by health minister Aaron Motsoaledi, in order to get it into the cabinet process before the end of the year. Given that public submissions closed on September 21 and about 180 were received, it is unlikely that Shisana and her team could have reviewed them properly by early November, as by this stage the Treasury was writing to complain about her changes.

This is typical of the way the ANC government has handled the development of its NHI policy, which it has rushed at every iteration for the past decade to meet politically motivated deadlines, from policy conferences to looming elections. That perpetual hurry has served no one's interests but those of politicians.

Weak policies clearly place at risk the government's hopes of providing decent healthcare services that are free at the point of delivery to everyone. But there are other pitfalls.

The presidency's apparent lack of consultation jeopardises the government's fragile relationship with the private sector. The presidential health summit convened by Ramaphosa in late October sought to strike an inclusive and consultative tone, with his deputy, David Mabuza, telling delegates all sectors need to be involved to tackle the problems confronting SA's health system.

If Shisana and her team are not even consulting properly within the government, how can the private sector trust its views will be heard on anything at all?