The South African Medical Association (Sama) believes that the Competition Commission Health Market Inquiry (HMI) provisional report is faulty in its findings, particularly that doctors increase demand for unnecessary services.
In a statement, the association says that in light of the fact that the investigation took almost four years to complete and runs to hundreds of pages, it is, on first review, somewhat disappointed in the overall analysis of the private healthcare sector.
Doctor-induced moral hazard
Sama is particularly concerned about the allegations that doctors increase demand of unnecessary services, including increased admissions to hospitals, says chairperson, Dr Mzukisi Grootboom.
“The HMI reached this conclusion after analysing claims data. We are of the considered view that the methods used by the HMI were not robust enough to conclude that many admissions are unexplained and thus constitute a doctor-induced moral hazard,” he says.
In 2017, the Medical Research Council presented to Parliament the top 10 diseases that kill South Africans. These included HIV and Aids, cerebrovascular disease, lower respiratory tract infections, ischaemic heart disease, tuberculosis, diabetes mellitus, hypertension, interpersonal violence, other trauma-related injuries, liver disease and diarrhoeal illnesses. In 2015, Statistics South Africa reported cancer to be the fifth cause of death in the country.
“Typically the private sector uses the Prescribed Minimum Benefit Chronic Conditions List (PMB CDL list) to define chronic conditions. The list only includes three of the conditions which kill South Africans. The HMI can therefore not conclude that there are unexplained admission after adjusting only for chronic diseases and age. Sama believes the increase in admission can be explained by high prevalence of injuries, acute infections, cerebrovascular accidents, cancer, tuberculosis, and substance abuse, amongst other factors,” says Grootboom.
Disregard of mental health
Dr Grootboom says it is also concerning that the HMI assumed all psychiatry and paediatric admissions are discretionary. This is patently wrong.
“This cannot be true given the recent developments in mental health. If psychiatry admissions are really discretionary, we would not have witnessed the development of the Life Esidemeni crisis. No doctor will choose to admit a mental health patient if an option for community-based care exists. In a country where high causes of mortality rates in children include lower respiratory tract infection and diarrhoea, assuming that all paediatric admissions are discretionary is quite flawed,” Grootboom notes.
The HMI analysed the proportion of discretionary admissions in 10 specialities. He says it is astounding that all cardiology and cardiothoracic admissions appear to have been considered discretionary against the backdrop of ischaemic heart disease being responsible for a significant proportion of deaths in the country.
He notes that almost all of urology and orthopaedics admissions were also considered discretionary.
“Treatment of hip fracture with arthroplasty or early prostate cancer is not discretionary; these are the standards of care,” he says.
In addition Grootboom notes that black men in South Africa are more likely to suffer aggressive forms of malignancies or cancer and that a watch and wait strategy is therefore clinically not appropriate in our setting.
Further to the report’s findings that unpaid claims should be construed as unnecessary care, Grootboom says schemes typically do not fund clinically appropriate care if they judge it is not a prescribed minimum benefit and not covered by plan type.
“Unfortunately, the allegations of doctor-induced demand can erode the patient-doctor trust. As a profession we will continue doing our level best to care for and save the lives of all South Africans. We will also further engage with the HMI after a complete analysis of this lengthy document.”
What are your chances of ending up in a hospital? Higher than you’d think if you are a medical aid member in a large city – and the reason reveals some never-before-seen truths about the country’s private healthcare sector.
A lack of competition within the private healthcare market is fuelling an epidemic of overtreatment — and mystery medical bills — in South Africa, the Competition Commission revealed on Thursday.
Supply-induced demand
As part of a four-year investigation into private healthcare costs, the Competition Commission looked at hospital admission rates among patients treated in nine specialised areas of medicine. People who had insurance and lived near more hospitals were more likely to be admitted than people with similar conditions that lived farther away from lots of empty beds, the statutory body found.
This correlation also held true when the body looked at intensive care unit (ICU) admissions.
It’s a phenomenon known in healthcare as “supply-induced demand” or the premise that the more supply you have of beds, doctors, medicine, the more people use them regardless of whether they need them or not.
But too much of anything can be a bad thing, including medicine — especially when it comes to your medical aid premiums.
The commission analysed hospital claims and found that almost a third of claim costs couldn’t be explained by factors such as a patient’s age or disease. These mysterious costs were being passed onto consumers in the form of increased premiums, the commission argues.
The unchecked rise of overtreatment is just one of the ways private healthcare isn’t working for South African consumers, the commission found. The report was released as part of the country’s first inquiry into the private healthcare market.
The body also argued that although South Africans are paying more for private healthcare than ever before — via nearly 300 medical aid benefit plans —they are getting less for their money. This is partly because the plethora of options makes it impossible for consumers to compare value for money.
Little market pressure
Meanwhile, with a few companies dominating sectors, including administrators, medical aid schemes and hospital groups, there’s little market pressure for companies to curtail unnecessary costs, explains the commission in its report.
“All schemes have failed to manage supply-induced demand adequately. We would expect medical schemes to force their administrators to actively manage this in the interest of protecting scheme members’ health and the financial sustainability of the scheme,” the commission writes.
“The widespread inability to manage supply-induced demand suggests a lack of effective competition in the market for administration.”
Private hospital groups
Discovery Health and Medscheme have cornered about 76% of the medical administration market based on contributions. Discovery Health Medical Scheme dominates 55% of the public medical scheme market. When it comes to hospitals, the big three — Netcare, Mediclinic and Life Healthcare — own 83% of private hospitals beds nationally.
“Competition [among medical aids] is simply not as rigorous as it should be and appears to be almost non-existent,” said inquiry chair and former Chief Justice Sandile Ngcobo.
Hospital groups compete to attract healthcare workers, particularly specialists — dynamics that may be fuelling the over-treatment of South Africa, the report says.
“There is an alignment of interests between facility and practitioner where both stand to benefit from higher treatment volumes and intensity.”
The uninformed patient, the report states, “assumes that these arrangements are always to his/her advantage and is not concerned with the longer term financial impact on medical scheme cover.”
Standardised medical aid benefits
Health Minister Aaron Motsoaledi initially approached the commission to investigate high private healthcare costs soon after taking office in 2009. He has viewed the commission’s work as crucial to helping make private healthcare cheaper and eventually allowing the government to purchase affordable services from the private sector as part of the National Health Insurance.
“Let me start by thanking you because, as the department of health, you have given us more than what we asked for,” said Motsoaledi, speaking at the report’s release.
Among the commission’s recommendations is the creation of a basic medical aid benefit option standardised among all schemes to help consumers better navigate benefits as well as the increased use of cost-effective measures such creating specialist groups to treat patients as a team. This concept is already being explored by companies including Discovery Health and healthcare management firm PPO Serve, which argue it could bring down costs but also improve patient care.
The commission will accept public comment on the report before releasing its final document in November.
A report by the Health Market Inquiry (HMI) looking into the private healthcare industry has recommended that there be increased transparency and improved competition.
Sandile Ngcobo, former chief justice. Photo: eThekwini Living Legends
The HMI released its provisional report on Thursday after hearing evidence from a number of stakeholders in the past three years.
The inquiry, which is chaired by the ex-Chief Justice, Sandile Ngcobo, was set up to look into the costs of healthcare and the operations of medical schemes.
“Overall we recommend changes to the way scheme options are structured to increase comparability between schemes and increase competition in that market.
“A system to increase transparency on health outcomes to allow for value purchasing.
“A set of interventions to improve competition in the market through a supply side regulator,” the report reads.
Cabinet has welcomed the release today of the interim report by the competition market inquiry (CMI) into the private healthcare industry.
Reviewing prescribed minimum benefits
In addition, the HMI proposed that the prescribed minimum benefits (PMBs) package, which will be included in the base benefit package, must be reviewed and updated at least every three years.
This is consistent with existing legislation and in line with current initiatives by the CMI to review the PMBs.
“This caution is required as the base cover is yet to be defined. To facilitate scheme members’ understanding of PMBs, including what they are entitled to and when additional out-of-pocket payments may arise.
“During the pre-authorisation process, members should explicitly be told whether their choice of service provider or treatment course has additional cost implications and what alternatives are available,” the report states.
The provisional report will be open for public comments for a period of two months.
The final report will be submitted to the minister of economic development, by the end of 2018, and will be tabled in parliament.
While the proposed amendments to the Medical Schemes Act seek to lower the cost of private healthcare, they may have the unintended consequence of threatening the sustainability of medical schemes.
Lerato Mosiah, CEO of the Health Funders Association
The amendments look at abolishing the practice of copayments on certain benefits, removing waiting periods and prescribed minimum benefits and tapping into the reserves medical schemes are required to hold.
These provisions in isolation could affect the financial stability of medical aids, says Lerato Mosiah, CEO: Health Funders Association (HFA). “Whilst we welcome the dialogue in the sector, it is critical that this takes into consideration the broader picture and context. It is thus important to understand that medical schemes utilise risk management measures in order to ensure that they remain viable.
Tampering with these limited measures in isolation would accelerate the erosion of reserves and leave medical schemes with very few options to maintain sustainability.”
Legislation governing medical schemes, despite its limitations, has been successful in ensuring that members are safeguarded in several ways. These include provisions in the Medical Schemes Act to ensure that members are not discriminated against according to their risk and age profile and that every member is entitled to a specified set of hospital, emergency and chronic benefits.
Notwithstanding, these provisions which protect consumers, should have been counterbalanced in the Act by provisions which keep medical schemes sustainable to ensure ongoing protection of consumers. Enhancements that could have been included are compulsory membership, a risk equalisation mechanism and a framework for healthcare tariffs.
Health Market Inquiry
Another key development in determining what healthcare in South Africa will look like on the future is the Competition Commission’s Health Market Inquiry (HMI) report. The commission was tasked with investigating the drivers of costs in the private healthcare sector, and will, in the next few days, hold a media briefing to announce the much-awaited provisional report on its findings and recommendations.
“We are looking forward to the HMI report which we hope will recommend interventions that will ensure the industry remains viable in support of universal health coverage (UHC). These could include a mechanism for negotiating doctors’ and hospital charges more effectively, and mandatory medical scheme membership for people earning above a certain threshold,” Mosiah says.
“Medical schemes have a bigger and critical role to play in increasing access to quality healthcare for more South Africans. Between medical schemes, doctors and hospitals there is sufficient data to be able to publish information on quality which would enable consumers to make educated choices when it comes to choosing their healthcare provider. It is therefore my hope that the HMI recognises this and makes recommendations to government to enable a sustainable industry that contributes to long-term benefits to consumers of healthcare products and services,” she concludes.
Bonitas Medical Fund welcomes the draft amendment Bill to the end that it aims to make healthcare more accessible.
Kenneth Marion, Chief Operating Officer of Bonitas Medical Fund
“While in principle we support the actions of the government and applaud them for taking proactive measures to improve the quality of national healthcare in South Africa, we have reservations and concerns around some of the proposed amendments. And this not only in respect of representing private medical schemes,” says Kenneth Marion, COO of Bonitas Medical Fund.
The universal National Health Insurance Bill proposed by The Minister of Health, Dr Aaron Motsoaledi, is defined by the World Health Organisation (WHO) as ‘universal health coverage means people will receive the health services they need without suffering financial hardship’.
Concerns
No one is disputing that a comprehensive and viable healthcare system is needed in South Africa and is long overdue. However there are a number of questions which still need to be answered:
How the system will ensure quality healthcare is provided; how it will be administered and how it will be funded?
Another is around the proposal that there be a single public purchaser and financier of health services for the country.
The role of medical schemes
Previous pronouncements on NHI intimated that medical schemes would essentially be reduced to playing a complementary role within the NHI dispensation. In the draft Bill, there are no explicit provisions for significant changes in the role, structure and functioning of the medical scheme industry, other than to mention that they will cover what the NHI doesn’t.
“However, it is important to note that the NHI Bill was published in tandem with the Medical Schemes Amendment Bill which contains some fundamental changes for schemes which have potentially far reaching implications on the benefits options, structuring, membership coverage and funding obligations.”
Funding
“Our knowledge and experience enable us to assist the Government with the funding aspect, ensuring there is value for money, for instance, by avoiding duplication,” Marion says. “We have a great deal of experience in keeping healthcare systems cost-efficient. We feel that perhaps the Bills were presented prematurely, are more of a strategy with the implementation being at best, vague.”
Fraud, Waste and Abuse (FWA)
“One of one of the major drivers of healthcare inflation and increased costs is fraud, waste and abuse (FWA) which adds an estimated R22bn to the annual cost of private healthcare,” says Marion.
“A conservative estimate is that between 10 and 15% of claims contain elements of fraud. Private medical schemes have invested heavily to introduce robust analytical software programme to help identify anomalies and irregularities to put a stop to FWA. We’re not sure that one central fund for all healthcare funding and purchasing power is the most prudent option. A system of this kind is open to corruption and abuse on an even larger scale.”
Medical aid – a complementary role
That said, we remain positive that we can play a role in plugging the gap left by the NHI, a gap conceded by the Government. The Bonitas mandate is to provide affordable and quality healthcare for all South Africans and we see our role as a complementary health product provider to the NHI.
Optical care
While comprehensive in terms of healthcare coverage, the NHI won’t cover everything. “Dentistry, optical care and other lifestyle conditions aren’t necessarily high priorities because there are bigger burdens in other areas,” says Marion. According to WHO, 246-million people worldwide have low vision and 39-million are blind – most of them in developing countries. As much as “80% of all visual impairment can be prevented or cured,” says the WHO, but many do not get the treatment needed.
So of the world’s 39-million blind people – most of whom are in the developing world – 30 million lost their sight unnecessarily; their blindness could have been prevented through basic health care and simple procedures like cataract operations.
In addition to this, 2.5 billion people don’t have access to glasses 700 years after they were invented. We believe this is one of the areas in which we could provide a complementary service.
Managed care
‘We are also keen to play an active role in preventative and managed healthcare something which has been neglected. Dr Motsoaledi has said numerous times that ‘Lifestyles diseases have become an epidemic in South Africa and this too needs to be addressed’. There are risks involved when people are only diagnosed once they suffer from a certain preventable condition.
Diabetes is a good example. Many people are pre-diabetic. Through our managed care programme we encourage people to change their lifestyle and make sure they go to the doctor regularly to prevent them from becoming full-fledged diabetics. The Government has made a pledge to tackle the epidemic of lifestyle conditions but we feel that the burden of disease is so vast that the NHI system will not be able to manage this for over 55 million people.
Changes to medical schemes Abolishing brokers
“We feel the role of brokers is not completely understood. Their role is not to simply to sign up members. Brokers help alleviate some of this confusion by providing an independent evaluation of a person’s specific circumstances, both from a financial and healthcare perspective,” says Marion.
From a servicing perspective, brokers are ‘invaluable’, as they aid consumers in resolving their queries quickly and efficiently, and help educate them. We feel South Africans should have a choice whether they would like to use a broker when it comes to making their healthcare choices.
Co-payments
The reason why rates are higher than those prescribed by the National Health Reference Price List (NHRPL) is that the last time the rates for healthcare services were set was in 2006 – 12 years ago. With an increase of around 3-6% the prices have not kept up with healthcare inflation, the rates are not viable for a healthcare provider to run a viable practice. In fact, the rates set by the NHRPL haven’t broken the R300 mark for a consultation yet. This is why most rates are higher why there are co-payments. The reality is that many medical scheme plans offer payment way over the medical aid rate.
Marion believes the abolishment of co-payments is quite idealistic. This amendment would mean the full cost of healthcare would be covered by schemes. Co-payments were initially introduced to contain and manage rising healthcare costs by encouraging members to use Designated Services Providers (DSPs) and network hospitals and to manage expensive elective surgical procedures.
But Marion explains that in all instances in which co-payments arise, consumers have alternative options to take. The reality is that healthcare inflation is rising at an alarming rate and comfortably outpacing general inflation. In order to mitigate the effect of this, medical schemes negotiate rates with DSPs to ensure members access care of high quality and get maximum value for money. However, a member is still free to utilise another provider but this may attract a co-payment as this is a means we use to not only encourage a member to make better healthcare decisions.
By way of example, co-payments often apply to elective procedures, or out-of-pocket payments for medicine if generics are available, and if a consumer receives healthcare from a service provider which has not been designated in terms of the rules of the scheme.
Solvency ratio and reserves
It has been indicated that the Council of Medical Schemes (CMS) is currently reviewing the legislated 25% reserves requirement. This with a view to introducing a more risk-based capital approach that could allow a portion of the existing reserves to be released to help alleviate members’ needs in terms of funding for health care services and/or reduce annual premium increases. This review is welcomed by the industry, should it be implemented responsibly.
Regulation of prices
There are large-scale changes that would affect private providers of care (both healthcare professionals and hospitals), including the data requirements, contracting and tariff regulations. It is envisaged that this will be the cause of much engagement and/or legal proceedings. There are some potential positives in the proposals for the introduction of some uniform prices for health services. This provision could be beneficial for the medical scheme industry as it will create a uniform set of prices/tariffs by which schemes can purchase services from providers and suppliers of health products – nonetheless, it is unclear in the Bill whether the prices that will be determined by the NHIF will be uniformly applicable to all purchasers of health care services.
We wish to re-iterate that the process is that comments will be received from various stakeholders within the industry over three months and that these will be considered before a final Bill is tabled.
There’s no dispute that South Africa’s health care system needs major reforms. There are considerable inequities in health care between urban and rural areas; between public and private health sectors and between primary health care and hospital care. And the country has a complex disease burden with heavy caseloads of HIV, TB and non-communicable diseases.
South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on health care. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector.
The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private health care costs and poor quality of care.
But in its current form the proposed legislation won’t be a silver bullet. There are still too many inconsistencies and unanswered questions for it to be the final roadmap to universal health care in the country.
For example, the bill focuses on curative services, missing an opportunity to take a public health approach that focuses on disease prevention, health promotion and health protection. In addition, it doesn’t address the relationship between the public and private health sectors which is seen as a major impediment to fundamental change.
How it will work
The bill is informed by a vision of ensuring equitable access to quality health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The proposed insurance fund envisages the consolidation of public and private revenue into one funding pool.
The idea is to enable a more equitable system through, for example, cross-subsidisation and ensuring that essential services are made available.
All people will have to register as users of the fund at an accredited health care establishment or facility (whether public or private). And the fund will decide on the health benefits that the facilities will have to provide. This will depend on what resources the facility has. People will be able to pay for complementary health service benefits not covered by the fund.
To be paid, health care providers, such as general practitioners and hospitals, will have to register with the fund. They will have to claim for each patient that they treat and will have to keep a record of diagnosis, treatment and length of stay.
The structure that’s been proposed for the fund is raising concerns on two fronts: it appears unnecessarily cumbersome and there’s a lack of clarity on lines of command.
Governance
The bill makes provision for the fund to establish an independent board that will report to South Africa’s Parliament. But it makes no mention of how the board will engage with the health minister (political custodian) and public servants in the health department. Nor does it explain how the performance of the fund will be evaluated.
The bill also introduces two additional management layers: district health management offices and contracting units for primary health care. These units will provide primary health care services in specific areas. It includes a district hospital, clinics and community health centres as well as ward-based outreach teams and private primary care service providers. They will be contracted by the fund.
National, provincial, and municipal health departments will still exist.
But the bill fails to explain the relationship between the district health management offices and the contracting units and how they will engage with the national, provincial and municipal health departments.
Given that there are ten health departments operating in South Africa – a national department and one in each of the country’s nine provinces – these additional offices and units could result in a more cumbersome bureaucracy. This could lead to more inefficiency and greater opportunity for corruption.
The new structure will also change the responsibilities of provincial health departments. Some of the proposals don’t make sense such as the idea that municipalities should take control of managing communicable diseases. Ideally this should be a national function, given the serious threat that is posed by some infectious diseases.
Many questions
Other parts of the bill are also unclear. These range from financing to how complaints will be managed.
Health financing and management: The bill doesn’t explain what the tax implications of the national health insurance will be for citizens. It also doesn’t set out the mechanisms that will be put in place to strengthen financial planning and monitoring systems, particularly in the public health sector. These are very important given current chronic overspending, inadequate financial management and corruption and lack of accountability in many provincial health departments.
Service provision: The bill says everyone is entitled to a comprehensive package of services at all levels of health care. But it doesn’t spell out what these packages will include. Given budgetary constraints, it’s obvious that there will inevitably have to be trade-offs and difficult choices.
The health workforce: South Africa doesn’t have a comprehensive health workforce strategy with detailed norms and standards. This remains the Achilles heel of health sector reform in the country. The lack of detail remains a serious omission in the bill.
Complaints mechanisms: The bill introduces a new separate complaints directorate – the investigating unit. But it’s unclear whether this will be the first level of complaints or whether it’s a duplication of the complaints directorate in the existing Office of Health Standards Compliance. There also isn’t clarity about where the Health Ombud fits in.
Ensuring that South Africa has a quality affordable health care system is critical. And the bill presents an important opportunity to think systematically about what needs to be done to fix the current health system. But there is still a long way to go.
Two of the proposed amendments to the Medical Schemes Act will do away with co-payments, and abolish the practice of using brokers within the medical schemes environment.
Health Minister, Dr Aaron Motsoaledi
Co-payments
Health Minister, Dr Aaron Motsoaledi, said co-payments mean that the scheme pays a portion of the bill that a provider – be it hospital or private doctor – charges to a patient. The rest of the funds are supposed to be paid by the patient from their own pocket.
“The amendment means that every cent charged to the patient must be settled fully by the scheme and the patient should not be burdened with having to pay. There are people who will scream that this amendment is outrageous and calculated to destroy medical schemes and leave beneficiaries with nothing. I want to assure you that this was well thought out,” he said.
According to data at the department’s disposal, medical schemes are holding close to R60bn in unused reserves. While there is a statutory requirement that medical schemes should have 25% of their income in reserves – a fund that caters for emergencies – presently, the R60bn is equivalent to 33% in reserves – an unnecessary accumulation at the expense of patients.
The Council for Medical Schemes is busy reviewing the 25% statutory requirement, with a view of releasing enough money for patients rather than holding a lot of reserves.
Taking out the middle man
“Almost two thirds of principal members of medical aid schemes pay monthly to a broker as part of their premium. Many of these members do not even know that they are paying this money, which in 2018 is R90 per month. The total amount paid to brokers in 2017 was R2.2bn,” Motsoaledi said.
He said the money should be made available to pay for direct health expenses of members rather than serving brokers who are actually not needed in the healthcare system.
Designated service provider
Another amendment, Motsoaledi said, will compel medical aid schemes to pass back savings if a member uses a designated service provider, in accordance with the rules of the scheme.
“Presently, medical aid schemes compel members to use designated service providers in order to save money. This is a good practice to be encouraged but however, the problem is that these savings are taken over by the scheme or the administrator instead of being passed on the member in the form of [a] premium reduction,” he said.
NHI to curb cost, improve quality of healthcare
Moving on to National Health Insurance (NHI), Motsoaledi said the programme is a health financing system that pools funds to provide access to quality health services for all South Africans based on their health needs, irrespective of their socio-economic status.
He said government is painfully aware of the fact that some people believe that even before speaking about the NHI, there is a need to fix the ailing public healthcare system first.
The National Development Plan (NDP), Motsoaledi said, has flagged it unambiguously and that in implementing NHI, poor quality of healthcare and the existing cost of private healthcare need to be addressed.
“Clearly, the NDP regards these two as the terrible twins of the healthcare system, hence the need to be tackled simultaneously. It we do them one after the other, it means we are planning to take the next half a century before we talk about NHI. That is undesirable,” he said.
In the massive reorganisation of the healthcare system, 12 Acts have been identified that should be amended for the healthcare system to be able to run smoothly.
Two of the 12 Acts include the National Health Act of 2003 (Act no. 61 of 2003) and the Mental Health Act, 2002 (Act no. 17 of 2002). The amendment of these acts also forms part of the Health Ombud recommendations in the Life Esidimeni aftermath.
“The National Health Act, as it stands currently, empowers the Minister of Health and the national department to come up with policies, guidelines, norms and standards for implementation by various provincial Departments of Health.
“The act also provides for the establishment of the National Health Council consisting of the minister and MECs, the director-general and HODs, as well as the sergeant general of the South African Military Health Services Act and SALGA. The functions of this body is to advise the minister on a broad range of issues pertaining to the running of the healthcare system,” Motsoaledi said.
Four NHI projects
While the amendments to the Bills are being debated, the department will implement at least four NHI projects from the money allocated in the MTEF (annual, rolling three-year expenditure planning) period. These will include school health, mental health, pregnant women with complicated pregnancies in 22 highly affected hospitals and oncology, with specific help for Gauteng and KwaZulu-Natal, while not ignoring other provinces.
While there are rumours that interest groups are trying to block the release of the findings of the report, Motsoaledi said the only assumption was that “they did not want the public to know the truth”.
“While we do not know the contents of that report, we however do know, because this was publicly done, that the presentation of the World Health Organisation (WHO) and the Organisation for Economic Cooperation and Development (OECD) stated that contrary to popular belief, only 10% of South Africa’s population can afford what is being charged in private health care.
“The amendments we are introducing are meant to provide much needed relief to patients finding themselves in serious financial hardships,” he said.
Health Minister Dr Aaron Motsoaledi says the release of two bills – the Medical Schemes Amendment Bill and the National Health Insurance (NHI) Bill – is poised to make history.
Health minister, Aaron Motsoaledi
The bills will pave the way for more access to medical healthcare through the NHI.
The Minister was speaking at the policy debate on the Health Budget Vote in the National Council of Provinces on Tuesday.
“On Thursday, I will be releasing two bills to the nation in a press conference – the Medical Schemes Amendment Bill and the NHI Bill.
“This question of universal health coverage, which we call NHI, is not going to leave the world unshaken. This is what we are going to be announcing on Thursday.”
The minister’s announcement follows cabinet’s approval of the two medical bills two weeks ago.
Motsoaledi cited the prestigious British medical journal, The Lancet, which dedicated one of its editorials to universal health coverage, saying it will be “the third transition of health ever since human beings started populating this planet”.
Universal health coverage was adopted by the United Nations as one of the 17 Sustainable Development Goals.
Referring to the NHI as the “land question of health”, Motsoaledi said the debates on the NHI will rage not only in the field of health but in the economic and social lives of the people.
“Yes, under NHI, the rich will subsidise the poor. The young will subsidise the old. The healthy will subsidise the sick. The urban will subsidise the rural.
“For this reason, we are contending that this will be a substantial policy shift. It will necessitate a massive reorganisation of the whole healthcare system, both public and private, and completely change the relationship between our spheres of government,” said the Minister.
According to Motsoaledi, laws will have to receive an overhaul to ensure the success of the NHI.
“We are going to be asking you to change most of the laws that you have painstakingly cobbled together since the advent of democracy.
“You might have had to dismantle some of the relationships between spheres of government and also rattle the corporate world in health.
“That is what we will mean by a massive reorganisation of the health system,” he said.
Amendments to acts to prevent disasters
According to Motsoaledi, disasters in the health sector such as Life Esidimeni, oncology in KwaZulu-Natal and Mediosa, stem from issues such as human resources, financial management, supply chain management and infrastructure maintenance.
“All the major disasters in health that occurred in our country are about these four and the way they are governed and controlled. We have already identified 12 Acts that will have to be amended by this House to accommodate NHI,” said the minister.
The minister said implementing NHI projects using the R4.1bn allocated by the finance minister for cancer, school and mental health will be the next step for his department.
I will never forget the first Canadian medical tourist I interviewed. I was gripped when this person told me about travelling abroad for invasive surgery, accompanied by their spouse. While in India, this spouse required emergency surgery to address a chronic condition that had worsened.
This situation sounded so distressing and the researcher in me wondered: Could the mental and physical stress of caregiving in an unfamiliar, international context have negatively impacted the spouse’s health to the point that surgery was required?
There are many reasons why patients opt to seek health care abroad. In some cases, it is because they cannot access timely surgery locally. In others, they are seeking an experimental procedure that is not available at home, such as an unapproved stem cell therapy.
For most of the last decade I have been involved in extensively studying medical tourism. I have spoken with patients, policy-makers, doctors, nurses, tourism officials, travel operators and many others in well over a dozen countries. Much of this research has examined ethical and equity questions related to medical tourism. For example, trying to understand if and how local patients, health-care providers and health systems can benefit from medical tourism in the Caribbean.
One thing I have learned is that many medical tourists do not travel on their own. Many travels with a friend or family member.
Friends and family provide support and companionship. They serve as a source of familiarity and comfort. They can assist with very practical matters, such as confirming travel plans and keeping people at home informed about the medical tourists’ health status. My own research has found that these roles and responsibilities can be quite extensive.
I would like to take a step back and offer a more critical perspective on this practice of informal caregiving by friends and family members in the context of medical tourism.
‘Shadow workers’ in a multi-billion dollar industry
Clinics, hospitals and entire countries are actively trying to attract medical tourists through costly advertisement campaigns and other promotional efforts. But what about the friends and family who accompany them?
I rarely see a mention of friends and family in the brochures, websites, e-mails and trade shows that advertise medical tourism services.
There is no formal guidance on what they can expect while they are abroad. No formal resources to prepare them to do things like change wound dressings in hotel rooms or navigate airports with someone recovering from surgery.
These friends and family are, in many ways, “shadow workers” in a multi-billion dollar global industry.
Yet, in my opinion, the industry does little to protect them.
Nine factors to consider
I think there are many things that can be done to transition these friends and family members from unpaid “shadow workers” to prepared members of medical tourists’ support networks.
I was recently involved, with a research team, in interviewing Canadians who had accompanied a family member or friend abroad for medical tourism. Their stories contained very important pieces of advice for people considering taking on this role. We gathered this advice together and published it in an academic article.
The information sheet we developed can be shared widely. The text can be copied and pasted freely onto the websites or promotional materials of clinics and hospitals seeking to treat medical tourists.
I invite people to read it, share it and talk about the content.
The global medical tourism industry relies on the unpaid labour provided by patients’ friends and family members. Their unpaid labour needs to be acknowledged. Their needs must be assessed. Their health and safety need to be protected.
I push for these things to happen when I meet with medical tourism sector representatives, and I call on others to push for the same.
I push for these things to happen when I meet with medical tourism sector representatives, and I call on others to push for the same.