The Hospital Association of South Africa (HASA) notes with some disappointment reports quoting the Health Professions Council of South Africa’s (HPSCA) Dr Kgosi Letlape as saying that ‘medical aids are a crime against humanity.’
His comments come at a time, says HASA, when the South African healthcare system faces a number of urgent challenges that must be addressed if we are to improve healthcare outcomes and if citizens are to enjoy quality and accessible care and are unlikely to assist the collaboration necessary to meet these challenges.
“Unfairly targeting one sector of the healthcare system that provides cover to millions of South Africans who are therefore able to receive necessary treatment while ignoring challenges like the debilitating shortages of doctors and specialists, the lack of infrastructure by which to produce the number of doctors we need, and the falling numbers of public sector hospital beds, is not helpful,” says Melanie Da Costa, chair of HASA.
“For instance, in South Africa, there are only 60 doctors per 100 000 people in South Africa – the world average is 152 per 100 000. This one issue affects the entire healthcare system and goes to the heart of whether it is able to function well or not,” she adds.
According to economics research consultancy Econex, the lack of infrastructure and training capacity in South Africa lies at the heart of the doctor-shortage problem.
In a research report, “Identifying the determinants of and solutions to the shortage of doctors in South Africa” the consultancy notes that South Africa has eight medical faculties producing doctors, or one medical school per 6.6m citizens. Across Africa, the number improves slightly to one school per 4.9m. But compared to the rest of the world the challenge comes into sharp focus: in the Americas the ratio is one school per 1.2m, in Asia it is one per 3.5m, in Europe, one per 1.8m, and in the Oceania region, one training facility per 1.2m.
India and Brazil are two countries that faced the same challenge and have achieved success in increasing the numbers of doctors in each of their healthcare systems by finding a role for the private education of doctors and nurses. South Africa does not allow private education of doctors.
“If we are to address the healthcare challenges we face in this country the long term sustainable solution is the production of more doctors. If we tackle this challenge along with a robust primary healthcare approach and a determination to increase the numbers of public hospital beds available, which is substantially below the numbers we had available in the mid-1970s, more people can be treated, the burden of disease better addressed, and there will be improved access to quality healthcare,” says Da Costa.
According to Da Costa, it does not help to re-arrange the deck chairs and to become embroiled in false debates about whether or not medical aids are a “crime against humanity.” The real debate, she says, is why are we not allowing private medical schools to contribute to solving the doctor-shortage challenge if government’s already tight budget does not enable the funding of new training institutions?
Letlape had told a panel of experts in the private and public health sectors and academia, discussing the National Health Insurance White Paper, that medical aid schemes are a “crime against humanity” and should be abolished because they cannot co-exist with the NHI. According to a report in The Mercury, he said that private medical aids and the Medical Schemes Act should be abolished if the NHI was to provide universal health care access for all citizens.
“There can be no national health if it is not for all of us. You try to engage about NHI with the privileged, and they say ‘don’t touch my medical aid’. Medical aid is a crime against humanity. It is an atrocity.”
Letlape is quoted in the report as saying that Health Minister Aaron Motsoaledi did not seem to have much support for NHI, and people such as parliamentarians and judges also had an attitude of “don’t touch my medical aid”.
However, he said it was possible to provide universal health care, which was not a new concept, as the country previously had one of the best health-care systems in the world under apartheid.
“South African whites had health for all. By 1967 they had a system that could give somebody a heart transplant for no payment. At the point of service, there were no deductibles, the doctor was on a salary and everyone could access health care.” But when the Medical Schemes Act was created 50 years ago, the exodus of medical professionals from the public to the private sector began, Letlape said. He estimated there were between 3,000 and 4,000 medical professionals working for medical schemes that could be redistributed to the health system if schemes were abolished.
Dr Mfowethu Zungu, deputy director-general for macro policy, planning and NHI at the KZN Health Department said only 48% of expenditure on health in South Africa was spent in the public sector, which served 87% of the population. The balance was spent in the private sector, which served medical aid members, who comprised around 17% of the population.
Heath Department deputy director-general for health regulation and compliance management, Dr Anban Pillay, said the provision of universal health care for all citizens was critical. “We currently have a system where people access care based on what they can afford. Clearly, there are a number of barriers to access, particularly in the lower socio-economic groups. NHI is a massive reorganisation of the public and private health-care system.”
Pillay said the poor were often most in need of health care, and funding for NHI would come from taxpayers based on a principal of social solidarity.
“Social solidarity means we all contribute to a fund, so that when I am sick I will have access to health care. But maybe I may never need to (access), but somebody else will.
“It’s not a concept South Africans are particularly used to in the current context. If you look at your medical scheme environment, which an individual contributes to as an insurance, you have a particular entitlement – it’s your money. This is very different to how the NHI works.”
The panel was discussing key issues the NHI White Paper missed in relation to a rights-based approach to health care, says a Sunday Tribune report. The White Paper outlines the state’s plans to set up a universal medical scheme for all South Africans. However, experts found that the poor and vulnerable could still find it difficult to access health care under the NHI.
The report says a panel of experts in the private and public health sectors and academia have noted gaps in the proposed strategies and implementation. The deputy-director of the Foundation for Human Rights, Hanif Vally, said it was crucial that civil society play an active role in the delivery of services. “The kind of society we want needs our participation to make sure that the constitutional rights of patients are met,” he said.
The report says the panel criticised the lack of clarity on some of the crucial NHI policies. “The paper states that vulnerable groups such as children, orphans, the aged, adolescent and people living with disabilities will be prioritised to receive cards but not prioritised in terms of the type of services offered,” Vally said.
Professor Leslie London, head of public health medicine at the University of Cape Town, said he was concerned that those in the lower socio-economic bracket could still receive sub-par health care. “Rural populations are expected to get themselves to facilities when it is often not possible, with the exception of chronic diseases. The NHI is silent on what information communities can expect and on language barriers to health care. Many health-care providers do not speak the languages of their patients, and patients are expected to bring their own interpreters. This is particularly problematic as it violates confidentiality, impairs effective communication and reduces the likelihood of good clinical outcomes.”
The panel criticised the White Paper for lack of clarity on how non-discrimination might end up discriminating in practice against rural populations and populations dependent on poor-quality state services. “For farm workers dependent on employers for access to services off the farm, there is additional discrimination implicit,” London said.
The report says the panel found that lack of discussion on what constituted appropriate rationing in a rights framework was thin. The members said there was no acknowledgement of the criteria that needed to be met if rationing was to be deemed fair.
“One of the key aspects of a rights-based approach to a health system is the obligation of the state to devise a plan and budget. The NHI lacks the commitment to factoring human resources and participation into the plan.”
The report says the panel recommended that the NHI develop effective vehicles for participatory decision-making, not just receiving new information on treatment protocols but in identifying an overall strategy.
[link url="http://econex.co.za/wp-content/uploads/2015/08/ECONEX_Doctor-shortages-and-training_FINAL1.pdf"]Econex study[/link]
[link url="http://www.iol.co.za/news/politics/abolish-private-medical-aid-7631962"]The Mercury report[/link]
[link url="http://sundaytribune.newspaperdirect.com/epaper/viewer.aspx"]Sunday Tribune report[/link]