Quality care for all is the goal
Garth Zietsman responded to my address at the National Editors’ Forum in Cape Town, during which I raised concerns about the cost of private healthcare in South Africa. I predicted that the private healthcare sector was likely to collapse if its current price increases continued.
Zietsman proposes a system that is in direct conflict with the generally accepted definition of a good healthcare system and his arguments are misleading. It is widely accepted that healthcare is a public good that cannot be subjected to market forces in the same way as other commodities. This is why many countries, including those that embrace the free market system, have implemented measures that ensure that all their citizens have access to healthcare.
In his article, Zietsman refers mostly to the issue of pricing. Towards the end he raises the issue of the poor quality of public healthcare in a manner that suggests that I deliberately kept mum about it.
I do not know whether Zietsman attended the editors meeting or whether a third party informed him about my address.
If he was indeed present and he listened carefully, he would have noted that I discussed the issue of private healthcare pricing in the context of the two preconditions for National Health Insurance to be implemented successfully in South Africa.
The first is the drastic, non-negotiable improvement of the quality of public healthcare. In my address, I emphasised that the public healthcare system needed to be overhauled. The second precondition was that the pricing of private healthcare had to be regulated because it had become excessive and unaffordable.
I quoted a few examples in support of my argument. Zietsman, however, disregards them as anecdotal evidence and considers them “useless”. The dictionary definition of an anecdote is “a short amusing or interesting story about a real-life incident or person. An account regarded as unreliable or hearsay.”
There is neither anything amusing or interesting about the examples I quoted, nor are they unreliable or based on hearsay. They are the real-life experiences of distressed South Africans who contacted me because they believed the health minister might be able to relieve their distress.
Some phone from the gates of private hospitals with sick children or relatives because huge sums of money are demanded from them before treatment is offered. Others write to me after their ordeal. One of them is a high-ranking official of the World Health Organisation (WHO), who was in South Africa when her child needed a minor procedure. She was shocked by the high charges.
Zietsman omits to mention, perhaps because it is inconvenient to his argument, that in my address I also related a complaint from Swaziland’s health minister. A Swazi patient on the government medical scheme was charged R500000 for the drainage of a peritoneal (abdominal) abscess, a standard medical procedure.
I referred to a circumcision costing R15 000 in a private hospital while the price quoted by general practitioners, also in private practice, was much lower. Zietsman attempts to justify this. He states: “The examples do not compare like with like and were probably chosen to be maximally misleading. No doubt the circumcision example compares straight forward circumcisions involving normal foreskins with the most complicated and expensive circumcision operation carried out in a private hospital.”
But the concept of a medically complex, high-cost circumcision procedure that can only be performed at a private hospital is a figment of his imagination. I have practised at a rural hospital. During winters I was responsible for corrective surgery of failed circumcisions at initiation schools. Even in those situations, where there was clear damage, surgery was never so complicated that it had to be done at a private hospital at exorbitant costs.
People without medical training are easily duped into believing that treatment is expensive because it is “extremely complicated”.
I would like to remind you of the excessive prices the government used to pay for antiretroviral drugs (ARVs). When we challenged those prices, we were given a number of doubtful reasons, such as the high cost of the ingredients and import tariffs. We then brought in several international suppliers to compete for the same tender. Suddenly the companies drastically reduced their prices by more than half - from R8.8-billion to R4.2-billion. As a result, we are now able to double the number of South Africans who have access to ARVs. It may sound like an anecdote to Zietsman, but to HIV-infected South Africans it is life-saving treatment.
Zietsman further states: “Yes, it is true that private medical scheme rates are growing faster than other categories of medical expenses and the consumer price index. This is not due to the cost of private medical care per se, but to the conditions forced on the medical scheme industry by the state. For example, they are not allowed to charge according to members’ health risks or exclude some pre-existing conditions and are forced to offer fairly generous minimum benefits to all. These measures quickly raise costs to levels way above those that a private medical scheme would institute if left alone.”
Basically, he is proposing that medical schemes should be allowed to charge patients with some medical conditions higher tariffs or, worse, deny those patients cover. The consequence would be that patients with multiple medical conditions would have to pay higher premiums, which would eventually force them to drop their medical scheme cover.
Zietsman is advocating for a society based on the laws of the jungle where only the fittest survive. But the WHO has declared healthcare a basic human right; so has our country’s Constitution. Zietsman’s free-market proposals disregard this.
My views are not out of step with the general consensus on pricing in the private sector. The Human Rights Commission has expressed concerns about private hospital costs and called on the industry to become transparent about its pricing structures. The Council for Medical Schemes’ report also demonstrates that private hospital costs are excessive and the main cost driver in the increase of medical scheme tariffs. The Board of Healthcare Funders, the representative body of medical schemes, has also asked for my intervention with regard to private hospital costs.
Over the past two years, member contributions were insufficient to pay provider claims and schemes have had to draw from their reserves. If this trend continues, the sector is certainly not sustainable.
Private and public sectors
Zietsman takes the bold step of suggesting that there is little difference in costs (5%) between the private and public sectors. I tried to compare the current fees for some basic services between the full costs of public facilities (uniform patient fee schedule tariff) and private tariffs as published by a private hospital. The public sector costs were always lower than the private sector prices, ranging between 5% and 75% less. In a few cases, the difference was 5%, yet Zietsman chooses to report only this anecdotal figure.
This debate is unfortunate because it creates the impression that the public and private health sectors are at war with each other. We must be open about the problems that both sectors face. I have stated on many occasions that the quality of public healthcare needs to improve significantly. In the private sector, prices are excessive and unaffordable.
The introduction of the National Health Insurance scheme requires that both sectors address their respective challenges and work together to improve the health of all South Africans.
Motsoaledi is the minister of health