Critical Consumer Pat Sidley
A PROPOSED new health care system, one of the ANC’s key=20 election promises, is the topic of hot debate at the=20 moment almost everywhere that counts: within the ANC,=20 the government of national unity, parliament, various=20 think tanks on health policy, the Department of Health=20 and among all health care professionals.
It also appears to be the focus of international=20 activity, with “experts”, consultants, professors and=20 presumably a few cranks all getting their penny’s worth=20
But one constituency is not being represented in this=20 debate: consumers, the people who will receive the=20 health care. In other words, you and me.
Predictably, consumer organisations have had nothing to=20 say on the subject, not even on the possibility that we=20 will be taxed very heavily to pay for the John Deeble=20 scheme, if it is adopted. The new Consumer Forum is=20 silent on this subject as it appears to be on all other=20 consumer matters. The Consumer Council, the Housewives=20 League, the Black Housewives League — none of these=20 groups has raised a murmur.
If that is not alarming enough, not one word on the=20 rights of health care consumers has been uttered by=20 Health Minister Dr Nkosazana Zuma or her special=20 adviser, Dr Olive Shisana. Very little has been said by=20 any of the various Health Department committees that=20 have been investigating health care or by the=20 economists pondering how to fund the various plans, or=20 by the medical aid societies and insurance companies=20 who will compete with any state-funded organisation to=20 get at our money. Not even the doctors or hospital=20 administrators, who actually deal with consumers every=20 day, have made reference to that average patient and=20 his or her rights and requirements.
None of the 12 Health Department committees, including=20 the new one investigating health insurance=20 possibilities, includes a person whose sole task is to=20 represent the interests of health care consumers. And=20 few, judging from the list supplied by the Department=20 of Health, would have automatically accepted such a=20 task as his or her brief.=20
This week, however, an international expert in the=20 field of health care systems, in the country for a=20 three-day conference on “Health Care Structure”, raised=20 the issue in what should have been seen as a stinging=20 reference to the absence from the debate of a focus on=20 the quality of care. Judging from the debate which=20 followed, nobody was stung.
The expert, Paul Gross, has experience in Australia, in=20 other countries overseas and in this country as well.=20 He has functioned as an academic, bureaucrat and=20 consultant. At the moment he serves as a consumer=20 representative, appointed by the Australian government=20 to one of its four major health care groups. He is=20 effectively under orders to make life as uncomfortable=20 for that group as it takes to represent appropriately=20 the needs and rights of consumers. There is a fair=20 amount of discomfort in these health care groups=20 already without Gross’ intervention, for unlike our=20 insurance schemes and medical aids, they are obliged to=20 take everybody without reference to prior health=20
Quoting yet another expert in the field to the=20 delegates at the conference, Gross described an “iron=20 triangle” in medicine with three policy goals: access=20 to care, quality of care and cost containment. The=20 angles of the triangle “cannot be adjusted without=20 affecting the other two angles”.
South Africa, Gross said, was trying to overhaul the=20 system radically, in “one fell swoop”, without knowing=20 what would happen to quality.
Anticipating that in this country health care types are=20 likely to raise the literacy and ignorance levels of=20 consumers as a reason not to draw them into the=20 process, he cites Thomas Jefferson on the issue. The=20 import of Jefferson’s words is: if consumers are unable=20 to be discerning enough because they are ignorant, the=20 “remedy is not to take discretion from them, but to=20 inform their discretion”.=20
He believes — and backs up with examples from the=20 research — that educating consumers and empowering=20 them to have some control over their own health care=20 needs eventually reduces the burden on health care=20 systems and in some cases reduces costs.
Over the past few years, an attempt has been made by=20 the Medical Association of South Africa (a trade union=20 of conservative doctors representing their own=20 interests) to introduce protocols of treatment. This=20 notion looks at various types of treatment, how=20 effective each treatment is in terms of quality of care=20 and cost and to recommend the most appropriate methods=20 for treating different problems or maladies, taking=20 quality and cost into account. Unfortunately, Masa has=20 not taken the public into its confidence, extended the=20 information out of its own closed circle, or even dealt=20 with certain very contentious categories of treatment=20 which earn Masa members money but may do little if=20 anything for patients.=20
In a US study of treatment protocols in the use of=20 intensive care units, said Gross, the involvement of=20 consumers in their own treatment had resulted in=20 shorter stays in the ICU and in the hospital. Similar=20 findings were apparent in studies on the role of US=20 consumers in the treatment of major disorders.
Back to South African conditions, Gross told the=20 conference that the availablity of completely free care=20 to all pregnant women and children under six has=20 swelled queues and drained resources in some areas. He=20 believes that any system we introduce in which large=20 amounts of ignorant consumers are given the green light=20 to go for free treatment with no payment will overload=20 the system, and it will not guarantee a high quality of=20 care for the patients. Patients have to be educated so=20 that they can participate appropriately in deciding on=20 their own health care needs.
There is no doubt that at the end of the line the=20 minister will glancingly refer to consumer rights when=20 she appeals to party suppporters to back her plans. It=20 will be a populist move and will resonate in the hearts=20 of the sick and the poor: we’ll take care of you, if=20 you back our plan.
In the meanwhile there is nothing for it but to yell=20 loudly. If you can find your member of parliament or=20 your member of the provincial legislature — in a non- constiuency system like ours, you can choose anyone you=20 like or are able actually to contact — let them know=20 how you feel about the quality of your own care and=20 make it clear that you want a stake in the argument and=20 won’t pay for it otherwise.
While economists ponder the costs, hospital=20 administrators panic about making ends meet and doctors=20 worry about their pockets, there is only one bunch out=20 there who will worry about the quality of the care they=20 devise and its cost to the victims: You and me. Don’t=20 wait for them to come to us — they won’t. They never=20